Botched Tarsal Tunnel Surgery Causes Severe Nerve Damage

This case involves a 52-year-old female patient who required a tarsal tunnel release surgery on her right foot. Within one week of surgery, the patient developed reflex sympathetic dystrophy caused by bandages that were applied too tightly after surgery. The patient now experiences long-term nerve damage to the afflicted limb and will require a second surgery as a result.

Question(s) For Expert Witness

1. What is the standard of care in a case that presents like this?

Expert Witness Response E-000800

If non-invasive treatment measures fail, tarsal tunnel release surgery may be recommended to decompress the area. The incision is made behind the ankle bone and then down towards but not as far as the bottom of the foot. The Posterior Tibial nerve is identified above the ankle. It is separated from the accompanying artery and vein and then followed into the tunnel at which point the nerves are released. Cysts or other space-occupying problems may be corrected at this time. If there is scarring within the nerve or branches, this is relieved by internal neurolysis. Neurolysis is when the outer layer of nerve wrapping is opened and the scar tissue is removed from within nerve. Following surgery, a large bulky cotton wrapping immobilizes the ankle joint without plaster. The dressing may be removed at the one week point and sutures at about three weeks. I do bandage and wrap all of my own patients, and for a case like this, I would have them come back to be inspected two to three days after the procedure. If the surgery went according to plan and it was indeed the bandaging that caused the RSD then this may be below the standard of care. It is a tricky procedure due to the fact that a nerve, a vein, and an artery are all in a very confined space. The nerve will grow back at about one inch per month. One can expect to continue the healing process over the course of about one year.