Surgical Treatment of Tarsal Tunnel Syndrome - Case Report

Case Report

Austin J Orthopade & Rheumatol. 2021; 8(1): 1095.

Surgical Treatment of Tarsal Tunnel Syndrome - Case Report

EL Maqrout A*, Fekhaoui MR, Boufettal M, Bassir RA, Kharmaz M, Lamrani O, Mahfoud M, Bardouni AEL and Berrada MS

Department of Orthopedic Surgery, University Mohamed V, Morocco

*Corresponding author: Amine EL Maqrout, Department of Orthopedic Surgery, University Mohamed V, Ibn Sina Hospital, Faculty of Medicine of Rabat, Avenue Mohamed Belarbi El Alaoui, Rabat, Morocco

Received: January 04, 2021; Accepted: February 09, 2021; Published: February 16, 2021

Abstract

The first description of tarsal tunnel syndrome is recent. Koppel in 1960 evoked the after-effects of lesions of the posterior tibial nerve. Keck in 1969 was the first to describe compression of the posterior tibial nerve by the internal annular ligament. It was a young soldier who, after intensive training, had bilateral plantar anesthesia. The opening of the internal annular ligament had allowed a total recovery in 48 hours. Our objective here is to discuss the circumstances of the diagnosis of this syndrome, to analyze its anatomical and pathological causes, to present the types of treatments followed, in the light of the literature.

Keywords: Tarsal tunnel; Neurolysis; Surgery

Introduction

Tarsal tunnel syndrome is a canal syndrome. It concerns the posterior tibial nerve, compressed behind the internal malleolus, in an osteofibrous process consisting of the tibia, the talus and the calcaneus and closed by the deep lamina of the ligament internal annular, extending the aponeurosis of the leg. This tunnel contains, in addition to the posterior tibial nerve, posterior tibial vascular bundle and the tendons of the flexor proper to the big toe, of the common flexor of the toes and of the posterior leg. This syndrome can be caused by trauma, varicose veins, tenosynovitis, compartment tumors or static abnormalities of the hindfoot. In most cases, this syndrome is idiopathic.

Case Presentation

A young 36-year-old man presented to the consultation for neurological pain of the burn type accompanied by paraesthesia of the inner edge of the ankle and foot. Negative neurological examination (radiculalgia, diabetes and neuropathy) negative static examination of the hindfoot: no palpable mass of the internal retro-malleolar region, irritative neurological syndrome in the form of the sign of percussion, the sign of kinoshita is positive (pain in dorsiflexion associated with prolonged foot eversion 10 seconds). A standard X-ray requested without bone abnormalities. The electromyogram confirms the diagnosis, which shows a slowing down of the speed of sensory conduction.

Surgical Treatment

It is indicated after at least three months of medical treatment without effect. This medical treatment must combine NSAIDs, physiotherapy, soles, or even plastered immobilization. The operation is carried out under general or locoregional anesthesia. the first is internal retro-malleolar, 6-8cm from the top of the malleolus following the path of the posterior tibial nerve to the internal edge of the sole of the foot (Figure 1) the leg fascia is open, continuing on the internal annular ligament and the posterior tibial nerve is located at the upper part of the incision; it is dissected until its termination into internal and external plantar nerves (Figure 2, 3). We will look for any expansive process that may be causing compression. At this level, the deep fascia of the abductor of the big toe is open because it can be a source of compression. The neurolysis practiced is an exo-neurolysis, without inter fascicular dissection on pain of postoperative fibrosis. Careful bipolar coagulation is recommended and hemostasis will be checked by releasing the tourniquet. All the fascias will be left open, only the subcutaneous and skin will be closed. We will do a compression bandage in a posterior splint, then a boot for two weeks on the fifteenth day after removal of the threads. The support is resumed at one month.