Proximal Medial Gastrocnemius Release versus Open Plantar Fasciotomy in Recalcitrant Plantar Fasciitis: A Multicenter Prospective Cohort Study

Proximal Medial Gastrocnemius Release versus Open Plantar Fasciotomy in Recalcitrant Plantar Fasciitis: A Multicenter Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Proximal Medial Gastrocnemius Release versus Open Plantar Fasciotomy in Recalcitrant Plantar Fasciitis: A Multicenter Prospective Cohort Study Assem Bastawisy, Aly T. Aly, Shehab M Abouhussain, Hussein A. Hussein This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6234938/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Plantar fasciitis is a leading cause of chronic heel pain, often requiring surgical intervention when conservative treatments fail. Open plantar fasciotomy (OPF) and proximal medial gastrocnemius recession (PMGR) are two widely used procedures, yet their comparative effectiveness remains unclear. This study evaluates their impact on pain relief, functional recovery, and health-related quality of life (HRQOL). Methods: In this multicenter prospective cohort study, 50 patients with recalcitrant plantar fasciitis unresponsive to at least nine months of conservative treatment underwent either OPF or PMGR. Standardized surgical techniques and postoperative rehabilitation were implemented. Outcomes included pain (Visual Analogue Scale, VAS), function (American Orthopaedic Foot & Ankle Society, AOFAS score), HRQOL (SF-36), and patient satisfaction, assessed preoperatively and at 1, 3, 6, and 12 months postoperatively. Results: Both procedures significantly improved pain and function at 12 months (p < 0.05). However, PMGR resulted in greater pain reduction (p = 0.009) and a significantly faster return to full activity (median: 5 vs. 10 weeks; p < 0.001). Patient satisfaction was high in both groups (p = 0.63), and postoperative complications were rare and comparable (p = 0.222). Conclusion: While both OPF and PMGR are effective, PMGR offers superior pain relief and faster recovery, particularly in patients with gastrocnemius tightness. These findings support a tailored approach to surgical decision-making based on patient-specific biomechanics. Plantar fasciitis Heel pain Open plantar fasciotomy (OPF) Proximal medial gastrocnemius recession (PMGR) Foot and ankle surgery Gastrocnemius tightness Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Plantar fasciitis is considered a multifactorial condition with biomechanical and inflammatory components. The condition is primarily characterized by pain in the heel and is often associated with mechanical stress on the plantar fascia. This stress can arise from various factors, including pes planus (flat feet), excessive pronation, and biomechanical faults that increase tension on the plantar fascia, leading to microscopic tears and potential inflammation [ 1 – 3 ]. The inflammatory component of plantar fasciitis is somewhat debated. Histological studies have shown that inflammation is not always present in chronic plantar fasciitis, and the condition may involve fibroblastic hypertrophy and degenerative changes instead [ 2 ]. Additionally, factors such as obesity, tightness of the Achilles tendon, and inappropriate footwear can exacerbate the biomechanical stress on the plantar fascia, contributing to the development and persistence of symptoms [ 3 , 4 ]. Given its multifactorial nature, the management of plantar fasciitis requires an individualized approach, with treatment strategies tailored to the underlying biomechanical dysfunction and symptom severity. The American College of Foot and Ankle Surgeons recommends a stepwise approach, starting with conservative measures and progressing to more invasive treatments if necessary. However, the variability in response to treatment for plantar fasciitis is significant, reflecting its multifactorial nature with both biomechanical and inflammatory components. Two studies have explored how plantar fasciitis responds differently to treatment. Wrobel et al. found that in nonchronic cases, patients with severe ankle equinus were more likely to improve with conservative treatments such as Achilles tendon stretching and supportive footwear. Patients without severe equinus or first-step pain were less likely to benefit [ 5 ]. In chronic plantar fasciitis, non-surgical treatment modalities also yield inconsistent long-term results. Uğurlar et al. compared extracorporeal shock wave therapy, platelet-rich plasma (PRP) injection, corticosteroid injection, and prolotherapy. They found that corticosteroid injections provided the fastest pain relief, but the effects faded over time. Shock wave therapy was effective in the first six months, while PRP and prolotherapy showed slower improvements. After 36 months, there were no significant differences between the four treatments, indicating that long-term outcomes were similar regardless of the initial approach [ 6 ]. This variability in treatment response underscores the challenge in managing chronic plantar fasciitis and the need for personalized treatment plans. Hence, an earlier access to advanced treatments may be needed. The main principles of surgical treatment for plantar fasciitis focus on relieving tension in the plantar fascia and addressing any associated pathologies. According to the American College of Foot and Ankle Surgeons, the primary surgical option is Plantar Fasciotomy involves surgically releasing part of the plantar fascia to relieve tension directly at the site of pain in the heel. Techniques include: Endoscopic Plantar Fasciotomy and Open Plantar Fasciotomy. Gastrocnemius Recession [ 3 , 7 ]. Open plantar fasciotomy involves releasing part of the plantar fascia to alleviate tension and pain. This procedure is traditionally used for patients who have not responded to conservative treatments. However, it can lead to potential biomechanical complications, such as arch instability and altered foot mechanics, which may result in prolonged recovery times and increased morbidity [ 8 , 9 ]. Partial medial gastrocnemius release, on the other hand, addresses the gastrocnemius contracture, which is often a contributing factor in plantar fasciitis. This procedure is particularly beneficial for patients with isolated gastrocnemius contracture, as it can improve ankle dorsiflexion and reduce tension on the plantar fascia without directly altering the foot's structural integrity. Studies have shown that gastrocnemius release can lead to faster recovery and higher patient satisfaction compared to plantar fasciotomy, with fewer complications and better functional outcomes [ 10 ]. The economic burden of plantar fasciitis is significant, encompassing direct costs such as medical treatments and indirect costs like lost workdays. Healthcare usage and costs for plantar fasciitis have been increasing, with a notable rise in the number of treated cases and patients over the years [ 11 ]. The faster recovery associated with gastrocnemius release can potentially reduce indirect costs related to lost workdays and prolonged rehabilitation. The purpose of this study was to determine which of 2 popular treatments, OPF or PMGR, could provide better results in terms of pain, satisfaction, the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and health-related quality of life (HRQOL) in patients with recalcitrant plantar fasciitis. 2. Methods This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines for cohort studies [12]. The study was approved by the Misr University for Science and Technology Institutional Review Board, on 27 September 2023 and was conducted according to the ethical principles of the Declaration of Helsinki. The approval number is [2022/0088]. MUST-IRB is registered at the Office for Human Research Protections, US Department of Health and Human Services and operates under Federal Wide Assurance NO. FWA00025577. Participation in this study was completely voluntary. Written consent was given to patients before enrollment and undergoing surgeries. Confidentiality and privacy of all collected data were preserved, and the personal data were securely stored and only accessible to the statistician. 2.1. study design: A multicenter prospective cohort study 2.2. setting: Within the period September 2022 to September 2024 2.3. Participants: We targeted recalcitrant plantar fasciitis patients of both sexes undergoing surgical treatment either by open plantar fasciotomy or proximal medial gastrocnemius release at Souad Kafafi University Hospital and Ahmed Maher Teaching Hospital. 2.3.1. The Inclusion criteria were Patients diagnosed with recalcitrant plantar fasciitis, unresponsive to conservative treatment for at least 9 months, adults aged 18 years or older, patients with clinical signs of plantar fasciitis, including morning heel pain and tenderness over the plantar fascia insertion. Eligible patients exhibited characteristic clinical signs, such as morning heel pain and tenderness over the plantar fascia insertion, with imaging confirmation through ultrasound or MRI when necessary. We excluded patients with bilateral plantar fasciitis, neuropathic heel pain, hindfoot deformities, such as pes planus, pes cavus, hyperlaxity, or malalignment. Those with diabetes mellitus and peripheral neuropathy or uncontrolled metabolic disorders were not included , patients with past personal history of ipsilateral foot and ankle fractures, previous infection or surgery, rheumatoid arthritis, or any other medical conditions that needed long-term analgesic administration. We excluded patients requiring long-term analgesic use or those with opioid dependency. We implemented reminders as phone calls and text messages to minimize loss of follow-up. 2.3.2. pre operative protocol; all patients received full conservative management. This conservative approach included anti-inflammatory medications, a structured daily stretching program targeting both the gastrocnemius muscle and the plantar fascia, and physical therapy sessions designed to enhance flexibility and strength across the foot and ankle complex. We also prescribed custom orthotic devices, such as heel cups or extra-padded heel inserts, to reduce mechanical strain at the plantar fascia’s insertion. 2.3.3. surgical technique; standardized surgical approaches were used for both procedures – OPF and PMGR -. The proximal medial gastrocnemius recession (PMGR) procedure was carried out with the patient placed in the prone position to allow optimal access to the posterior aspect of the lower leg. Following sterile preparation and the application of a thigh tourniquet, a 3 to 4 cm transverse incision was made approximately 1 cm distal to the popliteal crease on the medial side of the calf. Dissection was performed through the subcutaneous tissues until the proximal medial gastrocnemius tendon was exposed. Blunt dissection was used to isolate the tendon and its surrounding structures to ensure correct identification prior to proceeding. The tendinous portion of the gastrocnemius fascia was then incised, with the ankle placed in maximum passive dorsiflexion to confirm adequate lengthening of the muscle-tendon unit. Once the recession was complete, the surgical site was irrigated, and hemostasis was ensured prior to the wound's layered closure. A sterile dressing was applied, and the limb was placed in a rigid postoperative shoe to maintain protection during the initial healing period (Figure 1). The open plantar Fasciotomy was performed with the patient placed in the supine position under intradural anesthesia, with a thigh tourniquet applied to maintain a bloodless field. A 3 cm longitudinal incision was made along the medial aspect of the heel, adjacent to the calcaneal insertion of the plantar fascia (Figure 2). Following exposure of the plantar fascia, blunt dissection was used to carefully separate the fascia from surrounding soft tissues in a medial-to-lateral direction. The width of the fascia was measured intraoperatively using a mosquito clamp and a ruler to guide the extent of the release. A partial release was performed by transecting the medial third of the plantar fascia, approximately 2 to 3 cm from its calcaneal insertion. After confirming the release, the wound was irrigated and hemostasis was achieved before closing the incision in layers. A sterile dressing was applied. 2.3.4. Postoperative protocol; All patients received the same postoperative protocol. Discharge is usually on the second day. Full weight-bearing was allowed as tolerated from the first postoperative day with a rigid postoperative shoe or short leg posterior slab until the stitches were removed within 2 weeks. Upon removal of sutures, patients were referred to the same physiotherapy center. The physiotherapy protocol typically involves 3 phases, the early rehabilitation phase (2-4 weeks) post-operative includes gradually increasing weight-bearing activities and improving range of motion. Gentle stretching exercises for the gastrocnemius and soleus muscles and plantar fascia are introduced. The strengthening phase (4-6 weeks) post operative included progressive resistance exercises and focus to achieve symmetry in muscle strength and length bilaterally. The functional training phase (6-12 weeks) post operative included dynamic and functional exercise as single-limb heel raises, stair climbing, and gait training. 2.4. Variables and data measurements: This study contained one independent variable which is the surgical technique, with two groups: open plantar fasciotomy (OPF) and proximal medial gastrocnemius release (PMGR). Dependent variables contained patient demographic characteristics, baseline characteristics as laterality, comorbidty, presence of heel spur, Silfverskiold’s test as well as calf power post operatively by single-limb heel raise compared to contralateral side. The subject is asked to raise heel as many as they can as high as possible and an examiner stood in front of the subject to maintain balance (Nawoczenski DA et al). post operative use of patient controlled analgesia or pethidine were collected during hospitalization period. Subjective and objective patient evaluation. Pain scores were measured by the Visual Analogue Scale (VAS) at baseline and at 1-, 3-, 6-, and 12-months post-treatment, as well as the change in VAS scores over time. HRQOL was measured using the SF-36 scale (Arabic version) [13] and patient satisfaction using a Likert scale. Objective evaluation using American Orthopaedic Foot and Ankle Society (AOFAS) scores, recorded at baseline and at 1, 3, 6, and 12 months post-treatment, along with the time to return to full activity, measured in weeks (Figure 3). 2.5. bias: We implemented several measures to minimize potential sources of bias. By using standardized subjective and objective evaluations (VAS, AOFAS, SF-36), we ensured consistency and reliability in outcome assessment. Our multicenter study design enhanced external validity by reducing site-specific influences and improving the generalizability of our findings. To minimize variability in surgical technique, all procedures were performed by the same two senior experienced surgeons; however, the surgeons did not participate in postoperative scoring or assessments, reducing the risk of observer bias. 2.6. study size The first 10 patients were used as a pilot study to calculate sample size with statistical power fixed at 80%, and a significance level of 5%. a minimum sample size of 20 participants per group was needed to obtain a minimal clinically important difference of 30 on the visual analogue scale for pain following previously published recommendations (Kelly AM., Sutton RM., Todd KH.) Estimating a 20% loss to follow-up and multiplied by 4.5% for non-random sampling, a final sample size of 50 patients was calculated. 2.7. quantitative variables For normally distributed quantitative variables, the mean ± standard deviation (SD) was reported as SF-36 scores. For non-normally distributed variables, the median and interquartile range (IQR) were used as VAS and AOFAS scores. 2.8. statistical methods: Data from the patients were extracted into an Excel spreadsheet (Microsoft Corporation, Redmond, WA) and encoded to be compatible with the statistics software. Data analysis was performed using Jamovi software v 2.3.28. Descriptive statistics were used to summarize patient demographics, clinical characteristics, and outcome measures. Continuous variables were presented as mean ± standard deviation (SD) for normally distributed data and as median with interquartile range (IQR) for non-normally distributed data. Categorical variables were summarized as counts and percentages. Comparisons between groups were performed using the Chi-square (Χ²) test for categorical variables, such as sex distribution, laterality, comorbidities, patient satisfaction, and postoperative complications. For continuous variables, different statistical tests were applied based on data distribution. Independent Samples t-test was used to compare normally distributed SF-36 scale scores between surgical techniques. Mann-Whitney U test was applied for non-normally distributed continuous variables, including Visual Analog Scale (VAS) pain scores and American Orthopaedic Foot & Ankle Society (AOFAS) scores at different time points. Correlation analysis used Pearson’s correlation coefficient (r) to assess relationships between age, time to return to full activity and change in VAS scores. A p-value < 0.05 was considered statistically significant for all tests. We excluded participants with missing data from the analysis to maintain data integrity and avoid introducing bias through imputation. We chose complete case analysis as an appropriate strategy given the low proportion of missing data (<5%), ensuring that the exclusion of these cases did not significantly affect the statistical power or representativeness of the sample. 3. Results 3.1. Participants We assessed 61 patients and excluded 11 patients that did not meet the inclusion criteria; hence, a total of 50 participants. There were 5 losses to follow-up. Two participants In the proximal medial gastrocnemius release and three losses to follow-up in the open plantar fasciotomy group. Therefore, 23 patients in the proximal medial gastrocnemius release group and 22 patients in the open plantar fasciotomy group were included in the final analysis (Figure 4). 3.2. Baseline Characteristics The baseline characteristics of our participants were similar between the open plantar fasciotomy (OPF) and proximal medial gastrocnemius release (PMGR) groups, with no statistically significant differences observed. The mean age was 44.6 years ± 8.11 in the OPF group and 43.6 years ±11.13 in the PMGR group (p = 0.726). Body mass index (BMI) was also comparable, with a mean of 28.4 ±1.99 in OPF and 28.6 ±2.50 in PMGR (p = 0.818). The duration of symptoms was nearly identical, averaging 28.2 months ±4.97 in OPF and 28.1 months ±4.04 in PMGR (p = 0.957). We observed that gender distribution revealed 31.1% females in the OPF group and 40.0% in the PMGR group (p = 0.279). Laterality showed a statistically significant difference, with more left-sided cases in PMGR (35.6%) compared to OPF (17.8%) (p = 0.026). Other characteristics, including the presence of heel spurs, Silfverskiöld test results, calf power post-operatively, and comorbidities, did not differ significantly between the two groups. These similarities suggest that our comparative analysis between OPF and PMGR is robust and unlikely to be influenced by baseline disparities. During the study period, five participants were lost to follow-up at various phases. Two participants were lost within the first three months postoperatively, whereas three participants were lost during the six-month follow-up. This minimal loss to follow-up suggests a high level of adherence among our participants (Table 1) 3.3. Clinical Outcomes When examining pre-treatment pain levels, we found that Visual Analogue Scale (VAS) scores were comparable between groups, with a median score of 65.5 (IQR: 53.75–84.75) in OPF and 73.2 (IQR: 47.89–85.97) in PMGR (p = 0.919). Over time, both groups demonstrated reductions in pain, with the PMGR group showing slightly better outcomes at 12 months. Specifically, the median VAS scores at 12 months were 25.5 (IQR: 12.25–45) for OPF and 18 (IQR: 12–24.5) for PMGR, although this difference was not statistically significant (p = 0.086). However, when we analyzed the overall reduction in VAS scores, PMGR exhibited a significantly greater decrease compared to OPF (p = 0.009). This suggests that while both techniques effectively reduce pain, PMGR may offer superior long-term relief. The greater reduction in pain scores among PMGR patients may be an important factor in surgical decision-making for patients with recalcitrant plantar fasciitis. In addition to pain reduction, we assessed functional recovery using the American Orthopaedic Foot & Ankle Society (AOFAS) scores. Pre-treatment AOFAS scores were similar between groups (OPF: 47.5, IQR: 45–52 vs. PMGR: 46, IQR: 43–56.5; p = 0.964), and both groups experienced substantial improvements post-operatively. By 12 months, median AOFAS scores reached 90 (IQR: 89–93.75) in the OPF group and 88 (IQR: 84–98) in the PMGR group (p = 0.973), reflecting significant functional recovery in both groups. Despite the comparable final scores, we found that PMGR patients demonstrated a faster return to full activity. The median time to resume full activity was 5 weeks (IQR: 4–7) in the PMGR group compared to 10 weeks (IQR: 8–12) in the OPF group (p < 0.001). This accelerated recovery suggests that PMGR may be particularly advantageous for individuals seeking a quicker return to normal function (Table 2) 3.4. Subjective Evaluations Beyond objective clinical measures, we explored patient-reported outcomes to understand the subjective impact of each procedure. Our findings indicated differences in pre-operative perceptions but minimal differences post-operatively. Pre-treatment physical functioning scores were significantly higher in the PMGR group (35.7 ± 9.97) than in the OPF group (27.7 ± 8.82) (p = 0.007). However, these differences were no longer significant after treatment (p = 0.341), suggesting that both procedures resulted in comparable functional improvements. Similarly, vitality scores were initially higher in the PMGR group (48.6 ± 8.41 vs. 41.2 ± 12.84; p = 0.028), but this advantage disappeared post-operatively (p = 0.521). Other subjective measures, including bodily pain, general health perceptions, social role functioning, emotional well-being, and mental health, showed no significant differences between groups either before or after treatment (p > 0.05). These results highlight that while PMGR patients may have entered surgery with a slightly better baseline perception of their physical well-being, both groups ultimately achieved similar outcomes (Table 3). 3.5. Patient Satisfaction It was noted that assessment of patient satisfaction, served as a crucial measure of perceived treatment success. At the 12-month follow-up, both groups reported high levels of satisfaction. Among OPF patients, 66.7% were "very satisfied," compared to 80.0% in the PMGR group. However, satisfaction scores based on a Likert scale did not reveal a statistically significant difference between the groups (p = 0.63). These findings indicate that despite differences in pain reduction and recovery time, patient-reported satisfaction remained high across both surgical approaches (Table 4). 3.6. Complications In assessing the safety profile of both procedures, we found that post-operative complications were infrequent and comparable between groups (p = 0.222). Minor complications included hematoma (2.2% in PMGR), painful scars (4.4% in OPF), and transient nerve neuropraxia (2.2% in both groups). Opioid consumption rates were similar, with 22.0% of OPF patients and 24.0% of PMGR patients requiring post-operative opioid use (p = 0.884). Overall, both procedures were well tolerated, with low rates of adverse events, reinforcing their viability as treatment options (Table 5). 3.7. Correlations Finally, we conducted correlation analyses to explore potential factors influencing recovery. Our findings revealed that older age was associated with a longer time to return to full activity (r = 0.720, p < 0.001) and greater improvements in VAS scores (r = 0.548, p < 0.001). However, no significant correlation was observed between time to full activity and VAS improvements (r = -0.033, p = 0.818). These findings suggest that while older patients may experience greater pain relief, their recovery time may be prolonged. This insight may help guide clinicians in setting expectations and tailoring post-operative rehabilitation plans for older individuals (Table 6), (Figure 5). 4. Discussion 4.1. Key results summary The purpose of this study was to determine whether OPF or PMGR provided better outcomes for patients with recalcitrant plantar fasciitis in terms of pain relief, functional recovery (AOFAS), patient satisfaction, and health-related quality of life (HRQOL). Our findings demonstrated that PMGR led to greater reductions in pain (p = 0.009) and a significantly faster return to full activity (p < 0.001) compared to OPF. The accelerated recovery seen in the PMGR group suggests that this technique may be particularly beneficial for individuals aiming to resume daily activities or work more quickly. While both procedures resulted in similar final AOFAS scores (p = 0.973), indicating comparable long-term functional recovery, the faster timeline associated with PMGR highlights its potential advantages. Additionally, patient satisfaction levels were high in both groups, with no statistically significant differences observed (p = 0.63). These results suggest that while PMGR may offer improved pain relief and a quicker return to function, both techniques are effective surgical options for recalcitrant plantar fasciitis. In terms of safety, post-operative complications were infrequent and comparable between the two groups (p = 0.222). PMGR had a slightly higher rate of wound infections, whereas OPF was associated with a greater incidence of painful scarring. Importantly, opioid consumption did not differ significantly between groups (p = 0.884), reinforcing the overall tolerability of both interventions. Taken together, our results suggest that PMGR may be the preferred surgical option for patients seeking faster recovery and greater pain relief, particularly in younger individuals, while OPF remains a viable alternative for those with different clinical priorities. 4.2. Limitation While this study provides valuable insights into the effectiveness of OPF and PMGR, several limitations must be acknowledged. One of the primary limitations is the non-randomized design, which may introduce selection bias. Although efforts were made to match groups based on baseline characteristics, randomization would have strengthened the validity of our findings and minimized potential confounders. Additionally, the lack of blinding among patients and assessors, due to the nature of the procedures and the visibility of the incision site, could have introduced performance and assessment bias. Future studies employing blinded evaluations would improve objectivity and enhance the reliability of the findings. The multicenter design of this study improves the generalizability of our results. However, variations in surgical techniques, post-operative care, and patient follow-up across different centers may have influenced the outcomes. Establishing standardized protocols across centers would help mitigate this limitation in future studies. Another factor to consider is the Silfverskiöld test, which was used to assess gastrocnemius tightness. This test has inherent variability and relies on examiner interpretation, making it subject to potential measurement bias. This subjectivity may have impacted the accuracy of patient classification, and future studies should explore more objective measures of gastrocnemius tightness. Furthermore, our study was limited by a small sample size, which may reduce statistical power and limit the detection of subtle differences between OPF and PMGR. Larger-scale studies with increased sample sizes are needed to confirm our findings and ensure their robustness. We did not employ gait analysis and pedobarographic assessment, which could have provided a more comprehensive understanding of biomechanical changes post-surgery. These analyses would have offered valuable insight into how each surgical technique affects foot function and overall movement patterns. Incorporating these measures in future research would allow a more thorough evaluation of functional outcomes and patient recovery trajectories. 4.3. Interpretation 4.3.1. Clinical implications of significant results The significant reduction in pain scores observed in the PMGR group suggests that this technique may provide superior long-term pain relief compared to OPF. This finding is particularly relevant for patients with chronic plantar fasciitis who have exhausted conservative treatments and require surgical intervention for lasting symptom resolution. Given these findings, clinicians should consider PMGR as a viable option, especially for patients prioritizing pain relief as a key surgical outcome. The significantly faster return to full activity in the PMGR group further supports its potential advantages over OPF. Given that PMGR patients returned to activity an average of 5 weeks earlier, this technique may be preferable for athletes, active individuals, or those whose occupations demand early weight-bearing and mobility. Faster rehabilitation times may also reduce the indirect economic burden associated with prolonged recovery periods, such as time off work or reduced physical activity. Thus, the ability to resume daily activities more quickly makes PMGR an attractive option for highly active populations. Despite these advantages, it is important to consider the final functional outcomes. While PMGR may accelerate short-term recovery, OPF remains an effective option in specific cases. In instances where imaging or clinical evaluation indicates a localized pathology of the plantar fascia itself, such as a significant plantar fascia tear or degeneration, OPF might be more directly beneficial [ 8 ]. This is because OPF directly addresses the plantar fascia, making it a preferred option for patients with structural fascial abnormalities. Additionally, real-time dynamic assessment using ultrasound can aid in surgical decision-making, as it is cost-effective and widely accessible; however, operator dependency remains a limitation [ 14 ]. From a surgical decision-making perspective, both procedures demonstrated a favorable safety profile with low complication rates. However, surgeons should be mindful that PMGR was associated with a slightly higher incidence of wound infections, whereas OPF had a greater risk of painful scarring. These factors should be weighed when counseling patients on the potential risks and benefits of each approach, ensuring that treatment selection aligns with the patient’s specific needs and expectations. These findings reinforce the need for individualized treatment selection based on patient-specific factors such as age, activity level, and recovery expectations. Younger patients and those with higher physical demands may benefit more from PMGR due to its faster recovery trajectory, whereas OPF remains a reasonable alternative for patients with different clinical priorities. By considering patient characteristics and clinical presentation, surgeons can optimize treatment outcomes and ensure that each patient receives the most appropriate intervention for their condition. 4.3.2. Previous studies Riiser et al. conducted a long-term (six-year) randomized controlled trial (RCT) comparing PMGR combined with stretching versus stretching alone for patients with chronic plantar fasciitis and isolated gastrocnemius contracture. Their results demonstrated that, at six years, patients who underwent PMGR reported significantly lower pain scores (VAS 2.5 vs. 5.5, p < 0.001) and higher AOFAS scores (88.9 vs. 78.6, p = 0.012) compared to those treated with stretching alone. Despite these clear advantages, the study found no significant differences between the groups' ankle dorsiflexion or Achilles tendon performance [ 15 ]. Our study corroborates the superiority of PMGR in pain relief, echoing Riiser et al.’s findings that PMGR leads to sustained reductions in pain compared to non-surgical interventions. However, while Riiser et al. focused on comparing surgery and stretching, our study is distinct in that it directly compares PMGR with another surgical technique (OPF), making our findings more relevant for patients already considering surgical intervention. Another key difference lies in follow-up duration. Whereas Riiser et al. provide valuable long-term data extending to six years postoperatively, our study contributes complementary short-term and mid-term insights by tracking outcomes for 12 months. This allows for a more detailed examination of the recovery trajectory, particularly in the early postoperative phase. Furthermore, while Riiser et al. found no significant differences in ankle dorsiflexion, our study did not include biomechanical assessments such as gait analysis or pedobarography, which could have provided further clarity on functional outcomes. Importantly, both studies report high patient satisfaction with PMGR, reinforcing its role as an effective surgical option for recalcitrant plantar fasciitis. Hoefnagels et al. specifically evaluated gastrocnemius recession in patients with chronic therapy-resistant plantar fasciitis (CTRPF), focusing on the impact of gastrocnemius lengthening on pain, function, and foot biomechanics. Similar to our findings, Hoefnagels et al. demonstrated significant reductions in VAS pain scores (from 78 to 20 at one year) following PMGR, which is consistent with the degree of pain reduction we observed in our PMGR group. Importantly, both studies highlight the role of gastrocnemius tightness as a contributor to plantar fasciitis symptoms, further validating the Silfverskiöld test as a relevant preoperative evaluation tool [ 16 ]. Functional improvements were also central to the Hoefnagels study, which reported significant gains in FAAM scores and improved plantar pressure distribution after surgery. While our study used AOFAS scores and SF-36 HRQOL measures, both approaches capture substantial postoperative functional improvements in the PMGR group. Hoefnagels’ documentation of improved ankle dorsiflexion after gastrocnemius recession complements our findings of faster recovery and return to activity, further supporting the biomechanical benefits of addressing gastrocnemius tightness directly. Although Hoefnagels et al. incorporated detailed plantar pressure analysis, which our study did not, both studies share the conclusion that PMGR effectively improves pain, function, and biomechanics in patients with recalcitrant plantar fasciitis. Our study also improves on the evidence base by directly comparing PMGR with OPF, the traditional standard of care, thus offering a clearer comparative framework for clinicians making surgical decisions. Our study’s findings regarding pain reduction, functional outcomes, and recovery time align closely with those reported by Gamba et al., who conducted a prospective randomized trial comparing proximal medial gastrocnemius release (PMGR) and open plantar fasciotomy (OPF) for recalcitrant plantar fasciitis. Both studies observed that patients experienced significant pain relief following either procedure, although Gamba et al. did not detect a statistically significant difference in VAS scores between the two groups at final follow-up. In contrast, we found that PMGR provided significantly greater pain reduction at 12 months (p = 0.009), emphasizing the potential advantage of addressing gastrocnemius tightness directly. While Gamba et al. reported comparable AOFAS scores between the two techniques, they did not detect significant differences in functional outcomes using the SF-36 health-related quality of life (HRQOL) scores. Our study, in contrast, found both techniques led to similar long-term functional improvements, although PMGR patients returned to full activity significantly faster than those undergoing OPF (5 weeks vs. 10 weeks, p < 0.001). This quantified recovery timeline provides a clearer understanding of the postoperative course, which was less explicitly captured by Gamba et al., who only noted a “faster recovery” in the PMGR group [ 8 ]. Regarding complications, Gamba et al. observed low overall complication rates, with a single case of wound infection and a transient sural nerve lesion in the PMGR group. Similarly, our study found that PMGR was associated with fewer complications than OPF, though minor wound infections were also reported. Satisfaction rates in both studies were high across groups, further supporting the effectiveness of both procedures. Compared to Gamba et al., our study’s prospective cohort design with regular standardized follow-up at 1, 3, 6, and 12 months allowed a more granular understanding of recovery trajectories and patient experience over time. MacInnes et al. performed a retrospective long-term follow-up study on patients who underwent open partial plantar fascia release. Their findings present a much more cautious perspective on OPF, noting generally poor outcomes and prolonged recovery, with the authors questioning the overall clinical value of the procedure. In contrast, our prospective data demonstrated significant improvements in pain and function following OPF, although PMGR consistently outperformed OPF in terms of pain reduction, faster recovery, and lower complication rates [ 17 ]. MacInnes et al. highlighted the negative influence of preoperative steroid injections on postoperative outcomes, which is a factor we controlled for by standardizing conservative management prior to surgery. Our study design, incorporating prospective data collection and consistent follow-up intervals, provides a clearer understanding of the expected recovery timeline and outcomes, which MacInnes et al. could not fully capture due to the retrospective nature of their work. Unlike MacInnes et al., who relied on the MOXFQ and VAS-FA scores, our study used AOFAS scores and SF-36 HRQOL measures, providing a broader functional and quality-of-life assessment. Both studies highlight the potential for delayed or incomplete recovery following OPF, but our comparative design demonstrates that PMGR offers a faster and potentially more reliable path to recovery, particularly in patients with confirmed gastrocnemius tightness. The study by Ficke et al. provides valuable insights into the effectiveness of gastrocnemius recession, particularly in overweight and obese patients with chronic plantar fasciitis. They observed a significant reduction in pain, with VAS scores dropping from a mean of 8.3 preoperatively to 2.4 postoperatively (p < 0.01). This aligns with our findings that PMGR results in superior pain relief compared to OPF, though our study included a broader demographic rather than focusing exclusively on overweight individuals. The Foot Function Index (FFI) in their study improved from 66.4 to 26.5, reinforcing the functional benefits of PMGR. However, unlike our study, which incorporated AOFAS scores and HRQOL measures (SF-36), their analysis lacked standardized functional scoring beyond the FFI, which may limit direct comparability [ 18 ]. Regarding recovery time, Ficke et al. reported a mean return to full activity of 8.3 weeks, with patients transitioning to normal shoes at an average of 5.4 weeks. This is slightly longer than the five-week median return to activity observed in our PMGR group, which may be attributed to differences in patient populations. Given that their cohort had a higher BMI (mean 34.7), slower recovery might be expected. Our study provides a more granular timeline with a statistically validated comparison between OPF and PMGR, highlighting the significantly faster recovery associated with PMGR (p < 0.001). In terms of complications, Ficke et al. reported a relatively low incidence, with minor issues such as sural neuritis and a single case of post-operative foot drop, which resolved without intervention. This aligns with our findings that PMGR had fewer complications than OPF, though minor wound infections were observed. However, unlike our study, which directly compared OPF and PMGR, Ficke et al. did not include an alternative surgical technique for comparison, making it difficult to conclude the relative advantages of PMGR over OPF. The study by Monteagudo et al. also supports the advantages of PMGR, particularly in terms of pain reduction and functional improvement. They found a 95% satisfaction rate for PMGR versus 60% for OPF, with patients returning to work at an average of three weeks for PMGR compared to ten weeks for OPF. These findings align with our study, which quantitatively measured recovery time, revealing a median return to full activity of five weeks for PMGR versus ten weeks for OPF. Our study further strengthens these conclusions by providing a prospective analysis with standardized follow-ups, while Monteagudo et al. relied on a retrospective design [ 9 ]. While Monteagudo et al. primarily utilized AOFAS scores, our study expanded the scope by incorporating HRQOL (SF-36), offering a broader perspective on post-surgical quality of life. Additionally, their study noted that PMGR resulted in fewer complications compared to OPF, which is consistent with our findings. However, our study provided a more detailed account of post-operative issues, such as painful scarring in OPF patients and minor wound infections in PMGR patients, offering a more nuanced comparison of surgical outcomes. In terms of study design, Ficke et al. conducted a retrospective review, as Monteagudo et al., whereas our study employed a prospective cohort design with standardized follow-ups, reducing bias and enhancing the reliability of our findings. Furthermore, our study accounted for baseline characteristics such as age, BMI, and symptom duration, ensuring better comparability between the two surgical groups, whereas neither Ficke et al. nor Monteagudo et al. controlled for these confounding variables. 5. Generalizability The multicenter prospective cohort design of this study enhances its external validity, allowing for broader applicability of the findings across different clinical settings. By incorporating standardized objective and subjective evaluations, such as VAS, AOFAS, and SF-36, we minimized measurement bias and ensured a consistent assessment of pain, function, and quality of life. Additionally, the study was adequately powered, with a well-calculated sample size adjustment to ensure statistical reliability. However, certain limitations might hinder its generalizability. The non-randomized allocation introduces a potential selection bias, which may influence treatment group comparability despite efforts to match baseline characteristics. Furthermore, the 12-month follow-up period, while sufficient to assess early and mid-term outcomes, does not provide insights into the long-term durability of surgical benefits. Future randomized controlled trials with extended follow-up would be valuable in confirming these findings and further improving generalizability. 6. Conclusion In this prospective cohort study comparing proximal medial gastrocnemius recession (PMGR) and open plantar fasciotomy (OPF) for the treatment of recalcitrant plantar fasciitis, we found that both procedures provided significant and sustained improvements in pain and function at 12 months postoperatively. However, PMGR demonstrated a significantly faster return to full activity and greater reduction in pain scores, suggesting that addressing gastrocnemius contracture directly may offer biomechanical advantages in this patient population. Both techniques were associated with low complication rates and high levels of patient satisfaction, though painful scarring and delayed recovery were observed more frequently following OPF. Importantly, these findings were observed within a standardized treatment pathway, including consistent preoperative conservative management, structured postoperative rehabilitation, and regular longitudinal follow-up. Overall, while both PMGR and OPF remain effective surgical options for recalcitrant plantar fasciitis, PMGR appears to offer faster recovery and superior pain relief, particularly in patients with documented gastrocnemius tightness, supporting its role as a preferred first-line surgical approach in appropriately selected patients. Declarations 7. Funding This work was self-funded. The authors received no financial support for the research or authorship. Author Contribution All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work.Concept and design is done by A.B. and H.A.H. Acquisition, analysis, or interpretation of data: A.T. A, S.M.A.Drafting of the manuscript: A.T.A and S.M.A.Critical review of the manuscript for important intellectual content: A.B and H.A.H. Supervision: A.B. and H.A.H. Data Availability Data that support the findings of this study have been stored in the Souad Kafafi Universtiy hospital and Misr university for Science and Technology archives as well as Ahmed Maher Teaching Hospital archives and are available upon resonable request. References Rabadi D, Seo S, Wong B et al (2022) Immunopathogenesis, early Detection, current therapies and prevention of plantar Fasciitis: A concise review. Int Immunopharmacol 110:109023. https://doi.org/10.1016/j.intimp.2022.109023 Wearing SC, Smeathers JE, Urry SR et al (2006) The pathomechanics of plantar fasciitis. Sports Med 36:585–611. https://doi.org/10.2165/00007256-200636070-00004 Thomas JL, Christensen JC, Kravitz SR et al (2010) The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 49:S1–19. https://doi.org/10.1053/j.jfas.2010.01.001 Ryskalin L, Morucci G, Soldani P, Gesi M (2024) Do the fasciae of the soleus have a role in plantar fasciitis? Clin Anat 37:413–424. https://doi.org/10.1002/ca.24102 Wrobel JS, Fleischer AE, Matzkin-Bridger J et al (2016) Physical Examination Variables Predict Response to Conservative Treatment of Nonchronic Plantar Fasciitis: Secondary Analysis of a Randomized, Placebo-Controlled Footwear Study. PM R 8:436–444. https://doi.org/10.1016/j.pmrj.2015.09.011 Uğurlar M, Sönmez MM, Uğurlar ÖY et al (2018) Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial. J Foot Ankle Surg 57:913–918. https://doi.org/10.1053/j.jfas.2018.03.017 Nawoczenski DA, DiLiberto FE, Cantor MS et al (2016) Ankle power and endurance outcomes following isolated gastrocnemius recession for achilles tendinopathy. Foot Ankle Int 37:766–775. https://doi.org/10.1177/1071100716638128 Gamba C, Serrano-Chinchilla P, Ares-Vidal J et al (2020) Proximal medial gastrocnemius release versus open plantar fasciotomy for the surgical treatment in recalcitrant plantar fasciitis. Foot Ankle Int 41:267–274. https://doi.org/10.1177/1071100719891979 Monteagudo M, Maceira E, Garcia-Virto V, Canosa R (2013) Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop 37:1845–1850. https://doi.org/10.1007/s00264-013-2022-2 Arshad Z, Aslam A, Razzaq MA, Bhatia M (2022) Gastrocnemius release in the management of chronic plantar fasciitis: A systematic review. Foot Ankle Int 43:568–575. https://doi.org/10.1177/10711007211052290 Ahn J, Yeo J, Lee S-H et al (2023) Healthcare usage and cost for plantar fasciitis: a retrospective observational analysis of the 2010–2018 health insurance review and assessment service national patient sample data. BMC Health Serv Res 23:546. https://doi.org/10.1186/s12913-023-09443-2 von Elm E, Altman DG, Egger M et al (2014) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 12:1495–1499. https://doi.org/10.1016/j.ijsu.2014.07.013 Sheikh KA, Yagoub U, Elsatouhy M et al (2015) Reliability and Validity of the Arabic Version of the SF-36 Health Survey Questionnaire in Population of Khat Chewers—Jazan Region-Kingdom of Saudi Arabia. Appl Res Qual Life 10:1–13. https://doi.org/10.1007/s11482-013-9291-1 Flores DV, Goes PK, Damer A, Huang BK (2024) The heel complex: anatomy, imaging, pathologic conditions, and treatment. Radiographics 44:e230163. https://doi.org/10.1148/rg.230163 Riiser MO, Husebye EE, Hellesnes J, Molund M (2024) Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up. Foot Ankle Int 45:1–9. https://doi.org/10.1177/10711007231205559 Hoefnagels EM, Weerheijm L, Witteveen AG et al (2021) The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis. Foot Ankle Surg 27:543–549. https://doi.org/10.1016/j.fas.2020.07.003 MacInnes A, Roberts SC, Kimpton J, Pillai A (2016) Long-Term Outcome of Open Plantar Fascia Release. Foot Ankle Int 37:17–23. https://doi.org/10.1177/1071100715603189 Ficke B, Elattar O, Naranje SM et al (2018) Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients. Foot Ankle Surg 24:471–473. https://doi.org/10.1016/j.fas.2017.05.008 Tables Table 1 Demographic characteristics Surgical technique Mean SD T-test p value age OPF 44.6 8.11 0.726 PMGR 43.6 11.13 Duration OPF 28.2 4.97 0.957 PMGR 28.1 4.04 BMI OPF 28.4 1.99 0.818 PMGR 28.6 2.50 Surgical technique Counts % of Total OR (95% CI) X 2 p-value sex female OPF 14 31.1 % 0.486 (0.130-1.82) 0.279 PMGR 18 40.0 % male OPF 8 17.8 % PMGR 5 11.1 % Laterality left OPF 8 17.8 % 0.250 (0.0722-0.866) 0.026 PMGR 16 35.6 % right OPF 14 331.1 % PMGR 7 15.6 % Heel Spur No OPF 4 8.0 % 2.33 (0.382-14.3) 0.349 PMGR 3 6.0 % Yes OPF 21 42.0 % PMGR 22 44.0 % Slifverskiold's test negative OPF 5 11.1 % 1.4 (0.322-6.07) 0.655 PMGR 4 8.9 % positive OPF 17 37.8 % PMGR 19 42.2 % Calf power .Post normal OPF 20 44.4 % 0.952 (0.122-7.42) 0.963 PMGR 21 46.7 % weak OPF 2 4.4 % PMGR 2 4.4 % Comorbidity DM OPF 1 2.2 % 0.463 PMGR 0 0.0 % Smoker OPF 4 8.9 % PMGR 3 6.7 % Non-Smoker OPF 16 35.6 % PMGR 20 44.4 % smoker+DM OPF 1 2.2 % PMGR 0 0.0 % Table 2 Clinical scores Surgical_technique Median IQR Mann-Whitnney U VAS Pre corrected OPF 65.5 53.75 84.75 0.919 PMGR 73.2 47.89 85.97 VAS post 1 mo OPF 50 30.25 60 PMGR 42 19.5 54.5 Vas Post 3 mo OPF 43 24.25 49 PMGR 49 29.5 67.5 Vas Post 6 mo OPF 29.5 15.75 52.5 PMGR 30 16 36.5 Vas Post 12 mo OPF 25.5 12.25 45 0.086 PMGR 18 12 24.5 AOFAS Pre corrected OPF 47.5 45 52 0.964 PMGR 46 43 56.5 AOFAS post 1 mo OPF 79 72 84.75 PMGR 83 77.5 89 AOFAS post 3 mo OPF 81 74 88.5 PMGR 89 81 94 AOFAS post 6 mo OPF 81.5 70.5 88.75 PMGR 89 80 95.5 AOFAS post 12 mo OPF 90 89 93.75 0.973 PMGR 88 84 98 Change in VAS OPF 40 38 41 0.009 PMGR 55 36 60.5 Improvement in AOFASH OPF 42 375 44 0.185 PMGR 40 37.5 41.5 Time to return to full activity in weeks OPF 10 8 12 <0.001 PMGR 5 4 7 Table 3 Subjective evaluation SF-36 score Descriptives Surgical technique Mean SD Independent t test physical functioning Pre OPF 27.7 8.82 0.007 PMGR 35.7 9.97 physical functioning post OPF 47.1 8.03 0.341 PMGR 44 12.85 physical role functioning pre OPF 35.8 12.36 0.136 PMGR 41.1 10.87 physical role functioning post OPF 42.8 11.25 0.256 PMGR 46.2 8.43 bodily pain pre OPF 28.5 9.61 0.555 PMGR 30.1 7.96 bodily pain post OPF 44.3 7.55 0.403 PMGR 41.8 11.67 General Health Perceptions pre OPF 45.9 7.55 0.932 PMGR 45.7 5.73 General Health Perceptions post OPF 47 7.63 0.489 PMGR 48.9 7.72 vitality pre OPF 41.2 12.84 0.028 PMGR 48.6 8.41 vitality post OPF 49.2 12.53 0.521 PMGR 51.7 13.04 social role pre OPF 39.2 9.65 0.736 PMGR 40.2 10.49 social role post OPF 46.5 10.7 0.642 PMGR 45 10.81 emotional role pre OPF 41.3 11.33 0.665 PMGR 39.5 15.88 emotional role post OPF 46.8 10.33 0.607 PMGR 48.5 12.17 mental health pre OPF 40 13.06 0.683 PMGR 38.6 10.59 mental health post OPF 44 9.08 0.345 PMGR 47.4 14.10 Table 4 Patient satisfaction Surgical_technique Likert sacle 4-0 OPF PMGR X 2 p-value very unsatisfied 2 1 not completely satisfied 3 2 0.63 satisfied 5 4 very statisfied 12 16 Table 5 Complication Surgical technique Counts % of Total OR (95% CI) X 2 p-value opioid consumption Post op no OPF 11 28.0 % 1.09 (0.339-3.51) 0.884 PMGR 11 26.0 % yes OPF 11 22.0 % PMGR 12 24.0 % complications Non OPF 19 42.2 % 0.222 PMGR 19 42.2 % hematoma OPF 0 0.0 % PMGR 1 2.2 % painful scar OPF 2 4.4 % PMGR 0 0.0 % planter nerve neuropraxia OPF 1 2.2 % PMGR 0 0.0 % sural nerve neuropraxia OPF 0 0.0 % PMGR 1 2.2 % wound infection OPF 0 0.0 % PMGR 2 4.4 % Table 6 Correlation Age time to return to full activity time to return to full activity Pearson's r 0.720 — df 48 — p-value < .001 — change in VAS Pearson's r 0.548 -0.033 df 48 48 p-value < .001 0.818 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6234938","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440344224,"identity":"309417c4-82b7-4673-a312-b96233a46a19","order_by":0,"name":"Assem Bastawisy","email":"","orcid":"","institution":"Misr University for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Assem","middleName":"","lastName":"Bastawisy","suffix":""},{"id":440344225,"identity":"a0928812-eda0-458a-826b-82db2ff91638","order_by":1,"name":"Aly T. Aly","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACfvnDhx98qIDyeIjRIjmDLc1wxhkgi41YLQYzeAykedtI0iLdYGDMO29b4vz5DYwP3rYxyMk7ENBiLnMg4eHcbbcTNxxjYDac28ZgbHiAgBbLhoQDBm9BWtgY2EAuTNzYQMhhBxIbJHjn3E6c38bA/huopZ6wlhvJDJK8DbcTG44xsDEDtSTIE9DBINlzjM1wxrHbxhuOJTZLzjknYbiBkBZ+9v7PDz7U3Jad33z44Ic3ZTby8oQchgQYQWolgL4jXgsUkGLLKBgFo2AUjAwAABSkRIjxmBRXAAAAAElFTkSuQmCC","orcid":"","institution":"Misr University for Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Aly","middleName":"T.","lastName":"Aly","suffix":""},{"id":440344226,"identity":"235d33db-1b16-48a8-bd43-d54fcfb3cdf8","order_by":2,"name":"Shehab M Abouhussain","email":"","orcid":"","institution":"Misr University for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Shehab","middleName":"M","lastName":"Abouhussain","suffix":""},{"id":440344227,"identity":"320f2dff-f4d9-4964-89ef-95b5508a3fa5","order_by":3,"name":"Hussein A. Hussein","email":"","orcid":"","institution":"Ahmed Maher teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hussein","middleName":"A.","lastName":"Hussein","suffix":""}],"badges":[],"createdAt":"2025-03-15 22:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6234938/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6234938/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81019574,"identity":"9edf6067-5ee0-41d7-a2d5-656c5ba283fc","added_by":"auto","created_at":"2025-04-21 09:26:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81488,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical technique of Proximal medial gastrocnemius release\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/08dcf0f5e1a3c54a1b057d89.jpg"},{"id":81018463,"identity":"8d74ad58-4a5e-43b8-ae60-dc3b6e3ff4eb","added_by":"auto","created_at":"2025-04-21 09:18:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41066,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical technique of open plantar fasciotomy\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/76ca3c91029db627e6b7cc62.jpg"},{"id":81018464,"identity":"ded1beb4-1a53-4e3d-96e2-c563de43eef7","added_by":"auto","created_at":"2025-04-21 09:18:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39755,"visible":true,"origin":"","legend":"\u003cp\u003eSilfverskiold's test\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/6b18c6f8aa2db5ab09e6d2a3.jpg"},{"id":81018467,"identity":"e51e18c4-c4cf-450c-9ba8-922f487d5aea","added_by":"auto","created_at":"2025-04-21 09:18:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42890,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants flow diagram\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/9bf0808fdaab357b5a82f1d9.jpg"},{"id":81019572,"identity":"22a14942-333e-475b-aa83-1def4cfbd2af","added_by":"auto","created_at":"2025-04-21 09:26:41","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":21874,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation plot\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/18f5e0433ea3146d5b3fbe2d.jpg"},{"id":81412287,"identity":"9ffaa7c5-5f5b-4e9f-a6d3-41ddf24cb616","added_by":"auto","created_at":"2025-04-25 21:19:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1141271,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6234938/v1/a08713d6-30b2-431a-a487-f485b8566952.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Proximal Medial Gastrocnemius Release versus Open Plantar Fasciotomy in Recalcitrant Plantar Fasciitis: A Multicenter Prospective Cohort Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePlantar fasciitis is considered a multifactorial condition with biomechanical and inflammatory components. The condition is primarily characterized by pain in the heel and is often associated with mechanical stress on the plantar fascia. This stress can arise from various factors, including pes planus (flat feet), excessive pronation, and biomechanical faults that increase tension on the plantar fascia, leading to microscopic tears and potential inflammation [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The inflammatory component of plantar fasciitis is somewhat debated. Histological studies have shown that inflammation is not always present in chronic plantar fasciitis, and the condition may involve fibroblastic hypertrophy and degenerative changes instead [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, factors such as obesity, tightness of the Achilles tendon, and inappropriate footwear can exacerbate the biomechanical stress on the plantar fascia, contributing to the development and persistence of symptoms [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven its multifactorial nature, the management of plantar fasciitis requires an individualized approach, with treatment strategies tailored to the underlying biomechanical dysfunction and symptom severity. The American College of Foot and Ankle Surgeons recommends a stepwise approach, starting with conservative measures and progressing to more invasive treatments if necessary. However, the variability in response to treatment for plantar fasciitis is significant, reflecting its multifactorial nature with both biomechanical and inflammatory components. Two studies have explored how plantar fasciitis responds differently to treatment. Wrobel et al. found that in nonchronic cases, patients with severe ankle equinus were more likely to improve with conservative treatments such as Achilles tendon stretching and supportive footwear. Patients without severe equinus or first-step pain were less likely to benefit [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn chronic plantar fasciitis, non-surgical treatment modalities also yield inconsistent long-term results. Uğurlar et al. compared extracorporeal shock wave therapy, platelet-rich plasma (PRP) injection, corticosteroid injection, and prolotherapy. They found that corticosteroid injections provided the fastest pain relief, but the effects faded over time. Shock wave therapy was effective in the first six months, while PRP and prolotherapy showed slower improvements. After 36 months, there were no significant differences between the four treatments, indicating that long-term outcomes were similar regardless of the initial approach [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This variability in treatment response underscores the challenge in managing chronic plantar fasciitis and the need for personalized treatment plans. Hence, an earlier access to advanced treatments may be needed.\u003c/p\u003e \u003cp\u003eThe main principles of surgical treatment for plantar fasciitis focus on relieving tension in the plantar fascia and addressing any associated pathologies. According to the American College of Foot and Ankle Surgeons, the primary surgical option is Plantar Fasciotomy involves surgically releasing part of the plantar fascia to relieve tension directly at the site of pain in the heel. Techniques include: Endoscopic Plantar Fasciotomy and Open Plantar Fasciotomy. Gastrocnemius Recession [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Open plantar fasciotomy involves releasing part of the plantar fascia to alleviate tension and pain. This procedure is traditionally used for patients who have not responded to conservative treatments. However, it can lead to potential biomechanical complications, such as arch instability and altered foot mechanics, which may result in prolonged recovery times and increased morbidity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Partial medial gastrocnemius release, on the other hand, addresses the gastrocnemius contracture, which is often a contributing factor in plantar fasciitis. This procedure is particularly beneficial for patients with isolated gastrocnemius contracture, as it can improve ankle dorsiflexion and reduce tension on the plantar fascia without directly altering the foot's structural integrity. Studies have shown that gastrocnemius release can lead to faster recovery and higher patient satisfaction compared to plantar fasciotomy, with fewer complications and better functional outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe economic burden of plantar fasciitis is significant, encompassing direct costs such as medical treatments and indirect costs like lost workdays. Healthcare usage and costs for plantar fasciitis have been increasing, with a notable rise in the number of treated cases and patients over the years [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The faster recovery associated with gastrocnemius release can potentially reduce indirect costs related to lost workdays and prolonged rehabilitation.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to determine which of 2 popular treatments, OPF or PMGR, could provide better results in terms of pain, satisfaction, the American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) scale, and health-related quality of life (HRQOL) in patients with recalcitrant plantar fasciitis.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines for cohort studies \u0026nbsp;[12]. The study was approved by the Misr University for Science and Technology Institutional Review Board, on 27 September 2023 and was conducted according to the ethical principles of the Declaration of Helsinki. The approval number is [2022/0088]. MUST-IRB is registered at the Office for Human Research Protections, US Department of Health and Human Services and operates under Federal Wide Assurance NO. FWA00025577. Participation in this study was completely voluntary. Written consent was given to patients before enrollment and undergoing surgeries. Confidentiality and privacy of all collected data were preserved, and the personal data were securely stored and only accessible to the statistician.\u003c/p\u003e\n\u003cp\u003e2.1. study design: A multicenter prospective cohort study\u003c/p\u003e\n\u003cp\u003e2.2. setting: Within the period September 2022 to September 2024\u003c/p\u003e\n\u003cp\u003e2.3. Participants: We targeted recalcitrant plantar fasciitis patients of both sexes undergoing surgical treatment either by open plantar fasciotomy or proximal medial gastrocnemius release at Souad Kafafi University Hospital and Ahmed Maher Teaching Hospital.\u003c/p\u003e\n\u003cp\u003e2.3.1. The Inclusion criteria were Patients diagnosed with recalcitrant plantar fasciitis, unresponsive to conservative treatment for at least 9 months, adults aged 18 years or older, patients with clinical signs of plantar fasciitis, including morning heel pain and tenderness over the plantar fascia insertion. Eligible patients exhibited characteristic clinical signs, such as morning heel pain and tenderness over the plantar fascia insertion, with imaging confirmation through ultrasound or MRI when necessary.\u003c/p\u003e\n\u003cp\u003eWe excluded patients with bilateral plantar fasciitis, neuropathic heel pain, hindfoot deformities, such as pes planus, pes cavus, hyperlaxity, or malalignment. Those with diabetes mellitus and peripheral neuropathy or uncontrolled metabolic disorders were not included , patients with past personal history of ipsilateral foot and ankle fractures, previous infection or surgery, rheumatoid arthritis, or any other medical conditions that needed long-term analgesic administration. We excluded patients requiring long-term analgesic use or those with opioid dependency. We implemented reminders as phone calls and text messages to minimize loss of follow-up.\u003c/p\u003e\n\u003cp\u003e2.3.2. pre operative protocol; all patients received full conservative management. This conservative approach included anti-inflammatory medications, a structured daily stretching program targeting both the gastrocnemius muscle and the plantar fascia, and physical therapy sessions designed to enhance flexibility and strength across the foot and ankle complex. We also prescribed custom orthotic devices, such as heel cups or extra-padded heel inserts, to reduce mechanical strain at the plantar fascia\u0026rsquo;s insertion.\u003c/p\u003e\n\u003cp\u003e2.3.3. surgical technique; standardized surgical approaches were used for both procedures \u0026ndash; OPF and PMGR -. The proximal medial gastrocnemius recession (PMGR) procedure was carried out with the patient placed in the prone position to allow optimal access to the posterior aspect of the lower leg. Following sterile preparation and the application of a thigh tourniquet, a 3 to 4 cm transverse incision was made approximately 1 cm distal to the popliteal crease on the medial side of the calf.\u003c/p\u003e\n\u003cp\u003eDissection was performed through the subcutaneous tissues until the proximal medial gastrocnemius tendon was exposed. Blunt dissection was used to isolate the tendon and its surrounding structures to ensure correct identification prior to proceeding. The tendinous portion of the gastrocnemius fascia was then incised, with the ankle placed in maximum passive dorsiflexion to confirm adequate lengthening of the muscle-tendon unit.\u003c/p\u003e\n\u003cp\u003eOnce the recession was complete, the surgical site was irrigated, and hemostasis was ensured prior to the wound\u0026apos;s layered closure. A sterile dressing was applied, and the limb was placed in a rigid postoperative shoe to maintain protection during the initial healing period (Figure 1).\u003c/p\u003e\n\u003cp\u003eThe open plantar Fasciotomy was performed with the patient placed in the supine position under intradural anesthesia, with a thigh tourniquet applied to maintain a bloodless field. A 3 cm longitudinal incision was made along the medial aspect of the heel, adjacent to the calcaneal insertion of the plantar fascia (Figure 2).\u003c/p\u003e\n\u003cp\u003eFollowing exposure of the plantar fascia, blunt dissection was used to carefully separate the fascia from surrounding soft tissues in a medial-to-lateral direction. The width of the fascia was measured intraoperatively using a mosquito clamp and a ruler to guide the extent of the release. A partial release was performed by transecting the medial third of the plantar fascia, approximately 2 to 3 cm from its calcaneal insertion. After confirming the release, the wound was irrigated and hemostasis was achieved before closing the incision in layers. A sterile dressing was applied.\u003c/p\u003e\n\u003cp\u003e2.3.4. Postoperative protocol; All patients received the same postoperative protocol. Discharge is usually on the second day. Full weight-bearing was allowed as tolerated from the first postoperative day with a rigid postoperative shoe or short leg posterior slab until the stitches were removed within 2 weeks. Upon removal of sutures, patients were referred to the same physiotherapy center.\u003c/p\u003e\n\u003cp\u003eThe physiotherapy protocol typically involves 3 phases, the early rehabilitation phase (2-4 weeks) post-operative includes gradually increasing weight-bearing activities and improving range of motion. Gentle stretching exercises for the gastrocnemius and soleus muscles and plantar fascia are introduced. The strengthening phase (4-6 weeks) post operative included progressive resistance exercises and focus to achieve symmetry in muscle strength and length bilaterally. The functional training phase (6-12 weeks) post operative included dynamic and functional exercise as single-limb heel raises, stair climbing, and gait training.\u003c/p\u003e\n\u003cp\u003e2.4. Variables and data measurements: This study contained one independent variable which is the surgical technique, with two groups: open plantar fasciotomy (OPF) and proximal medial gastrocnemius release (PMGR). Dependent variables contained patient demographic characteristics, baseline characteristics as laterality, comorbidty, presence of heel spur, Silfverskiold\u0026rsquo;s test as well as calf power post operatively by single-limb heel raise compared to contralateral side. The subject is asked to raise heel as many as they can as high as possible and an examiner stood in front of the subject to maintain balance (Nawoczenski DA et al). post operative use of patient controlled analgesia or pethidine were collected during hospitalization period. Subjective and objective patient evaluation. Pain scores were measured by the Visual Analogue Scale (VAS) at baseline and at 1-, 3-, 6-, and 12-months post-treatment, as well as the change in VAS scores over time. HRQOL was measured using the SF-36 scale (Arabic version) [13] and patient satisfaction using a Likert scale. Objective evaluation using American Orthopaedic Foot and Ankle Society (AOFAS) scores, recorded at baseline and at 1, 3, 6, and 12 months post-treatment, along with the time to return to full activity, measured in weeks (Figure 3).\u003c/p\u003e\n\u003cp\u003e2.5. bias:\u003c/p\u003e\n\u003cp\u003eWe implemented several measures to minimize potential sources of bias. By using standardized subjective and objective evaluations (VAS, AOFAS, SF-36), we ensured consistency and reliability in outcome assessment. Our multicenter study design enhanced external validity by reducing site-specific influences and improving the generalizability of our findings. To minimize variability in surgical technique, all procedures were performed by the same two senior experienced surgeons; however, the surgeons did not participate in postoperative scoring or assessments, reducing the risk of observer bias.\u003c/p\u003e\n\u003cp\u003e2.6. study size\u003c/p\u003e\n\u003cp\u003eThe first 10 patients were used as a pilot study to calculate sample size with statistical power fixed at 80%, and a significance level of 5%. a minimum sample size of 20 participants per group was needed to obtain a minimal clinically important difference of 30 on the visual analogue scale for pain following previously published recommendations (Kelly AM., Sutton RM., Todd KH.) Estimating a 20% loss to follow-up and multiplied by 4.5% for non-random sampling, a final sample size of 50 patients was calculated.\u003c/p\u003e\n\u003cp\u003e2.7. quantitative variables\u003c/p\u003e\n\u003cp\u003eFor normally distributed quantitative variables, the mean \u0026plusmn; standard deviation (SD) was reported as SF-36 scores. For non-normally distributed variables, the median and interquartile range (IQR) were used as VAS and AOFAS scores.\u003c/p\u003e\n\u003cp\u003e2.8. statistical methods:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data from the patients were extracted into an Excel spreadsheet (Microsoft Corporation, Redmond, WA) and encoded to be compatible with the statistics software. Data analysis was performed using Jamovi software v 2.3.28. Descriptive statistics were used to summarize patient demographics, clinical characteristics, and outcome measures. Continuous variables were presented as mean \u0026plusmn; standard deviation (SD) for normally distributed data and as median with interquartile range (IQR) for non-normally distributed data. Categorical variables were summarized as counts and percentages.\u003c/p\u003e\n\u003cp\u003eComparisons between groups were performed using the Chi-square (\u0026Chi;\u0026sup2;) test for categorical variables, such as sex distribution, laterality, comorbidities, patient satisfaction, and postoperative complications. For continuous variables, different statistical tests were applied based on data distribution. Independent Samples t-test was used to compare normally distributed SF-36 scale scores between surgical techniques. Mann-Whitney U test was applied for non-normally distributed continuous variables, including Visual Analog Scale (VAS) pain scores and American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) scores at different time points. Correlation analysis used Pearson\u0026rsquo;s correlation coefficient (r) to assess relationships between age, time to return to full activity and change in VAS scores. A p-value \u0026lt; 0.05 was considered statistically significant for all tests. We excluded participants with missing data from the analysis to maintain data integrity and avoid introducing bias through imputation. We chose complete case analysis as an appropriate strategy given the low proportion of missing data (\u0026lt;5%), ensuring that the exclusion of these cases did not significantly affect the statistical power or representativeness of the sample.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1. Participants\u003c/p\u003e\n\u003cp\u003eWe assessed 61 patients and excluded 11 patients that did not meet the inclusion criteria; hence, a total of 50 participants. There were 5 losses to follow-up. Two participants In the proximal medial gastrocnemius release and three losses to follow-up in the open plantar fasciotomy group. Therefore, 23 patients in the proximal medial gastrocnemius release group and 22 patients in the open plantar fasciotomy group were included in the final analysis (Figure 4).\u003c/p\u003e\n\u003cp\u003e3.2. Baseline Characteristics\u003c/p\u003e\n\u003cp\u003eThe baseline characteristics of our participants were similar between the open plantar fasciotomy (OPF) and proximal medial gastrocnemius release (PMGR) groups, with no statistically significant differences observed. The mean age was 44.6 years \u0026plusmn; 8.11 in the OPF group and 43.6 years \u0026plusmn;11.13 in the PMGR group (p = 0.726). Body mass index (BMI) was also comparable, with a mean of 28.4 \u0026plusmn;1.99 in OPF and 28.6 \u0026plusmn;2.50 in PMGR (p = 0.818). The duration of symptoms was nearly identical, averaging 28.2 months \u0026plusmn;4.97 in OPF and 28.1 months \u0026plusmn;4.04 in PMGR (p = 0.957).\u003c/p\u003e\n\u003cp\u003eWe observed that gender distribution revealed 31.1% females in the OPF group and 40.0% in the PMGR group (p = 0.279). Laterality showed a statistically significant difference, with more left-sided cases in PMGR (35.6%) compared to OPF (17.8%) (p = 0.026). Other characteristics, including the presence of heel spurs, Silfverski\u0026ouml;ld test results, calf power post-operatively, and comorbidities, did not differ significantly between the two groups. These similarities suggest that our comparative analysis between OPF and PMGR is robust and unlikely to be influenced by baseline disparities.\u003c/p\u003e\n\u003cp\u003eDuring the study period, five participants were lost to follow-up at various phases. Two participants were lost within the first three months postoperatively, whereas three participants were lost during the six-month follow-up. This minimal loss to follow-up suggests a high level of adherence among our participants (Table 1)\u003c/p\u003e\n\u003cp\u003e3.3. Clinical Outcomes\u003c/p\u003e\n\u003cp\u003eWhen examining pre-treatment pain levels, we found that Visual Analogue Scale (VAS) scores were comparable between groups, with a median score of 65.5 (IQR: 53.75\u0026ndash;84.75) in OPF and 73.2 (IQR: 47.89\u0026ndash;85.97) in PMGR (p = 0.919). Over time, both groups demonstrated reductions in pain, with the PMGR group showing slightly better outcomes at 12 months. Specifically, the median VAS scores at 12 months were 25.5 (IQR: 12.25\u0026ndash;45) for OPF and 18 (IQR: 12\u0026ndash;24.5) for PMGR, although this difference was not statistically significant (p = 0.086).\u003c/p\u003e\n\u003cp\u003eHowever, when we analyzed the overall reduction in VAS scores, PMGR exhibited a significantly greater decrease compared to OPF (p = 0.009). This suggests that while both techniques effectively reduce pain, PMGR may offer superior long-term relief. The greater reduction in pain scores among PMGR patients may be an important factor in surgical decision-making for patients with recalcitrant plantar fasciitis.\u003c/p\u003e\n\u003cp\u003eIn addition to pain reduction, we assessed functional recovery using the American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) scores. Pre-treatment AOFAS scores were similar between groups (OPF: 47.5, IQR: 45\u0026ndash;52 vs. PMGR: 46, IQR: 43\u0026ndash;56.5; p = 0.964), and both groups experienced substantial improvements post-operatively. By 12 months, median AOFAS scores reached 90 (IQR: 89\u0026ndash;93.75) in the OPF group and 88 (IQR: 84\u0026ndash;98) in the PMGR group (p = 0.973), reflecting significant functional recovery in both groups.\u003c/p\u003e\n\u003cp\u003eDespite the comparable final scores, we found that PMGR patients demonstrated a faster return to full activity. The median time to resume full activity was 5 weeks (IQR: 4\u0026ndash;7) in the PMGR group compared to 10 weeks (IQR: 8\u0026ndash;12) in the OPF group (p \u0026lt; 0.001). This accelerated recovery suggests that PMGR may be particularly advantageous for individuals seeking a quicker return to normal function (Table 2)\u003c/p\u003e\n\u003cp\u003e3.4. Subjective Evaluations\u003c/p\u003e\n\u003cp\u003eBeyond objective clinical measures, we explored patient-reported outcomes to understand the subjective impact of each procedure. Our findings indicated differences in pre-operative perceptions but minimal differences post-operatively. Pre-treatment physical functioning scores were significantly higher in the PMGR group (35.7 \u0026plusmn; 9.97) than in the OPF group (27.7 \u0026plusmn; 8.82) (p = 0.007). However, these differences were no longer significant after treatment (p = 0.341), suggesting that both procedures resulted in comparable functional improvements.\u003c/p\u003e\n\u003cp\u003eSimilarly, vitality scores were initially higher in the PMGR group (48.6 \u0026plusmn; 8.41 vs. 41.2 \u0026plusmn; 12.84; p = 0.028), but this advantage disappeared post-operatively (p = 0.521). Other subjective measures, including bodily pain, general health perceptions, social role functioning, emotional well-being, and mental health, showed no significant differences between groups either before or after treatment (p \u0026gt; 0.05). These results highlight that while PMGR patients may have entered surgery with a slightly better baseline perception of their physical well-being, both groups ultimately achieved similar outcomes (Table 3).\u003c/p\u003e\n\u003cp\u003e3.5. Patient Satisfaction\u003c/p\u003e\n\u003cp\u003eIt was noted that assessment of patient satisfaction, served as a crucial measure of perceived treatment success. At the 12-month follow-up, both groups reported high levels of satisfaction. Among OPF patients, 66.7% were \u0026quot;very satisfied,\u0026quot; compared to 80.0% in the PMGR group. However, satisfaction scores based on a Likert scale did not reveal a statistically significant difference between the groups (p = 0.63). These findings indicate that despite differences in pain reduction and recovery time, patient-reported satisfaction remained high across both surgical approaches (Table 4).\u003c/p\u003e\n\u003cp\u003e3.6. Complications\u003c/p\u003e\n\u003cp\u003eIn assessing the safety profile of both procedures, we found that post-operative complications were infrequent and comparable between groups (p = 0.222). Minor complications included hematoma (2.2% in PMGR), painful scars (4.4% in OPF), and transient nerve neuropraxia (2.2% in both groups). Opioid consumption rates were similar, with 22.0% of OPF patients and 24.0% of PMGR patients requiring post-operative opioid use (p = 0.884). Overall, both procedures were well tolerated, with low rates of adverse events, reinforcing their viability as treatment options (Table 5).\u003c/p\u003e\n\u003cp\u003e3.7. Correlations\u003c/p\u003e\n\u003cp\u003eFinally, we conducted correlation analyses to explore potential factors influencing recovery. Our findings revealed that older age was associated with a longer time to return to full activity (r = 0.720, p \u0026lt; 0.001) and greater improvements in VAS scores (r = 0.548, p \u0026lt; 0.001). However, no significant correlation was observed between time to full activity and VAS improvements (r = -0.033, p = 0.818). These findings suggest that while older patients may experience greater pain relief, their recovery time may be prolonged. This insight may help guide clinicians in setting expectations and tailoring post-operative rehabilitation plans for older individuals (Table 6), (Figure 5).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Key results summary\u003c/h2\u003e \u003cp\u003eThe purpose of this study was to determine whether OPF or PMGR provided better outcomes for patients with recalcitrant plantar fasciitis in terms of pain relief, functional recovery (AOFAS), patient satisfaction, and health-related quality of life (HRQOL). Our findings demonstrated that PMGR led to greater reductions in pain (p\u0026thinsp;=\u0026thinsp;0.009) and a significantly faster return to full activity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to OPF. The accelerated recovery seen in the PMGR group suggests that this technique may be particularly beneficial for individuals aiming to resume daily activities or work more quickly.\u003c/p\u003e \u003cp\u003eWhile both procedures resulted in similar final AOFAS scores (p\u0026thinsp;=\u0026thinsp;0.973), indicating comparable long-term functional recovery, the faster timeline associated with PMGR highlights its potential advantages. Additionally, patient satisfaction levels were high in both groups, with no statistically significant differences observed (p\u0026thinsp;=\u0026thinsp;0.63). These results suggest that while PMGR may offer improved pain relief and a quicker return to function, both techniques are effective surgical options for recalcitrant plantar fasciitis.\u003c/p\u003e \u003cp\u003eIn terms of safety, post-operative complications were infrequent and comparable between the two groups (p\u0026thinsp;=\u0026thinsp;0.222). PMGR had a slightly higher rate of wound infections, whereas OPF was associated with a greater incidence of painful scarring. Importantly, opioid consumption did not differ significantly between groups (p\u0026thinsp;=\u0026thinsp;0.884), reinforcing the overall tolerability of both interventions. Taken together, our results suggest that PMGR may be the preferred surgical option for patients seeking faster recovery and greater pain relief, particularly in younger individuals, while OPF remains a viable alternative for those with different clinical priorities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Limitation\u003c/h2\u003e \u003cp\u003eWhile this study provides valuable insights into the effectiveness of OPF and PMGR, several limitations must be acknowledged. One of the primary limitations is the non-randomized design, which may introduce selection bias. Although efforts were made to match groups based on baseline characteristics, randomization would have strengthened the validity of our findings and minimized potential confounders.\u003c/p\u003e \u003cp\u003eAdditionally, the lack of blinding among patients and assessors, due to the nature of the procedures and the visibility of the incision site, could have introduced performance and assessment bias. Future studies employing blinded evaluations would improve objectivity and enhance the reliability of the findings.\u003c/p\u003e \u003cp\u003eThe multicenter design of this study improves the generalizability of our results. However, variations in surgical techniques, post-operative care, and patient follow-up across different centers may have influenced the outcomes. Establishing standardized protocols across centers would help mitigate this limitation in future studies.\u003c/p\u003e \u003cp\u003eAnother factor to consider is the Silfverski\u0026ouml;ld test, which was used to assess gastrocnemius tightness. This test has inherent variability and relies on examiner interpretation, making it subject to potential measurement bias. This subjectivity may have impacted the accuracy of patient classification, and future studies should explore more objective measures of gastrocnemius tightness.\u003c/p\u003e \u003cp\u003eFurthermore, our study was limited by a small sample size, which may reduce statistical power and limit the detection of subtle differences between OPF and PMGR. Larger-scale studies with increased sample sizes are needed to confirm our findings and ensure their robustness.\u003c/p\u003e \u003cp\u003eWe did not employ gait analysis and pedobarographic assessment, which could have provided a more comprehensive understanding of biomechanical changes post-surgery. These analyses would have offered valuable insight into how each surgical technique affects foot function and overall movement patterns. Incorporating these measures in future research would allow a more thorough evaluation of functional outcomes and patient recovery trajectories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Interpretation\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e4.3.1. Clinical implications of significant results\u003c/h2\u003e \u003cp\u003eThe significant reduction in pain scores observed in the PMGR group suggests that this technique may provide superior long-term pain relief compared to OPF. This finding is particularly relevant for patients with chronic plantar fasciitis who have exhausted conservative treatments and require surgical intervention for lasting symptom resolution. Given these findings, clinicians should consider PMGR as a viable option, especially for patients prioritizing pain relief as a key surgical outcome.\u003c/p\u003e \u003cp\u003eThe significantly faster return to full activity in the PMGR group further supports its potential advantages over OPF. Given that PMGR patients returned to activity an average of 5 weeks earlier, this technique may be preferable for athletes, active individuals, or those whose occupations demand early weight-bearing and mobility. Faster rehabilitation times may also reduce the indirect economic burden associated with prolonged recovery periods, such as time off work or reduced physical activity. Thus, the ability to resume daily activities more quickly makes PMGR an attractive option for highly active populations.\u003c/p\u003e \u003cp\u003eDespite these advantages, it is important to consider the final functional outcomes. While PMGR may accelerate short-term recovery, OPF remains an effective option in specific cases. In instances where imaging or clinical evaluation indicates a localized pathology of the plantar fascia itself, such as a significant plantar fascia tear or degeneration, OPF might be more directly beneficial [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is because OPF directly addresses the plantar fascia, making it a preferred option for patients with structural fascial abnormalities. Additionally, real-time dynamic assessment using ultrasound can aid in surgical decision-making, as it is cost-effective and widely accessible; however, operator dependency remains a limitation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a surgical decision-making perspective, both procedures demonstrated a favorable safety profile with low complication rates. However, surgeons should be mindful that PMGR was associated with a slightly higher incidence of wound infections, whereas OPF had a greater risk of painful scarring. These factors should be weighed when counseling patients on the potential risks and benefits of each approach, ensuring that treatment selection aligns with the patient\u0026rsquo;s specific needs and expectations.\u003c/p\u003e \u003cp\u003eThese findings reinforce the need for individualized treatment selection based on patient-specific factors such as age, activity level, and recovery expectations. Younger patients and those with higher physical demands may benefit more from PMGR due to its faster recovery trajectory, whereas OPF remains a reasonable alternative for patients with different clinical priorities. By considering patient characteristics and clinical presentation, surgeons can optimize treatment outcomes and ensure that each patient receives the most appropriate intervention for their condition.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e4.3.2. Previous studies\u003c/h2\u003e \u003cp\u003eRiiser et al. conducted a long-term (six-year) randomized controlled trial (RCT) comparing PMGR combined with stretching versus stretching alone for patients with chronic plantar fasciitis and isolated gastrocnemius contracture. Their results demonstrated that, at six years, patients who underwent PMGR reported significantly lower pain scores (VAS 2.5 vs. 5.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and higher AOFAS scores (88.9 vs. 78.6, p\u0026thinsp;=\u0026thinsp;0.012) compared to those treated with stretching alone. Despite these clear advantages, the study found no significant differences between the groups' ankle dorsiflexion or Achilles tendon performance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study corroborates the superiority of PMGR in pain relief, echoing Riiser et al.\u0026rsquo;s findings that PMGR leads to sustained reductions in pain compared to non-surgical interventions. However, while Riiser et al. focused on comparing surgery and stretching, our study is distinct in that it directly compares PMGR with another surgical technique (OPF), making our findings more relevant for patients already considering surgical intervention. Another key difference lies in follow-up duration. Whereas Riiser et al. provide valuable long-term data extending to six years postoperatively, our study contributes complementary short-term and mid-term insights by tracking outcomes for 12 months. This allows for a more detailed examination of the recovery trajectory, particularly in the early postoperative phase. Furthermore, while Riiser et al. found no significant differences in ankle dorsiflexion, our study did not include biomechanical assessments such as gait analysis or pedobarography, which could have provided further clarity on functional outcomes. Importantly, both studies report high patient satisfaction with PMGR, reinforcing its role as an effective surgical option for recalcitrant plantar fasciitis.\u003c/p\u003e \u003cp\u003eHoefnagels et al. specifically evaluated gastrocnemius recession in patients with chronic therapy-resistant plantar fasciitis (CTRPF), focusing on the impact of gastrocnemius lengthening on pain, function, and foot biomechanics. Similar to our findings, Hoefnagels et al. demonstrated significant reductions in VAS pain scores (from 78 to 20 at one year) following PMGR, which is consistent with the degree of pain reduction we observed in our PMGR group. Importantly, both studies highlight the role of gastrocnemius tightness as a contributor to plantar fasciitis symptoms, further validating the Silfverski\u0026ouml;ld test as a relevant preoperative evaluation tool [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFunctional improvements were also central to the Hoefnagels study, which reported significant gains in FAAM scores and improved plantar pressure distribution after surgery. While our study used AOFAS scores and SF-36 HRQOL measures, both approaches capture substantial postoperative functional improvements in the PMGR group. Hoefnagels\u0026rsquo; documentation of improved ankle dorsiflexion after gastrocnemius recession complements our findings of faster recovery and return to activity, further supporting the biomechanical benefits of addressing gastrocnemius tightness directly.\u003c/p\u003e \u003cp\u003eAlthough Hoefnagels et al. incorporated detailed plantar pressure analysis, which our study did not, both studies share the conclusion that PMGR effectively improves pain, function, and biomechanics in patients with recalcitrant plantar fasciitis. Our study also improves on the evidence base by directly comparing PMGR with OPF, the traditional standard of care, thus offering a clearer comparative framework for clinicians making surgical decisions.\u003c/p\u003e \u003cp\u003eOur study\u0026rsquo;s findings regarding pain reduction, functional outcomes, and recovery time align closely with those reported by Gamba et al., who conducted a prospective randomized trial comparing proximal medial gastrocnemius release (PMGR) and open plantar fasciotomy (OPF) for recalcitrant plantar fasciitis. Both studies observed that patients experienced significant pain relief following either procedure, although Gamba et al. did not detect a statistically significant difference in VAS scores between the two groups at final follow-up. In contrast, we found that PMGR provided significantly greater pain reduction at 12 months (p\u0026thinsp;=\u0026thinsp;0.009), emphasizing the potential advantage of addressing gastrocnemius tightness directly.\u003c/p\u003e \u003cp\u003eWhile Gamba et al. reported comparable AOFAS scores between the two techniques, they did not detect significant differences in functional outcomes using the SF-36 health-related quality of life (HRQOL) scores. Our study, in contrast, found both techniques led to similar long-term functional improvements, although PMGR patients returned to full activity significantly faster than those undergoing OPF (5 weeks vs. 10 weeks, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This quantified recovery timeline provides a clearer understanding of the postoperative course, which was less explicitly captured by Gamba et al., who only noted a \u0026ldquo;faster recovery\u0026rdquo; in the PMGR group [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding complications, Gamba et al. observed low overall complication rates, with a single case of wound infection and a transient sural nerve lesion in the PMGR group. Similarly, our study found that PMGR was associated with fewer complications than OPF, though minor wound infections were also reported. Satisfaction rates in both studies were high across groups, further supporting the effectiveness of both procedures. Compared to Gamba et al., our study\u0026rsquo;s prospective cohort design with regular standardized follow-up at 1, 3, 6, and 12 months allowed a more granular understanding of recovery trajectories and patient experience over time.\u003c/p\u003e \u003cp\u003eMacInnes et al. performed a retrospective long-term follow-up study on patients who underwent open partial plantar fascia release. Their findings present a much more cautious perspective on OPF, noting generally poor outcomes and prolonged recovery, with the authors questioning the overall clinical value of the procedure. In contrast, our prospective data demonstrated significant improvements in pain and function following OPF, although PMGR consistently outperformed OPF in terms of pain reduction, faster recovery, and lower complication rates [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMacInnes et al. highlighted the negative influence of preoperative steroid injections on postoperative outcomes, which is a factor we controlled for by standardizing conservative management prior to surgery. Our study design, incorporating prospective data collection and consistent follow-up intervals, provides a clearer understanding of the expected recovery timeline and outcomes, which MacInnes et al. could not fully capture due to the retrospective nature of their work.\u003c/p\u003e \u003cp\u003eUnlike MacInnes et al., who relied on the MOXFQ and VAS-FA scores, our study used AOFAS scores and SF-36 HRQOL measures, providing a broader functional and quality-of-life assessment. Both studies highlight the potential for delayed or incomplete recovery following OPF, but our comparative design demonstrates that PMGR offers a faster and potentially more reliable path to recovery, particularly in patients with confirmed gastrocnemius tightness.\u003c/p\u003e \u003cp\u003eThe study by Ficke et al. provides valuable insights into the effectiveness of gastrocnemius recession, particularly in overweight and obese patients with chronic plantar fasciitis. They observed a significant reduction in pain, with VAS scores dropping from a mean of 8.3 preoperatively to 2.4 postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This aligns with our findings that PMGR results in superior pain relief compared to OPF, though our study included a broader demographic rather than focusing exclusively on overweight individuals. The Foot Function Index (FFI) in their study improved from 66.4 to 26.5, reinforcing the functional benefits of PMGR. However, unlike our study, which incorporated AOFAS scores and HRQOL measures (SF-36), their analysis lacked standardized functional scoring beyond the FFI, which may limit direct comparability [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding recovery time, Ficke et al. reported a mean return to full activity of 8.3 weeks, with patients transitioning to normal shoes at an average of 5.4 weeks. This is slightly longer than the five-week median return to activity observed in our PMGR group, which may be attributed to differences in patient populations. Given that their cohort had a higher BMI (mean 34.7), slower recovery might be expected. Our study provides a more granular timeline with a statistically validated comparison between OPF and PMGR, highlighting the significantly faster recovery associated with PMGR (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIn terms of complications, Ficke et al. reported a relatively low incidence, with minor issues such as sural neuritis and a single case of post-operative foot drop, which resolved without intervention. This aligns with our findings that PMGR had fewer complications than OPF, though minor wound infections were observed. However, unlike our study, which directly compared OPF and PMGR, Ficke et al. did not include an alternative surgical technique for comparison, making it difficult to conclude the relative advantages of PMGR over OPF.\u003c/p\u003e \u003cp\u003eThe study by Monteagudo et al. also supports the advantages of PMGR, particularly in terms of pain reduction and functional improvement. They found a 95% satisfaction rate for PMGR versus 60% for OPF, with patients returning to work at an average of three weeks for PMGR compared to ten weeks for OPF. These findings align with our study, which quantitatively measured recovery time, revealing a median return to full activity of five weeks for PMGR versus ten weeks for OPF. Our study further strengthens these conclusions by providing a prospective analysis with standardized follow-ups, while Monteagudo et al. relied on a retrospective design [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile Monteagudo et al. primarily utilized AOFAS scores, our study expanded the scope by incorporating HRQOL (SF-36), offering a broader perspective on post-surgical quality of life. Additionally, their study noted that PMGR resulted in fewer complications compared to OPF, which is consistent with our findings. However, our study provided a more detailed account of post-operative issues, such as painful scarring in OPF patients and minor wound infections in PMGR patients, offering a more nuanced comparison of surgical outcomes.\u003c/p\u003e \u003cp\u003eIn terms of study design, Ficke et al. conducted a retrospective review, as Monteagudo et al., whereas our study employed a prospective cohort design with standardized follow-ups, reducing bias and enhancing the reliability of our findings. Furthermore, our study accounted for baseline characteristics such as age, BMI, and symptom duration, ensuring better comparability between the two surgical groups, whereas neither Ficke et al. nor Monteagudo et al. controlled for these confounding variables.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"5. Generalizability","content":"\u003cp\u003eThe multicenter prospective cohort design of this study enhances its external validity, allowing for broader applicability of the findings across different clinical settings. By incorporating standardized objective and subjective evaluations, such as VAS, AOFAS, and SF-36, we minimized measurement bias and ensured a consistent assessment of pain, function, and quality of life. Additionally, the study was adequately powered, with a well-calculated sample size adjustment to ensure statistical reliability.\u003c/p\u003e \u003cp\u003eHowever, certain limitations might hinder its generalizability. The non-randomized allocation introduces a potential selection bias, which may influence treatment group comparability despite efforts to match baseline characteristics. Furthermore, the 12-month follow-up period, while sufficient to assess early and mid-term outcomes, does not provide insights into the long-term durability of surgical benefits. Future randomized controlled trials with extended follow-up would be valuable in confirming these findings and further improving generalizability.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn this prospective cohort study comparing proximal medial gastrocnemius recession (PMGR) and open plantar fasciotomy (OPF) for the treatment of recalcitrant plantar fasciitis, we found that both procedures provided significant and sustained improvements in pain and function at 12 months postoperatively. However, PMGR demonstrated a significantly faster return to full activity and greater reduction in pain scores, suggesting that addressing gastrocnemius contracture directly may offer biomechanical advantages in this patient population.\u003c/p\u003e \u003cp\u003eBoth techniques were associated with low complication rates and high levels of patient satisfaction, though painful scarring and delayed recovery were observed more frequently following OPF. Importantly, these findings were observed within a standardized treatment pathway, including consistent preoperative conservative management, structured postoperative rehabilitation, and regular longitudinal follow-up.\u003c/p\u003e \u003cp\u003eOverall, while both PMGR and OPF remain effective surgical options for recalcitrant plantar fasciitis, PMGR appears to offer faster recovery and superior pain relief, particularly in patients with documented gastrocnemius tightness, supporting its role as a preferred first-line surgical approach in appropriately selected patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e7. Funding\u003c/h2\u003e \u003cp\u003eThis work was self-funded. The authors received no financial support for the research or authorship.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work.Concept and design is done by A.B. and H.A.H. Acquisition, analysis, or interpretation of data: A.T. A, S.M.A.Drafting of the manuscript: A.T.A and S.M.A.Critical review of the manuscript for important intellectual content: A.B and H.A.H. Supervision: A.B. and H.A.H.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData that support the findings of this study have been stored in the Souad Kafafi Universtiy hospital and Misr university for Science and Technology archives as well as Ahmed Maher Teaching Hospital archives and are available upon resonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRabadi D, Seo S, Wong B et al (2022) Immunopathogenesis, early Detection, current therapies and prevention of plantar Fasciitis: A concise review. Int Immunopharmacol 110:109023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.intimp.2022.109023\u003c/span\u003e\u003cspan address=\"10.1016/j.intimp.2022.109023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWearing SC, Smeathers JE, Urry SR et al (2006) The pathomechanics of plantar fasciitis. Sports Med 36:585\u0026ndash;611. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2165/00007256-200636070-00004\u003c/span\u003e\u003cspan address=\"10.2165/00007256-200636070-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas JL, Christensen JC, Kravitz SR et al (2010) The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 49:S1\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1053/j.jfas.2010.01.001\u003c/span\u003e\u003cspan address=\"10.1053/j.jfas.2010.01.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyskalin L, Morucci G, Soldani P, Gesi M (2024) Do the fasciae of the soleus have a role in plantar fasciitis? Clin Anat 37:413\u0026ndash;424. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ca.24102\u003c/span\u003e\u003cspan address=\"10.1002/ca.24102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWrobel JS, Fleischer AE, Matzkin-Bridger J et al (2016) Physical Examination Variables Predict Response to Conservative Treatment of Nonchronic Plantar Fasciitis: Secondary Analysis of a Randomized, Placebo-Controlled Footwear Study. PM R 8:436\u0026ndash;444. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pmrj.2015.09.011\u003c/span\u003e\u003cspan address=\"10.1016/j.pmrj.2015.09.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUğurlar M, S\u0026ouml;nmez MM, Uğurlar \u0026Ouml;Y et al (2018) Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial. J Foot Ankle Surg 57:913\u0026ndash;918. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1053/j.jfas.2018.03.017\u003c/span\u003e\u003cspan address=\"10.1053/j.jfas.2018.03.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNawoczenski DA, DiLiberto FE, Cantor MS et al (2016) Ankle power and endurance outcomes following isolated gastrocnemius recession for achilles tendinopathy. Foot Ankle Int 37:766\u0026ndash;775. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1071100716638128\u003c/span\u003e\u003cspan address=\"10.1177/1071100716638128\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamba C, Serrano-Chinchilla P, Ares-Vidal J et al (2020) Proximal medial gastrocnemius release versus open plantar fasciotomy for the surgical treatment in recalcitrant plantar fasciitis. Foot Ankle Int 41:267\u0026ndash;274. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1071100719891979\u003c/span\u003e\u003cspan address=\"10.1177/1071100719891979\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonteagudo M, Maceira E, Garcia-Virto V, Canosa R (2013) Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop 37:1845\u0026ndash;1850. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00264-013-2022-2\u003c/span\u003e\u003cspan address=\"10.1007/s00264-013-2022-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArshad Z, Aslam A, Razzaq MA, Bhatia M (2022) Gastrocnemius release in the management of chronic plantar fasciitis: A systematic review. Foot Ankle Int 43:568\u0026ndash;575. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/10711007211052290\u003c/span\u003e\u003cspan address=\"10.1177/10711007211052290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhn J, Yeo J, Lee S-H et al (2023) Healthcare usage and cost for plantar fasciitis: a retrospective observational analysis of the 2010\u0026ndash;2018 health insurance review and assessment service national patient sample data. BMC Health Serv Res 23:546. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-023-09443-2\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-09443-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M et al (2014) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 12:1495\u0026ndash;1499. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijsu.2014.07.013\u003c/span\u003e\u003cspan address=\"10.1016/j.ijsu.2014.07.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikh KA, Yagoub U, Elsatouhy M et al (2015) Reliability and Validity of the Arabic Version of the SF-36 Health Survey Questionnaire in Population of Khat Chewers\u0026mdash;Jazan Region-Kingdom of Saudi Arabia. Appl Res Qual Life 10:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11482-013-9291-1\u003c/span\u003e\u003cspan address=\"10.1007/s11482-013-9291-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlores DV, Goes PK, Damer A, Huang BK (2024) The heel complex: anatomy, imaging, pathologic conditions, and treatment. Radiographics 44:e230163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1148/rg.230163\u003c/span\u003e\u003cspan address=\"10.1148/rg.230163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiiser MO, Husebye EE, Hellesnes J, Molund M (2024) Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up. Foot Ankle Int 45:1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/10711007231205559\u003c/span\u003e\u003cspan address=\"10.1177/10711007231205559\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoefnagels EM, Weerheijm L, Witteveen AG et al (2021) The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis. Foot Ankle Surg 27:543\u0026ndash;549. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fas.2020.07.003\u003c/span\u003e\u003cspan address=\"10.1016/j.fas.2020.07.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacInnes A, Roberts SC, Kimpton J, Pillai A (2016) Long-Term Outcome of Open Plantar Fascia Release. Foot Ankle Int 37:17\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1071100715603189\u003c/span\u003e\u003cspan address=\"10.1177/1071100715603189\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFicke B, Elattar O, Naranje SM et al (2018) Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients. Foot Ankle Surg 24:471\u0026ndash;473. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fas.2017.05.008\u003c/span\u003e\u003cspan address=\"10.1016/j.fas.2017.05.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Demographic characteristics\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;border: none;margin-right: 6.75pt;width: 625px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border:solid #BFBFBF 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eSurgical technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border:solid #BFBFBF 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border:solid #BFBFBF 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border:solid #BFBFBF 1.0pt;border-left:none;padding:0in 5.4pt 0in 5.4pt;height:30.0pt\u003e\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;\"\u003e\u003cstrong\u003eT-test p value\u003c/strong\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eage\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e44.6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e8.11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.75pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e0.726\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e11.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eDuration\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e28.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e4.97\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e0.957\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e4.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eBMI\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e28.4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e1.99\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e0.818\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;border-bottom:solid #BFBFBF 1.0pt;\" colspan=\"2\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eSurgical technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eCounts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e% of Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 65.75pt;border-top: none;border-left: none;border-bottom: 1pt solid rgb(191, 191, 191);border-right: 1pt solid rgb(191, 191, 191);padding: 0in 5.4pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eX\u003csup\u003e2\u003c/sup\u003e p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003esex\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 65.75pt;border-top: none;border-left: none;border-bottom: 1pt solid rgb(191, 191, 191);border-right: 1pt solid rgb(191, 191, 191);background: rgb(242, 242, 242);padding: 0in 5.4pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003efemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e31.1\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.486 (0.130-1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e18\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e40.0\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003emale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e17.8\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e11.1\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eLaterality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eleft\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e17.8\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:red;\"\u003e0.250 (0.0722-0.866)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:red;\"\u003e0.026\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e35.6 \u003cspan style='font-family:\"Arial\",sans-serif;'\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eright\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e331.1 %\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e15.6 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eHeel Spur\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e8.0\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e2.33 (0.382-14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e6.0\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e42.0\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e22\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e44.0\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eSlifverskiold\u0026apos;s test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003enegative\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e11.1\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e1.4 (0.322-6.07)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e0.655\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e8.9\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003epositive\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e17\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e37.8\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e42.2\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eCalf power .Post\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:30.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003enormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e44.4\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"4\" style=\"width:65.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.952 (0.122-7.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e21\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e46.7\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eweak\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e4.4 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003ePMGR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom: solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e4.4\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 65.75pt;border-top: none;border-left: none;border-bottom: 1pt solid rgb(191, 191, 191);border-right: 1pt solid rgb(191, 191, 191);padding: 0in 5.4pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eDM\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e2.2\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"8\" style=\"width: 65.75pt;border-top: none;border-left: none;border-bottom: 1pt solid rgb(191, 191, 191);border-right: 1pt solid rgb(191, 191, 191);background: rgb(242, 242, 242);padding: 0in 5.4pt;height: 15pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" style=\"width:53.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e0.463\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.0\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eSmoker\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e8.9\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e6.7\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003eNon-Smoker\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e16\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e35.6\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e44.4\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width:123.6pt;border:solid #BFBFBF 1.0pt;border-top:none;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cstrong\u003e\u003cspan style=\"color:black;\"\u003esmoker+DM\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003eOPF\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;background:#F2F2F2;padding:0in 5.4pt 0in 5.4pt;height:15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e\u003cspan style=\"color:black;\"\u003e2.2\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026thinsp;\u003c/span\u003e\u003cspan style=\"color:black;\"\u003e%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:119.15pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:45.5pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:59.75pt;border-top:none;border-left:none;border-bottom:solid #BFBFBF 1.0pt;border-right:solid #BFBFBF 1.0pt;padding:0in 5.4pt 0in 5.4pt;height: 15.0pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Aptos\",sans-serif;text-align:center;line-height:normal;'\u003e0.0\u003cspan style='font-family:\"Arial\",sans-serif;'\u003e\u0026thinsp;\u003c/span\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 Clinical scores\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"656\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 179px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eSurgical_technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\n \u003cp\u003eMann-Whitnney U\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eVAS Pre corrected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e65.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e53.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e84.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.919\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e73.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e47.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e85.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eVAS post 1 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e54.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eVas Post 3 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e24.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e67.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eVas Post 6 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e15.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eVas Post 12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAOFAS Pre corrected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e47.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.964\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAOFAS post 1 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e84.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e77.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAOFAS post 3 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e88.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAOFAS post 6 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e81.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e70.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e88.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e95.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 147px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAOFAS post 12 mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e93.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.973\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eChange in VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e60.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eImprovement in AOFASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e0.185\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e41.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 179px;\"\u003e\n \u003cp\u003eTime to return to full activity in weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 Subjective evaluation SF-36 score\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\n \u003cp\u003eDescriptives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 238px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eSurgical technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eIndependent t test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ephysical functioning Pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e8.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e9.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ephysical functioning post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e47.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e8.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e12.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ephysical role functioning pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e12.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e41.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ephysical role functioning post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e42.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e11.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e8.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ebodily pain pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e9.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003ebodily pain post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e44.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e41.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e11.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003eGeneral Health Perceptions pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.932\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e45.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e5.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003eGeneral Health Perceptions post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e7.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003evitality pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e12.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e48.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e8.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003evitality post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e49.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e12.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e51.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e13.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003esocial role pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e9.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.736\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003esocial role post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e46.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003eemotional role pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e11.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e39.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e15.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003eemotional role post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e46.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.607\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e48.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e12.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003emental health pre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e13.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.683\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e38.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e10.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 238px;\"\u003e\n \u003cp\u003emental health post\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e9.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e14.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 Patient satisfaction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 207px;\"\u003e\n \u003cp\u003eSurgical_technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\n \u003cp\u003eLikert sacle 4-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\n \u003cp\u003every unsatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\n \u003cp\u003enot completely satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\n \u003cp\u003esatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 291px;\"\u003e\n \u003cp\u003every statisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 Complication\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 211px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eSurgical technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eCounts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e% of Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 106px;\"\u003e\n \u003cp\u003eopioid consumption Post op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e28.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.09 (0.339-3.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 50px;\"\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e26.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e22.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e24.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"12\" style=\"width: 106px;\"\u003e\n \u003cp\u003ecomplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003eNon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e42.2\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"12\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"12\" style=\"width: 50px;\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e42.2\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003ehematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.2\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003epainful scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e4.4\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003eplanter nerve neuropraxia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.2\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003esural nerve neuropraxia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.2\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 105px;\"\u003e\n \u003cp\u003ewound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eOPF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.0\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePMGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e4.4\u0026thinsp;%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 Correlation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003etime to return to full activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003etime to return to full activity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePearson\u0026apos;s r\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003echange in VAS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePearson\u0026apos;s r\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.548\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Plantar fasciitis, Heel pain, Open plantar fasciotomy (OPF), Proximal medial gastrocnemius recession (PMGR), Foot and ankle surgery, Gastrocnemius tightness","lastPublishedDoi":"10.21203/rs.3.rs-6234938/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6234938/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePlantar fasciitis is a leading cause of chronic heel pain, often requiring surgical intervention when conservative treatments fail. Open plantar fasciotomy (OPF) and proximal medial gastrocnemius recession (PMGR) are two widely used procedures, yet their comparative effectiveness remains unclear. This study evaluates their impact on pain relief, functional recovery, and health-related quality of life (HRQOL).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this multicenter prospective cohort study, 50 patients with recalcitrant plantar fasciitis unresponsive to at least nine months of conservative treatment underwent either OPF or PMGR. Standardized surgical techniques and postoperative rehabilitation were implemented. Outcomes included pain (Visual Analogue Scale, VAS), function (American Orthopaedic Foot \u0026amp; Ankle Society, AOFAS score), HRQOL (SF-36), and patient satisfaction, assessed preoperatively and at 1, 3, 6, and 12 months postoperatively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBoth procedures significantly improved pain and function at 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, PMGR resulted in greater pain reduction (p\u0026thinsp;=\u0026thinsp;0.009) and a significantly faster return to full activity (median: 5 vs. 10 weeks; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patient satisfaction was high in both groups (p\u0026thinsp;=\u0026thinsp;0.63), and postoperative complications were rare and comparable (p\u0026thinsp;=\u0026thinsp;0.222).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWhile both OPF and PMGR are effective, PMGR offers superior pain relief and faster recovery, particularly in patients with gastrocnemius tightness. These findings support a tailored approach to surgical decision-making based on patient-specific biomechanics.\u003c/p\u003e","manuscriptTitle":"Proximal Medial Gastrocnemius Release versus Open Plantar Fasciotomy in Recalcitrant Plantar Fasciitis: A Multicenter Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 09:18:37","doi":"10.21203/rs.3.rs-6234938/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd0dbe60-4982-4466-8c3c-dc720ebf4cb4","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-25T21:11:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-21 09:18:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6234938","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6234938","identity":"rs-6234938","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}