Fasciotomy

Fasciotomy

Definition

Fasciotomy is a surgical procedure that cuts away the fascia to relieve tension or pressure.

Purpose

Fascia is thin connective tissue covering, or separating, the muscles and internal organs of the body. It varies in thickness, density, elasticity, and composition, and is different from ligaments and tendons.

The fascia can be injured either through constant strain or through trauma. Fasciitis is an inflammation of the fascia. The most common condition for which fasciotomy is performed is plantar fasciitis, an inflammation of the fascia on the bottom of the foot that is sometimes called a heel spur or stone bruise.

Plantar fasciitis is caused by long periods on one's feet, being overweight, or wearing shoes that do not support the foot well. Teachers, mail carriers, runners, and others who make heavy use of their feet are especially likely to suffer from plantar fasciitis.

Plantar fasciitis results in moderate to disabling heel pain. If nine to 12 months of conservative treatment (reducing time on feet, nonsteroid anti-inflammatory drugs, arch supports) under the supervision of a doctor does not result in pain relief, a fasciotomy may be performed. Fasciotomy removes a small portion of the fascia to relieve tension and pain. Connective tissue grows back into the space left by the incision, effectively lengthening the fascia.

When a fasciotomy is performed on other parts of the body, the usual goal is to relieve pressure from a compression injury to a limb. This type of injury often occurs during contact sports or after a snake bite. Blood vessels of the limb are damaged. They swell and leak, causing inflammation. Fluid builds up in the area contained by the fascia. A fasciotomy is performed to relieve this pressure and prevent tissue death. Similar injury occurs in high-voltage electrical burns that cause deep tissue damage.

Demographics

People who are likely to need a fascictomy include the following:

• athletes who have sustained one or more serious impact injuries
• people who spend long periods of time on their feet
• people with severe burns
• persons who are overweight
• snakebite victims

There is a slight male predominance among people undergoing a fasciotomy.

Description

Fasciotomy in the limbs is usually performed by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed.

Plantar fasciotomy is an endoscopic (performed with the use of an endoscope) procedure. The doctor makes two small incisions on either side of the heel. An endoscope is inserted in one incision to guide the doctor. A tiny knife is inserted in the other. A portion of the fascia near the heel is removed. The incisions are then closed.

Diagnosis/Preparation

In the case of injury, fasciotomy is performed on an emergency basis, and the outcome of the surgery depends largely on the general health of the injured person. Plantar fasciotomies are appropriate for most people whose foot problems cannot be resolved in any other way.

Little preparation is needed before a fasciotomy. When the fasciotomy is related to burn injuries, the fluid and electrolyte status of the affected person are constantly monitored.

Aftercare

Aftercare depends on the reason for the fasciotomy. People who have endoscopic plantar fasciotomy can walk without pain almost immediately, return to wearing their regular shoes within three to five days, and return to normal activities within three weeks. Most will need to wear arch supports in their shoes.

Persons who require fasciotomy as a result of an injury or snake bite are usually able to resume their normal activities in a few weeks.

Risks

The greatest risk with endoscopic plantar fasciotomy is that the arch will drop slightly as a result of this surgery, causing other foot problems. Risks involved with other types of fasciotomy are those associated with the administration of anesthesia and the development of blood clots or postsurgical infections.

Normal results

Fasciotomy in the limbs reduces pressure, thus reducing tissue death. Endoscopic plantar fasciotomy has a success rate in excess of 95%.

Morbidity and mortality rates

The most common morbidity in a fasciotomy is an incomplete response that requires a repeat fasciotomy procedure. Mortality is very rare and usually due to a problem related to the original condition.

Alternatives

Conservative nonoperative treatment for plantar fasciitis consists of nonsteroidal anti-inflammatory drugs for several weeks. For persons who spend excessive time on their feet, a change of occupation or the use of arch supports may be useful. Overweight individuals may consider weight reduction to reduce the stress placed on their feet. For persons bitten by a poisonous snake, there are no acceptable alternatives to a fasciotomy, and there are rarely acceptable alternatives to fasciotomy for a person who has been burned.

Resources

books

Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001.

Canale, S. T. Campbell's Operative Orthopedics. St. Louis, MO: Mosby, 2003.

Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. M. Daly. Principles of Surgery. 7th ed. New York: Mc-Graw-Hill, 1998.

Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, and D. C. Sabiston. Sabiston's Review of Surgery. 3rd ed. Philadelphia: Saunders, 2001.

periodicals

Cook, S., and G. Bruce. "Fasciotomy for Chronic Compartment Syndrome in the Lower Limb." Australia New Zealand Journal of Surgery 72, no. 10 (2002): 720–723.

Fulkerson, E., A. Razi, and N. Tejwani. "Review: Acute Compartment Syndrome of the Foot." Foot and Ankle International 24, no. 2 (2003): 180–187.

Lin, Y. M. "Will Fasciotomy Help in the Patients with Crush Syndrome?" American Journal of Kidney Diseases 41, no. 1 (2003): 265–266.

Watson, T. S., R. B. Anderson, W. H. Davis, and G. M. Kiebzak. "Distal Tarsal Tunnel Release with Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis." Foot and Ankle International 23, no. 6 (2002): 530–537.

organizations

American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, IL 60018-4262. (847) 823-7186 or (800) 346-AAOS. Fax: (847) 823-8125. <http://www.aaos.org/wordhtml/home2.htm>.

American College of Foot and Ankle Surgeons. 515 Busse Highway, Park Ridge, IL 60068-3150. (888) 843-3338). mail@acfas.org. <http://www.acfas.org/index.html>.

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000. Fax: (312) 202-5001. postmaster@facs.org. <http://www.facs.org>.

American Orthopaedic Foot and Ankle Society. 2517 Eastlake Avenue E., Seattle, WA 98102. (206) 223-1120. Fax: (206) 223-1178. aofas@aofas.org. <http://www.aofas.org>.

American Podiatric Medical Association. 9312 Old Georgetown Road, Bethesda, MD 20814. (301) 571-9200 or (800) 275-2762. Fax: (301) 530-2752. <http://www.apma.org>.

other

Swain, R., and D. Ross. "Lower Extremity Compartment Syndrome." Postgraduate Medicine March 1999 [cited April 2, 2003]. <http://www.postgradmed.com/issues/1999/03_99/swain.htm>.

U. S. Department of Defense. "Postoperative Care." Virtual Naval Hospital (University of Iowa) [cited April 2, 2003]. <http://www.vnh.org/EWSurg/ch18/18PostoperativeCare.html>.

University of North Dakota School of Medicine. "Compartment Syndrome of the Foot." [cited April 2, 2003]. <http://www.med.und.nodak.edu/depts/fammed/Fractures/fracture.dir/oa2/76.htm>.

Yale University School of Medicine. "What Are the Signs of Compartment Syndrome?" [cited April 2, 2003]. <http://yalesurgery.med.yale.edu/surgery/sections/plastics/Core% 20Curriculum%20Pages/Lower%20Extremity%20Page/LegAns2.html>.

L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

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Fasciotomy in a limb is usually performed by a general surgeon. The typical location is an outpatient facility using regional anesthesia. For persons with burns or others who require extensive fasciotomy, the procedure is performed in a hospital operating room under general anesthesia.

Plantar fasciotomy is performed by a foot specialist in a professional office or outpatient surgical clinic under local anesthesia. The procedure requires 20 minutes to one hour.

QUESTIONS TO ASK THE DOCTOR

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• Is the surgeon board-certified in general or podiatric surgery?
• How many fasciotomy procedures has the surgeon performed?
• What is the surgeon's complication rate?