Comparative Effectiveness of Surgical Interventions for Recalcitrant Plantar Fasciitis: A Systematic Review and Network Meta-analysis.

BACKGROUND: Recalcitrant plantar fasciitis (PF) unresponsive to conservative treatment remains challenging, with multiple surgical options targeting different mechanisms and no clear consensus. PURPOSE: To evaluate and compare the clinical effectiveness and safety of recalcitrant PF surgical options. STUDY DESIGN: Systematic review and network meta-analysis. METHODS: A systematic search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Interventions were grouped by mechanism of action (plantar fascia release (PFR), gastrocnemius recession (GR), angiogenesis or tissue regeneration, nerve ablation (NA)) and surgical approach (open, endoscopic, percutaneous). Network meta-analyses and narrative synthesis were performed. Risk of bias was assessed using Cochrane Risk of Bias 2 (RoB 2.0) and Methodological Index for Non-Randomized Studies (MINORS) tools. RESULTS: We included 21 studies involving 1,064 patients. Endoscopic approaches showed greater improvement of American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores versus open and percutaneous techniques. GR demonstrated better VAS outcomes than other mechanisms, with no difference in AOFAS. Overall study quality was moderate to high risk of bias. CONCLUSIONS: Surgical management should be individualized to optimize outcomes. Higher quality standardized comparative studies with long-term follow-up are needed. LEVEL OF EVIDENCE: Level III.