What do we know?

Nothing- no solution Your situation will only get worse We dont like seeing these patients in our

office Chronic complainers Hopeless 20 million Americans with symptoms

What is the etiology?

Over 100 etiologies of peripheral neuropathy Diabetes ? Alcohol ? Chemotherapy ? Heavy Metal Poisoning ? Hereditary ? Idiopathic ?
WE REALLY DONT KNOW

 28 to 60% of Type I or II diabetics develop

Neuropathy (Young et al 1993) Sorbital Accumulation- not proven, theoretical Polyol Pathyway: oxidative stress, mitochondrial dysfunction, and ischemic nerve damage Treatment aimed at:
Controlling hyperglycemia Foot inspection Controlling pain

End result- Continued progression and

worsening of the condition

Numbness or insensitivity to pain or temperature Tingling, burning, or prickling sensation Sharp pains or cramps Extreme sensitivity to touch, even a light touch Loss of balance and coordination Symptoms are worse at night Muscle weakness (intermetatarsal)- digital deformities

Loss of Sensory Protection

15% develop ulceration

12-24% require

amputation 80% of diabetics who present with ulceration have decreased sensation in there foot/feet.

Persons who consumed large quantities of alcoholic beverages over an extended period of time. Symptoms are the same as diabetic and other neuropathyIncidence - unknown Treatment- basically the same as DPN and Stop Drinking

Medications

Lead & Heavy Metals

Arsenic Mercury Thallium Symptoms resemble

Disulfiram Metronidazole Phenytoin Cisplatin Statins

Rare- 2-4% Symptoms- Same as other Forms of neuropathy

the same as other forms of metabolic, compression, etc.

Diabetes

Alcohol

Same Symptoms

Idiopathic

Hereditary

Medications Heavy Metals

Damaged microvasculature Decreased oxygen to specific parts of the nerve

Signs of chronic inflammation Perineurial swelling Sites of specific nerve damage Sites of nerve repair

Areas of chronic flattening

A Patient presents with heel pain.

Diagnosis of Plantar Fasciitis What if they also a history of:

Diabetic Alcoholic had a family member with a history of plantar

fasciitis worked with heavy metal had chemotherapy.

What difference does it make?

Patient is hopeless Treatment options are useless We can help try to relieve the pain It will only get worse We dont know why you have developed this

I think that this is going to make a lot of sense

Lets change the way we think about neuropathy!

Chronic Damage to a peripheral nerve Mild Moderate Severe Ever heard of Carpal Tunnel Syndrome?

Chronic Repetitive Compression & Overstretching Leads to Median Nerve Damage

Pain Numbness Tingling

Pain to palpation of the carpal tunnel

Sound familiar

Conservative measures
NSAIDS Immobilizing braces

Physiotherapy
Localized steroid injections

Long term efficacy usually alter/eliminate

motion.

Treatment of choice Better out comes than wrist splinting Claim 90% success in eliminating symptoms

Feet feel best in the morning As the day goes on they get worse The more active I am the worse the symptoms

Numbness/burning in my toes/ball of foot Travels into my arch and up my leg Top of the foot feels fine, no problems there

At night when I go to bed they really start acting up

Used to happen after walking on the treadmill/mall but would stop after resting.

Usually has been to many other doctors first. (even though it is a foot symptom). Has had many expensive tests with or without abnormal findings Frustrated Very fearful

Middle aged or older Have a history of excessive walking/standing

House wife
Postal worker Etc.

Do their feet feel their best in the morning? Why do their feet become more symptomatic as the day goes on or with increased activity? Why are the symptoms worse at night?

The symptoms first started in the toes/ball of the feet Slowly after months/years went to the arches and up the leg

This is a nerve problem. What nerve supply is being affected?

The outer part of the posterior tibial nerve fibers lead to the tip of the plantar part of the toes Deeper fibers correlate to the ball/arch of the foot.

IF the patient can tell us where the symptoms are occurring then we should be able to figure out which nerve is being affected.

Can you tell me which blood vessels are not working? Lets use the same rational with the nerves

A nerve can only stretch so far Chronic overstretching will lead to damaged blood flow

A nerve can only be compressed so many times until there is partial nerve impairment Chronic compression leads to direct nerve damage (myelin).

Just like any other soft tissue of the body

A peripheral nerve can take SOME trauma without completely falling apart HOWEVER it can only take so much before pathology ensues.

If ignored or left untreated or improperly diagnosed the symptoms as well as the damage to the structure will progress.

Entire weight of body travels through the talus. Redirected from the tibia and fibula to the Calcaneus and Navicular bones.

Graham International Implant Institute, Inc.

Fulcrum point Should always stay open Abnormal closure of this space leads to deformity.

Graham International Implant Institute, Inc.

Obliteration of the sinus tarsi Plantar flexion of the talus Abnormal forces directed throughout the foot.

Graham International Implant Institute, Inc.

Medial Anterior Plantarflexion

Graham International Implant Institute, Inc.

Chronic Overstretching of the soft tissue to the rearfoot Can lead to compression of the posterior tibial nerve and its terminal branches.

Posterior Tibial Nerve

The most common thing we do besides breathing is walking Excessive rearfoot motion leads to chronic overstretching and compression of the posterior tibial nerve and its terminal brances By 50 years of age we have taken 180,000,000 steps

This is a gradual onset problem If left untreated will continue to develop more nerve damage Exercise/walking/standing leads to further damage At night we are not traumatizing the nerves which is why these patients symptoms are not as bad when they get out of bed in the morning

As the day progresses, more damage is caused to the nerve due to increased activity until.nerve goes numb
At night when going to be the patient stops traumatizing the nerves and the wake-up with a vengeance.

Some patients have to get out of bed and find if they walk for a while the pain subsides. Why? They are re-numbing their nerves.

Release the Lacinent Ligament-Proximal to Distal, start in the middle and work out from there. Use your pinkie Do not need to necessarily work your way to dissect the PTN and its terminal branches.

Go distal through the porta pedis. Usually have to create an opening, I use tenotomy scissors. Stick your pinkie into the porta pedis.

To show what effect hyperpronation has maximally pronate the foot with your pinkie in the porta pedis- carefully (I am not responsible for crushed pinkies!)

I feel that it isnt essential to go in and dissect out the nerves. As long as we free-up the neurovascular bundle the nerves will no long be crushed.
If we perform too much dissection around the nerve it is possible to form scar tissue If we dont do enough dissection it is possible to miss some of the fibers that are destroying the nerves.

Graham International Implant Institute, Inc.

Graham International Implant Institute, Inc.

Graham International Implant Institute, Inc.

Graham International Implant Institute, Inc.

Graham International Implant Institute, Inc.

Threaded portion locks the implant into the cervical ligament in the canalis portion of the sinus tarsi
Tapered portion abuts the lateral aspect of the canalis tarsi for accurate placement.

Outer wider diameter prevents obliteration of the sinus tarsi.

Grooved section allows for fibrous tissue ingrowth to prevent backing-out of the implant. Made of medical grade titanium Cannulated for guide wire insertion for accurate placement within the sinus tarsi.

Graham International Implant Institute, Inc.

Graham International Implant Institute, Inc.

Before

Weight bearing- 2 weeks post-op After

Graham International Implant Institute, Inc.

TaloTarsal Stabilization with HyProCure

Take about 10

Tarsal Tunnel Decompression/Neurolysis

Take about 20 min Should use loups

minutes to perform Takes about 10 15 stents placements before you really get comfortable

Takes about 25 before you

really feel comfortable in this area Take your time

Apply a tourniquet to the ankle I do not inflate the tourniquet unless there is excessive bleeding Use 10 ccs of 1:1 mix of 0.5% marcaine with and without epi with 1 cc of dex. Phosphate Close skin only

Depends on which fibers are being affected How damaged the nerves are How compliant the patients are How good of job YOU did on decompressing the nerves How much scar tissue the patient forms after surgery

Pain is almost immediately alleviated. Restoration of sensation- will take the longest to return Results may be felt in the recovery room Or may takes months to years

No matter, instead of the patients condition getting worse and worse, it will potentially get better and better.

This is real not imaginary. The damaged nerves of one foot affect the opposite foot. Scenarios:

Good Bad Ugly-

By decompressing one foot not only is there is improvement on that side there is also improvement in the contra-lateral limb.
IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the nerves

Surgery to the foot yield minimal results with no change in the contra-lateral limb
The opposite limb is the dominate nerve pathology and once that side is also decompressed there should be an additional effect on both feet. Must warn patients about this prior to surgery.

Nerve decompressions are performed on both feet (one at a time) and no results are felt. Dont take the patients word for it. Must perform nerve testing prior to surgery and routinely post-op. Their nerves may be so severely damaged that it was too late. No matter how severe I will still attempt. It just may takes years for the results to be felt.

Wound dehiscence Scar tissue formation

Hematoma Infection Temporary increase in nerve symptoms

?% revision rate

Increased Nerve Pain Loss of Sensation Ulceration Bone infection Amputation Charcots Foot

Decreased Activity Level Decreased metabolism Increased Weight (obesity) Diabetes Hypertension Arterial Disease

Biannual testing Extra depth shoes NSAIDS Pain pills Nerve Pills Psychiatry Wheelchair/walker

Shows increased nerve damage Prevent ulceration Do nothing Barely take off the edge See next slide Loosing battle Syndrome X- further decrease in activity

Mask the symptoms Do not help nerve repair Expensive Increased symptoms, increased dosage

Side-effects
Swelling/edema Blurred vision Drowsiness

Fatigue/muscle

weakness Muscle cramps Vomiting Constipation/Diarrhea Sexual dysfunction

Manifests after years of peripheral nerve symptoms We really dont know

Why
Who when

Only get worse Really no help

Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

Claim 80% effective within a year

20% will either just take > 1 year are the

nerves are just too severely damaged.

Doing nothing leads to progression Complications of proposed surgical treatment options have a better outcome than supervised neglect I hope that I have open some eyes so that we can change our thinking on this extremely serious condition

Changing Lives, One Step at a Time