Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Anatomic variations related to decompression of the common peroneal nerve at the fibular head.

Peroneal nerve decompression at the fibular head may be anticipated to be performed more often because lower extremity peripheral nerve surgery is used to restore sensation to the feet of diabetic patients. Although the basic concept of releasing the fascia of the peroneus longus is well-known, anatomic variants related to the peroneus muscle have been identified that must be included in the technique for decompression of this nerve. A comparison of these anatomic variants was done between a random selection of 29 cadavers (bilateral) and 65 patients who underwent unilateral peroneal decompression to treat symptoms of that compression. A fibrous band on the undersurface of the superficial head of the peroneus longus was found in 30% of the cadavers and it was found in 78.5% of the patients. The mean width of the band in cadavers was 9.1 mm and in patients it was 10.1 mm. A fibrous band on the superficial surface of the deep head of the peroneus longus was found in 43% of cadavers, and it was found in 20% of the patients. The soleus muscle origin was joined to the peroneus muscle origin in 9% of cadavers and it was noted in 6% of the patients. It is suggested that during surgical decompression of the common peroneal nerve at the fibular head, the surgeon be aware of these anatomic variants so that they may be released appropriately.