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.
