SLR - February 2022 - Kenny Luong
Reference: Uemura T, Watanabe H, Yanai T, Kawano H, Yoshida A, Okutsu I. A Minimally Invasive Full Endoscopic Approach to Tibial Nerve Neurolysis in Diabetic Foot Neuropathy: An Alternative to Open Procedures. Plast Reconstr Surg. 2021 Sep 1;148(3):592-596. doi: 10.1097/PRS.0000000000008299. PMID: 34432688.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Kenny Luong, DPM
Residency Program: St. Mary’s General Hospital – Passaic, NJ
Podiatric Relevance: With an increasing population of Diabetic patients each year, complications associated with diabetes also continues to grow. Of the many complications associated with diabetes, one of the most common is diabetic neuropathy. Diabetic neuropathy manifests as complaints of burning or tingling with diminished or loss of sensation, motor function or autonomic nerve function. The loss of sensation can lead to ulcerations that can be detrimental to the patient given the increased risk of infection and amputation, while its effect on motor function can lead to deformities in the foot and ankle. Recently, there has been an increased interest in attempting to reverse some of the neuropathy by decompressing the nerves involved. Many of the operative techniques for nerve decompression, specifically the tibial nerve, have been open techniques with varying outcomes. This article describes an endoscopic tarsal tunnel release for tibial nerve decompression.
Methods: This retrospective study includes 14 feet, which underwent an endoscopic tarsal tunnel release. This technique was first described by Yoshida et al. The Universal Subcutaneous Endoscope system and push knifer are utilized in the release. Pressure within the tarsal tunnel is also measure pre and post operatively to first confirm diagnosis of tarsal tunnel, and then to ensure adequate release was performed, decreasing the pressure post operatively. Preop tarsal tunnel pressure was measure at 10 minutes after administration of local anesthetic (10mL of 1% lidocaine with epinephrine). Additionally, the study assesses for perfusion around the tibial nerve by measuring indocyanine green intensity to see if it can be used to predict postoperative outcomes.
Results: A modified Toronto Clinical Neuropathy Score was utilized to measure changes that occurred before and after surgery. Preop mean scores were 17.57 ± 1.26 of 33; 2.28 for foot pain, 2.42 for numbness, 2.42 for tingling, zero for weakness and ataxia, 0.07 for upper limb symptoms, 2.53 for pinprick test, 2.5 for temperature test, 2.57 for light touch test, 2.78 for vibration test, and 0 for position sense test. One-year postoperative mean score rates were 7.25 ± 0.52 of 33; 1.07 for foot pain, 1.0 for numbness, 0.85 for tingling, 0 for weakness and ataxia, 0.07 for upper limb symptoms, 1.14 for pinprick test, 0.92 for temperature test, 0.92 for light touch test, 1.28 for vibration test, and zero for position sense test. There were statistical differences between pre and post op.
Preoperative tarsal tunnel pressure was 49.4 ± 46.4 mmHg (range, 16 to 187 mmHg). Postoperatively tarsal tunnel pressure decreased 4.5 ± 6.5 mmHg (range, 1 to 25 mmHg). There were statistical differences between pre and post op. Endoscopic indocyanine green showed greater than 30% increase in vascularity around tibial nerve. No recurrence after one year. One patient had a hematoma post op.
Conclusions: This study demonstrates improvement post operatively in nerve function and vascularity around the nerve after an endoscopic tarsal tunnel release to decompress the tibial nerve. With a minimal incision, fibrosis and scarring can be avoided. This study shows that a minimally invasive tarsal tunnel technique can be beneficial for patients with neuropathy.