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Terrible TTS results.

Posted by Dr. Zuckerman on 4/04/05 at 17:02 (172570)

I have a few minutes, so lets take a look at this ONE study. First of all complication rates were 30% ( sounds safe to me !!) and the 72% ONLY included the patients that could be follow up with . What about the patients they didn't follow up . Come on what is going on here, these are terrible results.

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1: Foot Ankle Int. 1998 Feb;19(2):65-72. Related Articles, Links

Tarsal tunnel syndrome: diagnosis, surgical technique, and functional outcome.

Bailie DS, Kelikian AS.

Center for Sports Medicine and Orthopedics, Phoenix, Arizona 85015, USA.

During a 10-year period, 47 patients underwent surgical management for tarsal tunnel syndrome (TTS). Of these, 34 (36 feet) were available for complete retrospective analysis by record review, questionnaire, and physical examination. An additional 10 patients were evaluated by record review alone. The mean age was 38 years (range, 12-65 years). Overall, average follow-up was 35 months (range, 15-102 months). All patients had nonsurgical care for an average of 16 months before surgery (range, 1-72 months). The symptom triad of pain, paresthesias, and numbness was the most common clinical presentation. All had a positive Tinel's sign and nerve compression test (NCT) at the tarsal tunnel. Electrodiagnostic studies were abnormal in 38 feet (81%). Two-point discrimination was diminished significantly by an average of 6.7 mm. At a follow-up examination two-point discrimination improved by an average of 3.8 mm (P < 0.001). Eighteen feet continued to have a positive Tinel's sign and had a residual NCT. Subjectively, patients were satisfied with the surgical outcome in 72% of the cases. Postoperative improvement in the median Symptom Severity Score and the Functional Foot Score reflected this satisfaction. The perioperative complication rate was 30%. We conclude that the diagnosis of TTS is made primarily on history and clinical evaluation with electrodiagnostic studies supporting the diagnosis in 81%. Surgical treatment is warranted after nonsurgical management has failed. Division of the deep portion of the abductor hallucis fascia is important

Re: Terrible TTS results.

cindyp on 4/04/05 at 18:33 (172574)

I wish they had talked to me I have no complaints what so ever.

Re: Terrible TTS results.

Amy on 4/04/05 at 20:46 (172584)

Dr Z-

Besides cryotherapy - which is also invasive, correct? - what else do you recommend TTS sufferers to do? My TTS is not due to a biomechanical prob - orhotics are not going to fix it, in fact I think they caused it. What other conservative measures do you tell your patients to seek?

Amy

Re: Terrible TTS results.

Darlene on 4/04/05 at 21:18 (172586)

Amy:
If you think that orthotics caused your TTS, it may mean that biomechanics are in fact the problem. Were the orthotics poorly made?

Re: Terrible TTS results.

Dr. Z on 4/04/05 at 21:35 (172588)

Make sure you have the correct diagnosis would be the first most important thing I would do.

Re: Terrible TTS results.

Dr. Z on 4/04/05 at 21:36 (172589)

Are you the Cindy P that had a vien removal from the lateral plantar nerve a few years ago. Sorry I just want to make sure

Re: Terrible TTS results.

Dr. Z on 4/04/05 at 21:38 (172590)

Amy,
I am not so sure you have TTS. Lets see what the sensory nerve testing shows. If you have a lateral plantar nerve entrapement and a local injection does work that I would release the nerve with a partial plantar release.

Re: Terrible TTS results.

elliott on 4/04/05 at 22:00 (172596)

Dr. Z, regarding followup, that's probably pretty typical. You could also wonder about the FDA studies on ESWT too; if I recall, they had some rather poor followup.

Terrible results? I wouldn't call 72% terrible. Remember, we're debating 60-63% vs 75%. Also, it said *perioperative* complication rate was 30%, which may just be suggestive of obstructions found or other repairs that had to be done together with the TT release, so many of these might actually be the cases definitively determined to be TTS.

Re: Terrible TTS results.

Dr. Z on 4/04/05 at 22:21 (172598)

Or cases that were determined to be TTS with Post tib tear. Maybe the 75% were from other repairs beside the TTS release. I would like to have a definition of what they called perioperative complications. What do they mean? Additional pathology not predicted before surgery or damage from the surgery itself. ESWT isn't TTS . I would think that you would de much more careful discussing TTS results which is an invasive procedure that can and does produce infection, permenant pain and even RSD.
Why aren't you attacking the methology that was used in these articles when the results if over inflated or the complications not fully explained could destroy a patient life. \

Its just so strange that I have to ask the questions when it comes to TTS. I would think that you would realize that this is a very serious operative with very serious complication .

Re: Terrible TTS results.

Amy on 4/04/05 at 22:26 (172600)

Yes. Also in the wrong shoes (which my pod at the time assured me were fine). I have a neutral foot, mid to high arch, with no gait problems. I probably never should have had orthotics in the first place. i felt the were pushed on me - but that is hindsight.

Re: Terrible TTS results.

elliott on 4/04/05 at 22:36 (172605)

Dr. Z,

I totally agree that a TTS release is a very serious operation with the potential for very serious complications. It is also true that if one has unbearable nervy pain at the inner ankle often radiating from there, his or her life is already ruined. You can't know what I'm talking about unless you've experienced it. The choice may be to continue in that state or weigh surgery.

I've posted numerous times to be super-wary of a TTS diagnosis without any obvious nervy pain, and also to avoid schlock doctors, which, sorry to say, includes many run-of-the-mill pods with an overstated opinion of themselves who think they can handle TTS releases with ease. Too many failed TTS cases appearing on heelspurs failed to avoid one of these two pitfalls.

The abstracts I've quoted from include authors that are among the most respected in their fields. That doesn't mean the numbers can't theoretically be inflated. But the more such articles with similar figures, the more credence given them.

Re: Terrible TTS results.

Dr. Z on 4/04/05 at 22:48 (172608)

The correct diagnosis and the doctor who has alot of experience is very important. I have always been a podiatrist that knows what he does best and refers to the doctor he KNOWS can do a TTS release.the best.
When you talk about schlock doctors I have seen schlock run of the mill doctors who are podiatrists and also orthopedic surgeons Just because you are that fellowship trained foot and ankle orthopedic surgeons who works at a big name university doesn't mean he or she is the one to do this operation called TTS.
How to find a doctor who can help you is sometimes tough, and sometimes a very long journey.
Who really knows the why of many of these failed TTS posters. A posting just isn't a complete history and lower extremity physical.
I will repeat something that is so important with plantar fascia releases you can't apply your theory of correct diagnosis and then correct surgery . You can have both and have complete failure with foot worse off. This may be the cases with TTS surgery

Re: Terrible TTS results.

elliott on 4/04/05 at 23:09 (172612)

Dr. Z,

Agree there are also schlock orthos who shouldn't be used for TTS releases. I just get the sense that there's more schlock pods, but I don't want to belabor that point. I have found a few pods I highly respect.

I've repeated numerous times in these threads the necessity to choose one's surgeon for this procedure very carefully, and also for the surgeon to choose the patient carefully. That helps cut down some of the failures, but certainly does not eliminate them.

Another thing is, as often postulated here, this board tends to see failures, be they TTS, EPF, or ESWT; that's often how they ended up here. So we may be getting a somewhat distorted, i.e., negative view, of all of these procedures.

Re: Terrible TTS results.

Casey on 4/05/05 at 09:33 (172632)

I had a well known doctor supposed to be an 'expert' in TTS and nerve problems do my first TTS surgery. Was a disaster from the start. Still have terrible pain after a second TTS surgery and then a vein wrap. A local podiatrist did a TTS surgery on the other foot and have had no problems. My point is that sometimes the so called expert isn't so good.

Re: Terrible TTS results.

Amy on 4/05/05 at 10:16 (172636)

I agree with Elliot concerning the number of unhappy TTS patients (post surgery) who visit this website. On the other hand, there is a cohort of die hard posters who are happy with their experiences and who post quite regularly - but we seem to always hear from the same group (This is not meant as an aside - your comments are valuable and much appreciated). There seems to be a bit of a distorted view, as Elliot states.

Amy

Re: Terrible TTS results.

cindyp on 4/05/05 at 11:10 (172640)

yes that be me

Re: Terrible TTS results.

Dr. Zuckerman on 4/05/05 at 11:58 (172647)

If I recall then you had a specific growth on the lateral branch of your lateral plantar nerve and not a true Tarsal Tunnel Release. Correct ? How can I forget your pain !!

Re: Terrible TTS results.

Dr. Zuckerman on 4/05/05 at 11:59 (172648)

You may in fact need some kind of release and be a very good candidate

Re: Terrible TTS results.

Kim on 4/05/05 at 15:45 (172653)

Dr.Zuckerman, I want to thank you for the time spent& all others that have shared their wealth of knowledge on this board.I have recently began searching for information on the internet for accurate & detailed info regarding the surgery itself & for failed TTS surgeries. It's amazing to discover their is only a couple articles with accurate descriptions of the procedure & the postop care. I have found this website to be helpful,useful,& much of info on this board was provided by pt.s.Patients need to be concerned that their is such a lack of knowledge regarding the surgery & postopertive care prior to surgery.A significant other shared a nice summary of questions to ask posted on 3/7/05. Health care providers need to take a look at this plus they need to take a look at why TTS surgery success rates are not as high as they should be & need to be & what can be done to improve success rates.
I was wandering if Birinstock Arizona Sandals are a option for pt.s that are sevearal weeks postop after TTS surgery?

Re: Terrible TTS results.

Fed Up Also on 4/05/05 at 16:58 (172661)

Dr. Z, Is there any figures you agree with (besides your ESWT success rate of 94%????)? You don't agree with the FDA results for ESWT, you don't agree with TTS results. Why is it you only agree with your 94% which doesn't agree with the FDA. But I think (it hard to tell) you agree the FDA is correct when they issue a success rate, so are you changing your ESWT rates to reflect the FDA study?

QOUTED FROM YOUR PREVIOUS POSTS, 'I know. I just don't agree with the results that are stated. Come on you should know that the doctors do the surgery, do the study and now the results. Unlike FDA studies where they are multi- doctor, multi-center etc. I am just surprised that you just accept these results. which bring me to asking you again to talk about your decision to have extentive foot surgery after what I though you use to say was a failed TTS surgery or a screwed up TTS release that left you with a damage post tib tendon. Something did go wrong??? . What was it and please lets us understanding your bravery and thinking to have this fusion procedure with a major cutting of the heel bone ( dwyer).

Re: Terrible TTS results.

cindyp on 4/05/05 at 17:01 (172662)

i had a growth but dr. george quill (he saved my sanity and my life god bless him) also did TTS surgery as well. all on same foot the right one. and i am happy to report my pain used to be a 75 on a scale of one to ten and now is a 3 only occasionally.

Re: DR Z

Fed Up Also on 4/05/05 at 17:14 (172663)

You may want to check out the link below, here is a doctor claiming 85-90% success rate for TT release and having runners back on the track. One doctor claiming a greater than 90% success rate. Link is from Podiatry Today.....

http://www.podiatrytoday.com/podtd/displayArticleaa.cfm?articleID=article2777

Re: DR Z

Dr. Z on 4/05/05 at 17:39 (172665)

He is talking about neuroma's not TTS releases. Close but not close enough

Re: DR Z

Dr. Z on 4/05/05 at 17:41 (172666)

I agree that it a great time to block you because there is a high percentage of risk that you are not who you say you are or really care about anyone or anything.

Re: To Casey

Darlene on 4/05/05 at 18:24 (172669)

Casey:

Would you share how long ago you had your second TT surgery. What did the doc say about the results?

Thanks.

Re: DR Z

Fed Up Also on 4/05/05 at 20:15 (172672)

First, who did I say I was? I never mentioned anything to that fact.

Second, I care, more than you, your gaol is to convince everyone that ESWT (your company) is the ultimate answer to everyones foot ailments. You claim that you have no knowledge of that cute little card that I recieved in the mail however, the telephone number you gave to elliot is exactly the same telephone number that is on the card (interesting to say the least).

Third, how can you dispute all the statistics regardless if ESWT FDA PMA, TT release by other doctors, etc. but in the same breath claim that your ESWT success rates are higher than anyone elses including the FDA PMA.

Never once have you given a valid argument why you right and the rest of the world is wrong.

Re: DR Z

Amy on 4/05/05 at 20:24 (172673)

I don't think this conversation belongs on the TTS board (in fact I think it is completely irrelevant to what the rest of us come here for). Stop wasting our time.

Re: Terrible TTS results.

elliott on 4/05/05 at 20:26 (172674)

Kim,

Regarding not finding many articles describing the procedure, once it becomes standardized, it tends to appear mainly in standard surgical references. One such (complete with gross pictures of the foot cut open--I've seen 'em) is Surgery of Disorders of the Foot and Ankle:

http://www.sciencedaily.com/cgi-bin/apf4/amazon_products_feed.cgi?Operation=ItemLookup&ItemId=185317212X&myOperation=Image

Maybe you could find it in a medical library if interested. Regarding post-op care, not as much to be said about it for TTS: Some recommend just a wrap and walking as soon as possible, e.g., in two weeks after a standard TTS release if no major complications, others a boot cast. Some are pro-PT, others not.

You can be assured that the docs would like to and are looking into anything that might improve the odds. Newer journal articles are often the place for such ideas and individual and case studies. In addition to pubmed, you may want to use the search features of the relevant journals in the following list:

http://www.medbioworld.com/cgi-bin/displaycontents.cgi?table=med&type=Journals&filecode=(M)%20Orthopaedic

For example, browsing in Current Opinion in Orthopaedics, I found the following intriguing abstract:

http://www.co-orthopaedics.com/pt/re/coortho/abstract.00001433-200404000-00002.htm;jsessionid=CT1gh9d7kv27f1JSvSLNyEEO1o0FWrpmweewEKUc9YajFVWA4qTU!884695698!-949856031!9001!-1?index=1&results=1&count=10&searchid=1&nav=search

For 'just' $25 you could have instant online access to it.

Re: DR Z

JG on 4/05/05 at 20:41 (172677)

I agree with Amy. Why don't you guys exchange phone numbers and discuss percentages among yourselves?

Re: DR Z ( Scott R

Dr. Z on 4/05/05 at 20:55 (172678)

Actually this is a post to finally remove Fed Up, great honest name, on this board. Now that Scott has the ability it is time to remove the poster. I guess you don't know his history of insult, ridiculous and most important wasting my time while trying to answer and help people on this board. Sorry I forgot to add Scott to my post. I have now We have the ability to clean this board up . Now is the time

Re: DR Z ScottR

Dr. Z on 4/05/05 at 20:57 (172679)

Beside these posts being ridiculous by Fed Up . He does know the difference between TTS and Neuroma. Scott its time to block this guy. His past, present and future posts are just one waste of time

Re: block who?

Scott R on 4/05/05 at 21:16 (172680)

Block who Dr. Z? I see one person using the Fed Up Also alias. But they post under a different name sometimes and they don't seem malicious yet. For the newcomers: you shouldn't use different names, especially if it's to be mean to someone or to cause trouble on the board.

Re: Terrible TTS results.

Kim on 4/05/05 at 22:14 (172687)

Please add extra info if needed: patients or consumers of pts with TTS or to have surgery or have had surgery: to be the best advocate for the patient or for yourself we need to keep up the education this board provides & support. Please ask questions even if you feel the question is little. Ask about medications before, during & after. What can be done conventionally such as physical therapy, light therapy, ultrasound therapy , water therapy. Ask about test such as nerve conduction, EMG test, MRI, ask about splints, ask about if any back problems also make sure the Doctor does a actual physical assessment of the foot & ask about the anatomocial structures of the foot affected, have the Doctor draw a line on the foot affected, See if nerve blocks help.Marcaine is generally used. Also make sure the Doctor is going to assist you with Medications & teachings if things go not as planned. Have the Doctor explain the Surgery & exactly what is going to be done. Do Not be rushed into anything. Know the postoperative care. You will be on bedrest for 3 weeks usually then, partial weight bearing for another 3 weeks. Pt.s will need crutches!! & possible bedside commode if necessary. Surgery is done ambulatory & will come home with a bulky dressing. Have your MD. provide explicit instructions. Do not get the cast wet. You might have some swelling & after you start walking plan on getting different size sneakers they recommend new balances unless you find the sneaker to heavy a Nike Airdyne is light & has a support arch. Also if you never used crutches before. Have someone teach you use crutches. Ask about anasthesia whether it be a spinal or general, or nerve block.Ask what are my risk for infection,RSD,dehiscence of wound, swelling etc. Plan on taking a least a year possible to heal.Nerves grow only so slow. Ask about zingers, Numbness or tightness, pinching pain. What precautions to take for scar tissue & if it develops what can be done to miminize scarring/or break scar tissue up. Have MD. check high Tarsal tunnel Zone in foot,ankle to leg(4inches up from ankle.Please See Surgeon Recommendation Needed:Questions to ask also posted on this board 3/7/05.Sorry this is so long but we need to continue to educate ourselves about TTS & What can do to improve ourlives.The success rate is still not ask good as it should be. Again All that support this board & whom continue to educate Thank You.

Re: Terrible TTS results.

Kim on 4/05/05 at 22:18 (172688)

Elliot, thanks for the websites will check them out.

Re: Terrible TTS results.

Amy on 4/05/05 at 22:27 (172689)

good post - useful to all of us - thanks.

Re: DR Z ( Scott R

JG on 4/05/05 at 22:40 (172690)

Good luck cleaning up this message board. There was a nasty detour somewhere along the way and we lost sight of the reason most of us are here.....for help and support.

Re: block who?

Dr. Z on 4/06/05 at 00:01 (172695)

It was Fed Up. He just jumps into a post for no other reason but to interfere with a thread.

Re: Terrible TTS results.

Dr. Z on 4/06/05 at 00:03 (172696)

Good one

Re: DR Z

Fed Up Also on 4/06/05 at 15:16 (172720)

You can block, that's fine, but how about a straight forward honest answer before I'm blocked.

1. How can you say that the FDA results for ESWT were flawed and your results are more valid (i.e. 50% FDA verses 94% for your company).

2. How can you claim to have no knowledge of that cute little card I recieved reference ESWT but give the same telephone to elliot that appears on the card.

3. Why are the stats by Dr. for TTS flawed and not capable of being that high?

Re: DR Z

Dr. Z on 4/06/05 at 16:57 (172726)

Answers

1. Never stated that the FDA results were Flawed. The 94% is the Roles Maudsley scoring at one year follow up with the patients that were contacted. The 62% R/ D is from the 12 weeks follow.
2. Why should I know about this card. It probaby did come from Excellence
3. I can disagree with results. There is a big difference with a TTS study done by one doctor and a multi-center, double blind, randonized study done thru the FDA for ESWT.
4. I still feel that you should be banned you contribute nothing to this board. It is Scott R board and he can do whatever he wants.

This will be the last post to you. I would appreciate that you don't ask, reference or address Dr. Z at all on this board.

Re: Terrible TTS results.

Ed Davis, DPM on 4/12/05 at 21:14 (173100)

Dr. Z:
It would be great if the studies divided patients consistently into 2 categories: 1)those who have an identifiable growth placing pressure on the nerve. 2)those who do not. I think category 1 patients have a clear need and advantage with surgery. Category 2 patients most likely are in the group that pulls the stats down as they are getting a procedure to release scar tissue from the nerve and since surgery itself is a cause of scar tissue, there is an inherent reason for success rates to be modest.
Ed