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Revision tarsal tunnel surgery was performed on 44 patients (two bilaterally). The surgical procedure included a neurolysis of the tibial nerve in the tarsal tunnel, the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, excision of the intertunnel septum, and neuroma resection as indicated. A painful tarsal tunnel scar or painful heel was treated, respectively, by resection of the distal saphenous nerve or a calcaneal nerve branch. Postoperative, immediate ambulation was permitted. Outcomes were assessed with a numerical grading scale that included neurosensory measurements. Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean follow-up time was 2.2 years. Outcomes in terms of patient satisfaction were 54% excellent, 24% good, 13% fair, and 9% poor results. The mean preoperative numerical score was 6.0 and the mean postoperative score was 2.7. There was a significant improvement seen, based on the median difference between scores ( P < 0.001). Prognostic indicators of poor results in our patient group were coexisting lumbosacral disc disease and/or neuropathy. An approach related to resecting painful cutaneous nerves and neurolysis of all tibial nerve branches at the ankle offers hope for relief of pain and recovery of sensation for the majority of patients with failed previous tarsal tunnel surgery.
A very difficult procedure since one never knows (unless the revision surgeon was the initial surgeon, in which case the laws of diminishing returns should apply)
ALL OTHER INTANGIBLES BEING EQUAL, I find a few common "errors" in surgeons performing unsuccessful TT Decompressions:
1. The Porta Pedis is not, or not completely, released.
2. If varicosities exist they need to be ligated, no matter how difficult or how much time it may take.
3. Post operative protocol is important. If the surgeon does not understand the post operative measure which are needed for proper wound healing then the possibility of failure increases, regardless of how well the surgery itself was performed.
4. If the patient has any classic heel spur/fasciitis pain then perform a faciotomy/spur resection along with the release.
5. A suspected non compliant patient should not be booked for surgery.
Basically, in my humble opinion, Tarsal Tunnel release is a demanding procedure if you want repeatable, high success rates. This is not a procedure that should be done by the inexperienced 3 or 4 times a year, nor by the surgeon incapable and not trained to deal with the possible intra and post operative complications.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Neurolysis for Failed Tarsal Tunnel Surgery
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