"Quadriceps Fibrosis after Intramuscular Injections in Children" : Abstract f...Sophea HENG (Dr)
Repeated IM injections,especially at thigh cause fibrosis of quadriceps leading deficiency of flexion of knee.
To be careful with adequate technique of injections and doses for children.
"Quadriceps Fibrosis after Intramuscular Injections in Children" : Abstract f...Sophea HENG (Dr)
Repeated IM injections,especially at thigh cause fibrosis of quadriceps leading deficiency of flexion of knee.
To be careful with adequate technique of injections and doses for children.
Severe
patellofemoral arthritis secondary to patellofemoral
malalignment
treated by Fulkerson osteotomy plus tricortical
bone graft. A retrospective cohort of 45 knees.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Early Outcome of Discectomy with Interspinous Process Distraction Device a Re...CrimsonPublishersOPROJ
Early Outcome of Discectomy with Interspinous Process Distraction Device a Retrospective Cross-Sectional Study by Gunaseelan Ponnusamy* in Crimson Publishers: Orthopedic Research and Reviews Journal
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot T...CrimsonPublishersOPROJ
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot Treatment by Mario Lampropulos* in Crimson Publishers: Orthopedic Research and Reviews Journal
Clinical Improvement after ESSURE® devices removal, a systematic reviewFrançois PARANT
Removal of Essure® in symptomatic patients improve symptoms and quality-of-life in majority of cases. The physiological mechanisms underlying Essure®-attributed-symptoms remains unknown, but are probably related to release of metallic elements. Managing the few proportion of patients with no improvement remain a challenge.
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
Severe
patellofemoral arthritis secondary to patellofemoral
malalignment
treated by Fulkerson osteotomy plus tricortical
bone graft. A retrospective cohort of 45 knees.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Early Outcome of Discectomy with Interspinous Process Distraction Device a Re...CrimsonPublishersOPROJ
Early Outcome of Discectomy with Interspinous Process Distraction Device a Retrospective Cross-Sectional Study by Gunaseelan Ponnusamy* in Crimson Publishers: Orthopedic Research and Reviews Journal
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot T...CrimsonPublishersOPROJ
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot Treatment by Mario Lampropulos* in Crimson Publishers: Orthopedic Research and Reviews Journal
Clinical Improvement after ESSURE® devices removal, a systematic reviewFrançois PARANT
Removal of Essure® in symptomatic patients improve symptoms and quality-of-life in majority of cases. The physiological mechanisms underlying Essure®-attributed-symptoms remains unknown, but are probably related to release of metallic elements. Managing the few proportion of patients with no improvement remain a challenge.
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Percutaneous fenestration.pdf
1. Percutaneous fenestration of the anteromedial aspect of the
calcaneus for resistant heel pain syndrome
Freih Odeh Abu Hassan F.R.C.S. (Eng.), F.R.C.S. (Tr. & Orth.)*
Department of Orthopedics Surgery, Jordan University Hospital, P.O. Box 73, Jubaiha 11941, Amman, Jordan
Received 28 May 2008; received in revised form 13 August 2008; accepted 13 August 2008
Abstract
Introduction: The failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and
pain, which mandates a further treatment modality.
Aim of study: The presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief
of resistant heel pain syndrome.
Material and methods: Between September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an
unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25–
59 years). The average follow-up was 46 months (range, 14–84 months). Clinical evaluation of the intensity of pain (VAS score system),
walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular
follow-up.
Results: The preoperative pain score level was 8.4 (range, 6–10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3–9), at 8
weeks the value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at 8 months 1.7 (range, 0–3) and at 12 months zero. A clinical
improvement was seen in all patients irrespective of the duration of symptoms ( p = 0.0041). Three heels (7.9%) had partial relief of pain, but
after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal
nerve that resolved spontaneously after 8 weeks post-surgery.
Conclusion: The results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with
recalcitrant heel pain syndrome after failed conservative treatment.
The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical
techniques and warrants further study.
# 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Foot; Heel pains; Fenestration; Calcaneal spur; Fasciitis
1. Introduction
Heel pain is a frequent orthopaedic problem encountered
in daily practice and plantar fasciitis forms the most common
aetiology, affecting 10% of the population, which may lead to
significant morbidity and place strict activity limitations on
the patient [1]. The heel pain syndrome includes a continuum
of three different entities, including plantar fasciitis, calcaneal
periostitis and the calcaneal spur [2].
The aetiology is not known but it is believed to be the
result of chronic repetitive injury as a result of the nature of
upright human activity leading to repetitive tensile and
compressive stress of the fascia that has a cumulative ability
to damage or transform the tissue, causing a chronic
degenerative/reparative process with or without inflamma-
tory changes, which may include fibroblastic proliferation at
the calcaneal interface [3,4].
The majority of patients can be treated initially by a
combination of one or more of the following in a therapeutic
regimen: heel cord stretching, plantar fascia stretching, arch
support, heel pads, custom orthosis, taping, non-steroidal
anti-inflammatory drugs (NSAIDs), physiotherapy, ice,
www.elsevier.com/locate/fas
Available online at www.sciencedirect.com
Foot and Ankle Surgery 15 (2009) 90–95
* Tel.: +962 6 5240 346; fax: +962 6 5240 346.
E-mail address: freih@ju.edu.jo.
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2008.08.006
2. massage, lithotripsy, cast immobilization, activity modifica-
tions, night splints or steroid injections. Independent of the
mode of therapy used, if at all, 10–15% of patients fail to
respond to conservative treatment [5–9]. There is limited
evidence for the superiority of corticosteroid injections over
orthotic devices, stretching exercises and heel pads over
custom-made orthoses in people who stand for more than 8 h
per day [10]. Extracorporeal shock wave therapy is
ineffective in the treatment of chronic plantar fasciitis
[10,11]. Despite the used multiple modalities of treatment, it
takes a long time to heal. Many surgical techniques have
been tried with non-response rates varying from 2 to 35%
[12,13].
The aim of this study is to assess the effectiveness of
percutaneous fenestration of the anteromedial aspect of the
calcaneus at the insertion of the plantar fascia as a treatment
modality for chronic heel pain syndrome, to abate the
painful symptoms and to allow a rapid return to ordinary
activity, on the assumption of the degenerative and calcaneal
periostitis process as factors playing a role in the
pathogenesis of plantar fasciitis [2–4].
2. Material and methods
Between 2001 and 2006, 34 patients (38 feet) were
treated for their chronic heel pain syndrome after the
failure of conservative methods, using percutaneous
fenestration. There were 23 females and 11 males, with
an average age of 41 years (25–59 years). The left heel
was affected in 17 patients, the right heel in 13 and the
problem was bilateral in 4 patients; all were treated with
the same technique by the author. All the patients
diagnosed with painful plantar fasciitis were questioned
concerning the type of pain, site of pain, duration of pain,
walking distance, standing duration, extent of conserva-
tive therapy, previous surgical treatment and past medical
history. All the patients had an assessment of the range of
motion of the ankle and subtalar joints actively
and passively, and they were checked for gait pattern.
Each patient was treated for 3 months with conservative
methods, including physical therapy, Achilles tendon
and plantar fascia stretching, icing, heel pads and
NSAIDs. If the patient was not improving, an 8-week
course of additional therapy, including three courses of
ultrasound of six sessions each, and continued heel
pads and NSAIDs were prescribed before considering
surgery.
All the patients had weightbearing lateral radiographs of
the feet. Our inclusion criteria were the following: the
presence of a chronic pain of at least 6 months duration
(range 6–43 months) at the proximal insertion of the plantar
fascia at the anteromedial of the heel, which failed to
respond to a trial of conservative treatment. None of the
patients had symptoms of inflamed joints, tendon attach-
ments, inflammatory back pain, iritis, blood or mucus per
rectum, urethritis or skin problems as a manifestation of the
underlying inflammatory process.
Pain was evaluated using the subjective 11-point visual
analogue scale (VAS), where 10 represented unbearable
pain and 0 absence of pain. Patients were checked for any
signs of inflammation at the entry point of the fenestration
and impaired sensation of the sole using a pinprick. Pain and
gait pattern were evaluated preoperatively, 4 weeks, 8
weeks, 4 months, 8 months and 12 months after the
fenestration procedure. We defined the clinical results as
follows: excellent, patients who reported a subjective
decrease in pain ranging from 100 to 80% (VAS), no
complications and normal gait; very good, a decrease from
80 to 60% (VAS), no complications and minimal short-term
antalgic gait; good, a decrease of less than 60–40% (VAS),
minor complications and/or antalgic gait; and poor, a
decrease of less than 40–0% (VAS), major complications
and/or impossible gait.
2.1. Surgical technique
Under general anesthesia, the patient is placed in the
supine position with a sand bag under the opposite buttock
and the leg placed in external rotation. Without using the
tourniquet, the foot and ankle are draped. After a betadine
preparation of the skin, localization of the entry point is
performed under an image intensifier, followed by a
medial single 5 mm stab incision. Using the image
intensifier, the Steinmann pin is introduced through the
incision at the anteromedial aspect of the calcaneus and
multiple bone fenestration for about 1 cm made from the
same single hole in the superolateral direction, then
withdrawn slightly and directed posteriorly then anteriorly
and finally towards the lateral side perpendicular to the
calcaneus (Figs. 1 and 2).
No trial was made to break the plantar heel spur if
present. To infiltrate the heel at the end of operation, 5 ml
Marcaine local anesthesia is used. The entry site is not
sutured and a light, sterile compressive dressing with an
elastic bandage is applied.
2.2. Postoperative management
Postoperatively, the patient is given oral analgesia and
instructed for partial weight bearing for 7 days then to
continue with full weightbearing as tolerated. The dressing
is removed after 1 week and a small sterile dressing is
applied.
2.3. Statistical analysis
Statistical analysis of the data was performed by using a
PC program (SPSS 14 for Windows). Repeated measures
analysis (analysis of variance) was performed to compare
statistically pain ratings preoperatively, at 4 weeks, 8 weeks,
4 months, 8 months and 12 months.
F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 91
3. F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95
92
Fig. 1. Serial clinical photographs of the fenestration technique.
Fig. 2. Serial radiological views of the fenestration technique.
4. 3. Results
The average follow-up was 46 months (range, 14–84
months). Five patients had diabetes mellitus, two hyperten-
sion, five carcinoma of the breast and four osteoarthritis of
the knee joints. In all cases, the exact cause of the plantar
fasciitis could not be defined. There were 23 heel spurs
noticed in the standing lateral plain radiograph of the foot.
Pain was graded by each individual patient preoperatively
and postoperatively.
Pain ratings before fenestration were significantly
reduced from the average pain ratings after the procedure.
The average pain score before fenestration was 8.4 (range,
6–10) on the VAS.
At regular follow-up, the mean postoperative VAS for
pain at 4 weeks dropped to 5.89 (range, 3–9), at 8 weeks the
value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at
8 months 1.7 (range, 0–3) and at 12 months zero (Fig. 3).
Based on the aforementioned parameters, we analysed the
results at 4, 8 and 12 months.
We had excellent results in 78.94% (30 feet), 92.09% (35
feet) and 100% (38 feet) at 4, 8 and 12 months, respectively.
Very good results were observed in 13.15% (5 feet) at 4
months; all become excellent at 8 months. Good results in
7.9% (3 feet) at 4 months become very good at 8 months and
excellent at 12 months (Fig. 4). None of our patients had
poor results. There was significant heel pain relief as
indicated by ( p = 0.0041). Pain distribution revealed that
92.09% (N = 35) of the heels had complete or substantial
relief of heel pain after an average period of 10 weeks (4–34
weeks), with a pain rating of 1.7 on the VAS 8 months after
the procedure. Three heels (7.9%) had partial relief, but after
43 weeks they had complete subsidence of pain.
All the patients had a limited walking distance
preoperatively and they used to avoid prolonged standing.
Patients were able to walk for an average of 0.76 km (range,
70–2.5 km) and stand for an average of 24 min (range, 15–
60 min). The average postoperative walking distance was
4.1 km (range, 1.5–8 km) and the average postoperative
standing period was 3.9 h (range, 2.5–8 h). We observed a
persistent improvement in heel pain as evidenced by
prolonged walking distance and an improvement in standing
period ( p = 0.033).
None of the patients had localized tenderness at the
insertion of the plantar fascia at 12 months postoperatively.
All the patients showed a normal range of motion in the
subtalar joint preoperatively, although there was a limited
dorsal flexion of the ankle joint in 21 of 38 feet (0–58 in 14
feet and 6–108 in the other 7 feet).
Clinical examination showed a normal postoperative
range of motion in the subtalar joint and ankle joint. Gradual
recovery of the sensation occurred in the three patients with
neuropraxia of the medial calcaneal nerve in an 8-week
period. None of the patients were sent for rehabilitation.
No infections, hypertrophic scar formations or vascular
complications occurred in our patients. Complications
include three patients having impaired sensation at the
plantar aspect of the heel; this resolved spontaneously in 8
weeks.
4. Discussion
Although this problem is common, patients’ heel pain
improves spontaneously, demonstrating that the condition
is self-limiting in some patients [10]. Most patients of
plantar fasciitis respond very well to conservative
treatment. There was conflicting, limited or no evidence
for the effectiveness of topical steroids, low-energy
extracorporeal shock wave therapy, night splints, ther-
apeutic ultrasound or low-intensity laser therapy in
altering the clinical course of plantar heel pain [10].
The first line of management is by non-steroidal anti-
inflammatory drugs and heel pads [14]. After the failure of
all conservative options and permanent pain, an indication
for surgical intervention should be considered. The
literature is plethoric with different methods of surgical
treatment, and it seems there is no agreement on a single
method as the curative remedy.
F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 93
Fig. 3. The graph shows the mean value of pain (VAS) at the time of
preoperative and postoperative periods.
Fig. 4. The clinical results obtained with the treatment using percutaneous
fenestration.
5. Conventional open fasciotomy, fluoroscopic-assisted
fasciotomy, neurolysis, denervation, osteotomy or drilling
of the posterior calcaneus were the described surgical
methods [13,15–18]. Considerable attention was paid to the
complications of such procedures: healing problems,
vascular and neural lesions, hypertrophic scars and even
fractures of the calcaneus [19]. Apart from this, bad
results after operations are always frustrating for both the
patient and the surgeon [17]. Uni- or bi-cortical drilling in
the posterior body of the calcaneus has been tried before
as another modality of treatment to decrease the intraoss-
eous vascular congestion, with a 75–94% success rate
[18,20,21].
Drilling can be performed with an open procedure
through making 7–10 separate holes that traverse the
calcaneus from the lateral to the medial cortex or
percutaneous drilling of the calcaneus can be performed
over the medial surface of the heel by making three separate
small holes in the medial cortex, without traversing the
lateral cortex.
The aim of all described methods of drilling to decrease
the high intraosseus pressure in the calcaneus. Our method
based on the degenerative and periostitis process at the
calcaneal interface of the plantar fascia as possible
pathogenesis of this condition, the technique enhance
healing process and accelerate resolution of this challenging
problem.
By performing fenestration at anteromedial aspect
of the calcaneal interface of the plantar fascia, a
process of inflammation can be induced which will be
followed by opening the channels of the blood to
the site of pathology where the reparative cells
produce healing of the degenerative insertion of the
plantar fascia.
Again the described methods of drilling are performed
through the posterior body of the calcaneus away from the
pathology site in the anteromedial aspect of the heel and may
be associated with calcaneal fracture or nerve injury
[18,20,21].
Our technique is directed to the site of the pathological
process at the insertion of the plantar fascia in the
anteromedial aspect of the calcaneus at the inferior
calcaneal tubercle, by one fenestration and four
different directions of the Steinmann pin penetration
without perforating the lateral cortex. Compared with
other surgical procedures, our technique disturbs
neither the normal anatomy nor the biomechanical
function of the hind foot. With resolved chronic heel
pain in all treated feet, the clinical results are better than
those found in the literature, whether local calcaneal
drilling, minimal invasive procedure or open fasciotomy
[19,20,22,23]. We believe that there is no risk of
permanent damage to the branches of the sural nerve or
the medial calcaneal nerve or fracture of the calcaneus,
despite the three cases of the neuropraxia of the medial
calcaneal nerve which could be attributed to slippage of
the Steinmman pin during the targeting of the site of the
plantar fascia insertion or an abnormal course of the
nerve.
5. Conclusion
Despite the successful outcome of our technique, the
suggested method of healing needs further confirmation by
other laboratory methods or histological studies. These
results from a small group of patients studied over a few
years indicate that the described technique may provide a
useful method for treating this challenging refractory heel
pain syndrome. A larger study combined with random
variables would be helpful in the elimination of such
limitations.
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