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A Guide To Nerve Wrapping For Tarsal Tunnel

WARNING: INCREASED
RATE OF MORTALITY
SECONDARY TO
MALIGNANCY An

Surgery
increased rate of mortality
secondary malignancy was
observed in patients
treated with 3 or more
tubes of REGRANEX
(becaplermin) Gel, 0.01%
November 19, 2015 in a postmarketing
retrospective cohort study.
REGRANEX Gel should
Volume 28 - Issue 12 - December 2015 (/issue/5495) Proper wound only be used when the
benefits can be expected
Pages: 32 - 39 care requires to outweigh the risks.
REGRANEX Gel should be
Michael S. Downey, DPM, FACFAS used with caution in
patients with known
malignancy.
Click here for
Prescribing information
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shoes-better-minimalist-running-shoes)

A Closer Look At Imaging Options For

Adhesive neuritis can be a challenging, unpredictable complication of tarsal tunnel Complicated Heel Pain (/closer-look-imaging-
surgery. Accordingly, this author o!ers a closer look at the emergence of nerve wrapping options-complicated-heel-pain)
to prevent post-op extraneural scarring.

(/files/pt12nerve1_1.jpg)Primary tarsal tunnel decompression surgery for

Current Issue
tarsal tunnel syndrome is sometimes unsuccessful in providing
satisfactory symptomatic relief. When this occurs and despite the
November 2018
presence of an intact posterior tibial nerve, revisional surgery will often be necessary.
Heel Elevation In The
There are many potential causes of recurrent tarsal tunnel syndrome. We can loosely Shoe: What The
Literature Reveals
divide these etiologies into six categories: incorrect initial diagnosis; inadequate
(/heel-elevation-shoe-
release; adhesive neuritis; intraneural damage; double crush syndrome and idiopathic what-literature-reveals)
causes.1 Adhesive neuritis or tethering of the nerve to scar tissue can be an
unpredictable outcome that can occur in even the most experienced surgeon’s hands.
This postoperative extraneural scarring can cause ischemia in the nerve,
circumferential mechanical constriction and/or impaired gliding of the nerve.2 In recent (/issue/8942)

years, the idea of nerve entubulation or “wrapping” around the nerve has emerged as a Current Issue ▶ Issue Archive
means of providing a barrier or “shield” against such extraneural scarring.
THIS WEEK'S TOP STORIES

Study Compares Four Treatments For Chronic

Plantar Fasciitis (/study-compares-four-
treatments-chronic-plantar-fasciitis)
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Plantar Fasciitis (/study-compares-four-

The ideal barrier nerve wrap is one that the surgeon can place around a nerve that has treatments-chronic-plantar-fasciitis)
undergone external neurolysis and decompression. In addition to limiting postoperative Heel Elevation In The Shoe: What The Literature
external nerve scarring, this nerve wrap would o!er the following properties: Reveals (/heel-elevation-shoe-what-literature-
reveals)
(/files/pt12nerve2.jpg)1) biocompatibility and no provocation of
inflammatory response; Assessing The Role Of Gastroc Recession For
Posterior Heel Pain (/assessing-role-gastroc-
2) flexible, soft and of su!icient size to prevent constriction or recession-posterior-heel-pain)
compression upon the repaired nerve;
Point-Counterpoint: Are Maximalist Running
3) biomaterial that is biodegradable while maintaining a stable mechanical architecture
Shoes Better Than Minimalist Running Shoes?
during the healing process, including tear resistance if sutures are involved; (/point-counterpoint-are-maximalist-running-
4) biomaterial that is semi-permeable to allow the influx of oxygen and nutrients from shoes-better-minimalist-running-shoes)
the interstitial fluid to the repaired nerve tissue through pores in the biomaterial wall;
Current Perspectives On The Di!erential
5) biomaterial that is su!iciently impermeable to prevent the influx of fibrous tissue Diagnosis For Peripheral Neuropathy (/current
ingrowth through the biomaterial wall and retain the secreted neurotrophic factors of perspectives-di!erential-diagnosis-peripheral-
neuropathy)
the repaired nerve;
6) biomaterial that is neuroinductive and neuroconductive; and
7) biomaterial that one can easily obtain, sterilize and store, and that has good surgical
Interactive Poll
handling properties (e.g., ease of placement and suture tear resistance).3

Physicians have used many substances as barrier nerve wraps. These substances
include fat, fascia, collagen, gelatin, decalcified bone, blood vessels (veins), cartilage,
Which treatment do you use most
muscle, polyglactin, rubber, silicone tubing, silicone sheeting and amniotic membrane. often for plantar fasciitis?
Unfortunately, the literature and research on most of these substances have
concentrated on their use as nerve conduits for the repair of nerve deficits where one Corticosteroids

must span a nerve gap to allow nerve regeneration. There is very limited evidence Extracorporeal shockwave therapy

supporting any of these materials as barrier nerve wraps. Although the evidence is Stretching
limited, several of these substances have shown early promise in the described role of Platelet rich plasma
wrapping previously scarred nerves following external neurolysis. At this time, there is Orthotics
no one universally preferred material for nerve wrapping.

(/files/pt12nerve3.jpg)Who Is A Candidate For Nerve Wrapping? VOTE

Patients with scar-tethered nerves usually have a history of previous
surgery (e.g., prior tarsal tunnel decompression surgery), trauma (e.g.,
open fracture, dislocation or crush injury) or infection. These patients present most FEATURED ARTICLE
often with unrelenting, severe, neuritic pain that is often elusive in nature. In cases of
Keys To Deltoid Ligament
recurrent tarsal tunnel pain, the symptom complex will frequently include varying Repair After Ankle Fracture
combinations of burning and lancinating pain, numbness, paresthesias, dysesthesias (/keys-deltoid-ligament-repair-
and the sympathetic dysfunction commonly associated with tenderness to palpation of after-ankle-fracture)
By Je!rey E. McAlister, DPM, FACFAS,
the involved nerve(s) and a positive Tinel’s sign with percussion of the involved and Eric So, DPM, AACFAS | Reads:
nerve(s). (/keys-deltoid-
769

ligament-repair-
Furthermore, the patient’s history frequently reveals that the patient had temporary,
after-ankle-
short-term relief after the index neurolysis surgery. The symptoms may have subsided fracture)
for weeks or months until recurrent scar tissue formation tethers the nerve, causing
adhesive neuritis and a return of pain. In the case of a recurrent tarsal tunnel syndrome,
the physical examination may reveal tenderness over the posterior tibial nerve, porta TRENDING TOPICS
pedis and/or medial heel and distal tingling upon percussion (i.e., positive Tinel’s sign) Nutrition (/topics/nutrition)
with percussion of the posterior tibial nerve and/or its terminal branches. Dermatology (/topics-27)

(/files/pt12nerve4.jpg)Electrodiagnostic testing usually reveals slowing Sesamoid (/topics/sesamoid-0)

of sensory nerve conduction velocities, and both sensory and motor Nerve Entrapment (/topics/nerve-entrapment)
latencies may be delayed. However, remember that the electrodiagnostic Jones Fracture (/topics-35)
testing is not definitive and when scar tissue inhibits the nerve gliding of an intact
nerve with less than moderate nerve compression, the electrodiagnostic studies may
be normal. In cases of adhesive neuritis, advanced imaging modalities such as Follow us on Twitter
Podiatry Today

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Podiatry Today
magnetic resonance imaging (MRI) or musculoskeletal ultrasound will likely reveal @PodiatryToday
findings consistent with post-surgical changes and the accompanying scar tissue. Top 10 Columns #9: Is Microfracture Obsolete For

The primary indication for nerve wrapping is following the neurolysis of scar tissue that Osteochondral Lesions Of The Talus?
By Bob Baravarian, DPM
both compresses the involved nerve and causes adhesions between the nerve and (Treatment Dilemmas, May
surrounding tissues. Wrapping the nerve prevents recurrent adhesive scar tissue and 2018)tinyurl.com/yc82wldb@ACFAS @APMA

pain from traction on the nerve.

Pertinent Insights On The Surgical Technique Of Nerve Decompression And

Nerve Wrapping
Any surgical nerve decompression technique that involves nerve wrapping starts with
external neurolysis with, or more commonly without, internal neurolysis. Make an
incision over the involved nerve(s). If there was a previous incision, use the same
incision (if possible), extending it both proximally and distally. The proximal and distal
extensions of the prior incision allow the surgeon to identify the involved nerve(s) in CLASSIFIEDS
normal, unscarred tissue where one can then trace the nerve into the entrapment site.
Wound Care Specialist
Carefully dissect the nerve free from the incarcerating scar tissue throughout the
(https://healthjobconnect.com/job/230/wound
length of the wound, preferably under loupe or similar magnification. After full care-specialist/)
decompression of the nerve, perform gentle, circumferential release of the nerve from
all adhesions. Optimally, when only external neurolysis is needed, one can leave the
epineurium of the involved nerve(s) intact. In the case of recurrent tarsal tunnel ONLINE CME
syndrome, the surgeon should address any scarring or damage of adjacent tendons via
Modern Techniques to Manage Infected
tenolysis and/or tendon repair. Wounds in the Diabetic Patient: Integrating
Advanced Technologies to Optimize Healing
(/files/pt12nerve5.jpg)After performing a complete external neurolysis, (https://www.naccme.com/program/2016-667-
take measurements for the appropriate nerve wrap and then cut it to 11)
size, insert the wrap and suture it (if needed). Then close the
Integrating Emerging Research into Biofilm
subcutaneous tissue and skin. It is not recommended to close the laciniate ligament Management
(i.e., flexor retinaculum), and I routinely leave it unsutured. (https://www.naccme.com/program/biofilm)

What The Literature Reveals About Nerve Wrapping With Di!erent Biomaterials Biologically Clearing the Barriers to Wound
My initial experience with nerve wrapping involved the placement of 0.007-inch Healing: Changing the Wound Healing
Environment through Debridement
silicone sheeting around the involved nerves after external neurolysis in revisional (https://www.naccme.com/program/2016-667-
tarsal tunnel decompression surgery. This approach led to unpredictable and highly 2b)
variable results. Subsequent studies have shown that this ensheathing material is very
impermeable and often results in fibrous encapsulation of the wrapped nerve, likely
secondary to loss of the nerve’s extrinsic blood supply.4 UPCOMING EVENTS

Subsequent to the use of the synthetic silicone sheeting, I progressed to trying a Windy City Podiatry Conference
biologic material, namely the use of an autogenous saphenous vein graft wrap. With (/events/windy-city-podiatry-conference-4)
this technique, the surgeon harvests the greater saphenous vein from the ipsilateral
New York Foundation for Podiatric Medicine
lower extremity and wraps the vein around the involved nerve(s) with its endothelial (/events/new-york-foundation-podiatric-
surface against the nerve. Theoretically, the autogenous vein provides an external medicine)
barrier against scarring of the nerve and the surrounding tissues, which allows Podiatry Institute 26th Annual Winter
improvement in the vascular supply to the nerve. Hypothetically, the vein acts as a Conference (/events/podiatry-institute-26th-
gliding conduit for the nerve and the vascular endothelium prevents internal scar annual-winter-conference)
formation. American College of Foot and Ankle Surgeons
Annual Scientific Conference
In several clinical series, authors have examined the use of this technique for recurrent
(/events/american-college-foot-and-ankle-
tarsal tunnel syndrome.5-7 Gould reported wrapping a total of 65 nerves in the lower surgeons-annual-scientific-conference-2)
extremity, including the posterior tibial, superficial peroneal, common and deep
Foot and Ankle Surgery: Building Blocks for
peroneal, sural and intermetatarsal nerves.5 He reported 63 percent good or excellent Success (/events/foot-and-ankle-surgery-
results (i.e., no pain or occasional pain with exertion) and 37 percent fair to poor results. building-blocks-success)
Seventy five percent of the patients were satisfied with the results. The best outcomes
were in patients with external adhesions and those with internal scarring did the worst.

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(/files/pt12nerve6.jpg)Campbell and colleagues examined the histologic

findings in a vein graft case study 17 months after surgery to try to
validate the proposed theoretical mechanisms.6 Specifically, histological
evaluation demonstrated viable vein graft with adequate vascularity evidenced by a
patent adventitial lumens. No degeneration of the vein graft occurred. Although
researchers did not detect an internal scar within the nerve, the study did identify an
obvious gliding surface between the nerve and vein graft. This finding suggests this to
be a less likely mechanism of action of a vein wrap.

Easley and Schon reviewed their series of vein wrapping procedures used for adhesive
neuralgia in 25 patients.7 They used the saphenous vein in 19 cases and a fetal
umbilical vein in six cases. Twenty one of their 25 cases were entrapment neuropathies
of the posterior tibial nerve. Seventeen of the 25 patients were satisfied with the
procedure (with or without reservations) whereas eight patients gained minimal or no
relief of their symptoms. The indications for vein wrapping in this series were (a)
intractable neurogenic pain, (b) failure of the non-operative management protocol, (c)
temporary relief of symptoms after previous neurolysis with subsequent recurrence and
(d) clinical findings consistent with adhesive neuralgia. The primary limitations of the
use of autogenous vein grafts to wrap a nerve are donor site morbidity and added
surgical time to harvest the vein graft.

Exploring The Potential Of Emerging Modalities For Nerve Wrapping

(/files/pt12nervechart.png)In an e!ort to eliminate the limitations of
obtaining an autogenous biologic graft, numerous other materials have
emerged as potential nerve wraps (see “A Guide To Available FDA
Approved Absorbable Nerve Protectant Wraps” at left). The SaluTunnel (SaluMedica)
nerve device is composed of a hydrophilic, polyvinyl alcohol (PVA) hydrogel that is a
non-resorbable biomaterial. The synthetic material emerged in 2010 and o!ers the
advantage of water content in similar proportions to human tissue and a stable
mechanical structure that one can easily sterilize. The material is available in 2 mm, 5
mm and 10 mm diameters and a fixed length of 6.35 cm. The length of the SaluTunnel is
the longest available and one can shorten it as desired. The key limitations to the
material are its non-degradable nature and the lack of any clinical studies examining its
use.3

Another material introduced for nerve wrapping is the AxoGuard Nerve Protector
(AxoGen). This xenograft material is a strong, pliable, cell-free collagen matrix
composed of porcine small intestinal submucosa (SIS). The SIS material degrades over
a three-month period. The AxoGuard Nerve Protector is available in a range of
diameters from 2 mm to 10 mm with each diameter available in 2 cm and 4 cm lengths.
Several clinical studies have assessed its use and the SIS material appears to do well
with human implantation without any obvious adverse immunologic response.3

(/files/pt12nerve7_0.jpg)The other two FDA-approved nerve wrap

materials are NeuraWrap (Integra LifeSciences) and NeuroMend
(Stryker), which are both comprised of bovine-derived type I collagen.
Type I collagen is abundant, easily isolated and purified, and available in
varying degrees of resorbability. Further, type I collagen has an established record of
biocompatibility and typically has a minimal immunologic response. NeuraWrap and
NeuroMend di!er primarily in their resorption rate with NeuraWrap degrading in 36 to
48 months and NeuroMend degrading in four to eight months. The shorter degradation
time may be desirable in nerve wrap indications as a longer time for complete
biodegradation may lead to nerve compression. NeuraWrap is available in diameters of
3 mm to 10 mm and lengths of 2 cm and 4 cm. NeuroMend is available in diameters of

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4 mm to 12 mm (the largest diameter available of any of the nerve wrap biomaterials)

and lengths of 2.5 cm and 5 cm. NeuroMend is designed to be self-curling to match the
outer dimensions of the released nerve(s).1-2

Amniotic Membrane: Can It Have An Impact For Nerve Wrapping?

Finally, the last biomaterial currently being used as a nerve wrap is human amniotic
membrane. When one uses amniotic membrane as a biomaterial, it is easily obtainable,
has no donor site morbidity, has minimal inflammatory response, degrades with time
and may enhance nerve healing (i.e., neurotrophic e!ect).

There are no current studies assessing the value of using an amniotic membrane wrap
for revisional tarsal tunnel decompressions. However, there is mounting animal
research evidence and a few case reports in humans that strongly support its
continued use and investigation.

(/files/pt12nerve8.jpg)In 2010, Kim and coworkers reported their study

results assessing the e!ect of wrapping human amniotic membrane
around the repaired ulnar nerve in a New Zealand rabbit model of
perineural adhesion.8 The investigators found that amniotic membrane
can reduce fibrosis and adhesion around neurorrhaphy sites in their animal model.

In 2011, Meng and colleagues published their assessment of the use of processed
human(/)amniotic membrane as a protective barrier in nerve defects created in Sprague Login (/user/login)
Dawley rats.9 The authors reported that wrapping of the sciatic nerves of rats with
human amniotic membrane enhanced functional recovery and nerve regeneration Subscribe (/e-news)
during the early stage after surgical injury and repair.

In 2014, Fesli and colleagues assessed the enhancement of the nerve healing potential
of a combined use of amniotic membrane wrap and granulocyte-colony-stimulating
factor injections after the primary repair of transected sciatic nerves in Wistar rats.10
The researchers concluded that their approach had supportive e!ects on nerve
regeneration.

Several isolated reports focus on the use of amniotic membrane wrapping of the
posterior tibial nerve and its terminal branches using products such as XWrap (Applied
Biologics), Clarix and Neox (Amniox Medical), and AlloWrap DS (AlloSource).11-13 When
using these products, wrap a sheet of the desired amniotic membrane material around
the decompressed nerve(s). The surgeon may or may not suture the wrap upon itself.
Do not suture the wrap to surrounding soft tissues.

(/files/pt12nerve9.jpg)What You Should Know About Postoperative

Care
The postoperative care following revisional nerve decompression with a
nerve wrap does not substantially di!er from the postoperative care of
the same surgery without the nerve wrap. If one has harvested autogenous tissue, such
as the saphenous vein graft, an additional dressing and appropriate precautions for
bleeding will be necessary. Typically, the patient stays non-weightbearing for the first
three to four weeks. The first dressing change most commonly happens in the first
seven to 10 days. At that time, apply a controlled ankle motion (CAM) walker boot and
instruct the patient to begin gentle range of motion exercises. Physical therapy and
weightbearing begin after three or four weeks, and increase after that based upon the
patient’s response.

Final Thoughts
Repeated nerve decompression (i.e., external neurolysis) alone does not always provide
satisfactory results in patients with recalcitrant tarsal tunnel syndrome. Surgeons can
use supplementary techniques with either synthetic or biologic adhesion barriers to

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A Guide To Nerve Wrapping For Tarsal Tunnel Surgery | Podiatry Today 11/16/18, 8'22 PM

wrap the nerve, improving functional recovery and preventing recurrent scarring.
Knowledge of these materials and the evidence supporting their use is critical to
patient safety and successful surgical outcomes.

Future advances in bioengineering and a better understanding of nerve biology

combined with appropriately designed human studies may lead to the optimal method
of peripheral nerve reconstruction. At this point in time, nerve wrap techniques appear
to have a role in the salvage management of adhesive compressive neuritis. These
nerve wraps are designed to inhibit recurrent nerve tissue adhesions and diminish
inflammatory and immunologic reactions in peripheral nerve surgery.

Dr. Downey is the Chief of the Division of Podiatric Surgery at Penn Presbyterian Medical
Center in Philadelphia. He is a Senior Faculty member of the Podiatry Institute. Dr.
Downey is in private practice at Ankle & Foot Medical Centers of the Delaware Valley in
Pennsylvania.

References

1. Downey MS, Yarmel DJ. Tarsal tunnel syndrome. In Southerland JT, Boberg JS,
Downey MS, Nakra A, Rabjohn LV (eds.): McGlamry’s Comprehensive Textbook of
Foot and Ankle Surgery, Fourth Edition. Wolters Kluwer Health I Lippincott
Williams & Wilkins, Philadelphia, 2013, pp. 934-949.
2. Masear VR. Nerve wrapping. Foot Ankle Clin. 2011; 16(2):327-337.
3. Kehoe S, Zhang XF, Boyd D. FDA approved guidance conduits and wraps for
peripheral nerve injury: A review of materials and e!icacy. Injury. 2012; 43(5):553-
572.
4. Merle M, Dellon AL, Campbell JN and Chang PS. Complications from silicon-
polymer intubulation of nerves. Microsurgery. 1989; 10(2):130-133.
5. Gould JS. Autogenous vein wrapping for painful nerves in continuity. Foot Ankle
Clin. 1998; 3:527-536.
6. Campbell JT, Schon LC and Burkhardt LD. Histopathologic findings in
autogenous saphenous vein graft wrapping for recurrent tarsal tunnel syndrome:
a case report. Foot Ankle Int. 1998; 19(11):766-769.
7. Easley ME and Schon LC. Peripheral nerve vein wrapping for intractable lower
extremity pain. Foot Ankle Int. 2000; 21(6):492-500.
8. Kim SS, Sohn SK, Lee KY, Lee MJ, Roh MS, Kim CH. Use of human amniotic
membrane in reducing perineural adhesions in a rabbit model of ulnar nerve
neurorrhaphy. J Hand Surg Eur Vol. 2010; 35(3):214-219.
9. Meng H, Li M, You F, Du J, Luo Z. Assessment of processed human amniotic
membrane as a protective barrier in rat model of sciatic nerve injury. Neurosci
Lett. 2011; 496(1):48-53.
10. Fesli A, Sari A, Yilmas N, Comelekoglu U, Tasdelen B. Enhancement of nerve
healing with the combined use of amniotic membrane and granulocyte-colony-
stimulating factor. J Plast Reconstr Aesthet Surg. 2014; 67(6):837-843.
11. Chicano D. Can amniotic membrane graft have an impact in lower extremity
surgery? Podiatry Today. 2012; 25(10):77.
12. Jacoby R. Tarsal tunnel compression neuropathy case study using FloGraft.
Applied Biologics. Available at https://www.appliedbiologics.com/education/.
2014.
13. Lee TH. Tarsal tunnel syndrome decompression. Available at
http://www.amnioxmedical.com/c222cda6a9_sites/www.amnioxmedical.com/files/EDU-
CS-04_Rev_G_2014_07_07Tarsal_Tunnel.pdf .

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