Failed Tarsal Tunnel

ReleaseEllianne Nasser, DPM, FACFAS, CWS

Podiatry Associate, Department of Orthopaedics

Geisinger Health System

Assistant Program Director, Podiatric Medicine and Surgery Residency

Geisinger Community Medical Center

Success Rates/Timing of Procedure

• Success rates 44%-96%

• Continued compression intraneural fibrosis muscle atrophy and irreparable nerve damage

• Better outcomes with symptoms < 1 year

• Sammarco/Chang 75 TTR

• Results favorable if symptoms < 1 year

• Babba et al 34 TTR

• 61% relief of symptoms after TTR with “longstanding symptoms”

• Turan et al 18 TTR

Technique Pearls/Pitfalls

• Bleeding wound dehiscence and post-op scarring

• Drop tourniquet

• Consider drain

• Evacuate seroma/hematoma in timely fashion

• Correct Etiology

• Minimal manipulation of nerve

Failed Tarsal Tunnel Release

No relief?

Relief with recurrence?

No Improvement – Double Crush Syndrome

• Systemic disease

• Radiculopathy/Plexopathy

• Proximal tibial nerve compression

Proximal Tibial Nerve Compression

• Soleal Sling Syndrome

• Severe POP calf 9cm

distal to popliteal crease

• Conduction block btwn

stimulation at knee and

ankle

No Improvement- Incomplete Release

Lamm et al

2007

No Improvement:

Etiology not Addressed

• Space occupying lesions

• Hindfoot deformity

• Varicosities

• Neurilemoma

• Hypertrophic flexor retinaculum

• Post-traumatic fibrosis

• Low-lying muscle belly

Etiology: Schwannoma

Preoperative Imaging

Etiology: Ganglion

Preoperative Imaging/Workup

No Improvement: Incorrect Diagnosis

No Improvement: Intrinsic Nerve Pathology

Peripheral Nerve Stimulation

Temporary Relief with Recurrence:

Adhesive Neuritis

• Relief 2-4 months then return of symptoms

• Post-op joint motion scarring

• Nerve adhesions prevent gliding traction neuritis/pain

• Risk factors

• Tender, hypertrophic scar, decreased joint mobility

Revision Decompression with Nerve Wrap

Conclusions

• Meticulous surgical technique

• Address etiology

• When it fails…

References• Baba H, Wada M, Annen S, Azuchi M, Imura S, Tomita K. The tarsal tunnel syndrome: evaluation of surgical results using multivariate analysis. Int Orthop. 1997;21:67-71.

• Bezerra MJC, Leite JAD, Neto JE, Romero S. Endoscopic release of the tarsal tunnel: a suggested surgical approach. Acta Ortop Bras. 2005;13(1): 46-48.

• Day III FN, Naples JJ. Endoscopic tarsal tunnel release: update 96. J Foot Ankle Surg. 1996;35(3):225-229.

• Day III FN, Naples JJ. Tarsal tunnel syndrome: an endoscopic approach with 4- to 28-month follow-up. J Foot Ankle Surg. 1994;33(3):244-248.

• Ducic I, Endara M, Quadri H. Minimally invasive peripheral nerve surgery: a short scar technique. Microsurgery. 2010; 622-626.

• Ducic I, Felder J. Tibial nerve decompression: reliable exposure using shorter incisions. Microsurgery. 2012;32:533-538.

• Easley ME, Schon LC. Peripheral nerve vein wrapping for intractable lower extremity pain. Foot Ankle Int. 2000;21:492-500.

• El Shazly O, El Shazly A, Desouky A, El Zohiery AK, Sakr HM. Anatomical bases of endoscopic tarsal tunnel release: anatomical and ultra-sonographic study with a preliminary case report. Surg Radiol Anat. 2011;33:929-936.

• Franson J, Baravarian B. Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels. Clin Pod Med Surg. 2006;23:597-609.

• Gkotsoulis EN, Simonson DC, Roukis TS. Outcomes and safety of endoscopic tarsal tunnel decompression: a systematic review. Foot Ankle Spec. 2013;7(1):57-60.

• Gould JS. Tarsal tunnel syndrome. Foot Ankle Clin N Am. 2011;16:275-286.

• Gould JS. The failed tarsal tunnel release. Foot Ankle Clin N Am. 2011;16:287-293.

• Jolly GP. Tarsal tunnel syndrome: can a minimally invasive release be advantageous? Podiatry Today. 2009;3(22).

• Krishnan KG. Endoscopic decompression of the tarsal tunnel. Tech Foot Ankle Surg. 2010;9(2):52-57.

• Krishnan KG, Pinzer T, Schackert G. A novel endoscopic technique in treating single nerve entrapment syndromes with special attention to ulnar nerve transposition and tarsal tunnel release: clinical application. Neurosurgery. 2006;59(1):89-100.

• Lamm BM, Paley D, Testani M, Herzenberg JE. Tarsal tunnel decompression in leg lengthening and deformity correction at the foot and ankle. J Foot Ankle Surg. 2007, 43(6): 201-206.

• Pfeiffer WH, Cracchiolo A. Clinical results after tarsal tunnel decompression. J Bone Joint Surg. 1994;76-A:1222-1230.

• Raikin SM, Minnich JM. Failed tarsal tunnel syndrome surgery. Foot Ankle Clin N Am. 2003;8:159-174.

• Sagi HC, Papp S, Dipasquale T. The effect of suture pattern and tension on cutaneous blood flow as assessed by laser Doppler flowmetry in a pig model. J Orthop Trauma. 2008;22:171-175.

• Sammarco GJ, Chang L. Outcome of surgical treatment of tarsal tunnel syndrome. Foot Ankle Int. 2003;24:125-131.

• Schon LC, Easley ME. Chronic Pain. In: Myerson, MS, editor. Foot and ankle disorders. Philadelphia: WB Saunders; 2000. p. 851-881.

• Turan I, Rivero-Melian C, Guntner P, Rolf C. Tarsal tunnel syndrome: outcome of surgery in longstanding cases. Clin Orthop Relat Res. 1997;343:151-156.

• Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973;2:359-362.

• Williams EH, Rosson GD, Hagan RR, Hashemi SS, Dellon AL. Soleal sling syndrome (proximal tibial nerve compression): results of surgical decompression. Plast Reconstr Surg. 2012;129:454-462.

• Williams EH, Williams CG, Rosson GD, Dellon LA. Anatomic site for proximal tibial nerve compression: a cadaver study. Ann Plast Surg. 2009;62:322-325.