I was perusing the most recent edition of "Podiatry Today", (http://www.podiatrytoday.com/closer-look-endoscopic-nerve-decompression-morton%E2%80%99s-%E2%80%98neuroma%E2%80%99?page=1), and noticed that they kind of were reminding us that there is an endoscopic procedure for neuroma decompression. This made me think back on how many neuroma's I've excised over the years and which techniques I used; some I liked, some I didn't prefer as much. As you all know, a symptomatic neuroma can be treated surgically when conservative measures fail. This may be via an endoscope, via ligamentus release (either open or by the "Kobygard system"), Radiofrecency oblation,  or via traditional open incisional formal neurectomy.

Now, back to my personal experience. I never liked the notion of injecting dehydrated alcohol into someone's foot - so that technique went out the window. I have performedthe above referenced procedures on numerous occasions and I still prefer the good old fashioned "open" method. That said, I have not operated on a neuroma in at least 2-3 years. I have been achieving great results by simply performing corticosteroid injections, and any combination of physical therapy, orthotics, or shoegear changes. Maybe it's my "cocktail" of injections & treatments, or just plain old good luck (which I don't believe in). I don't know, but as i stated I haven't need to operate on a neuroma in years.

My question to you folks is what has your experience been with neuromas and what is your preference (if any) in surgical technique?

 

  • Comments (18)
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  • Mike - for the most part I feel neuromas can be treated conservatively with 4percent dehydrated alcohol as taught to me by Dr. Dockery.
    When they fail, which I find to be uncommon my next step is he kobyguard. If your patient had pain, I wonder if your local block was good?? I, like your rep stated to twist the kobyguard almost like a key in an ignition. I also mark on the skin where the transverse met ligament is and I don't shove the instrumentation so proximally....
    They work well. I have not. Had to go beyond the kobyguard, I don't recall the last time I had to excise a neuroma.
  • Hi Alex,

    Read your question about neuromas, and wondered what you use for a cocktail for your neuroma injections?  Thank you for your help

    Mike McGowan

  • Hi Jeff, 

    Just read about your tx of neuromas with Koby gard, do you still use this?  I used it a few times but seemed to work about 6 months or so then the pain came back. A rep from KG told me to twist the instrument (iso-guard) after cutting the ligament. I did this and the pt. had so much pain po that I have not done another neuroma with the KG system.  You have helped me with the Hypocure thought you may have some insights on Koby gard.  Thanks Jeff,

    Mike

  • "Previous diagnoses like partially compensated forefoot valgus and fully compensated forefoot varus do not help us define Fhl and we are left with a subjective discussion of the nerve pattern into the forefoot which has never been proven."


    I would never disagree with Dr. Shavelson. I might have a second opinion or way of looking at the above 

    statement. First of all Dr. Shavelson takes a marveous wonderful approach to breaking down the eitiology

    of neuroma. Yet one can indeed further classify a partially compensated forefoot valgus into the "flexible"

    type not the rigid type. This flexible type yields the "relative subtalar joint pronation" and I cannot possilby 

    understand how that compensation for the flexible planterflexed ray differs from the functional hallux limitus?

    The compenstation for flexible plantar first ray is relative pronation of the rearfoot involving not that suponatory rock on the frontal plane that is noted during the compensation of the rigid deformity but quite the opposite compensation on the frontal plane. Didn't Dr. Wernick podiatrist teach these concepts very well? Every one of my teachers including Dr. Shavelson were wonderful and I am grateful to all of them. To be a teacher

    in podiatric biomechanics is probably one of the most wonderful professions. Think of all the people you help.

    Most neuromals also occur between the 4th and 5th metarasals.

     

    Dan

    class 84

  • Quote:

    I believe that all painful neuromas [and plantar fasciitis] is due to uncompesated Functional Hallux Limitus. I treat this with a Dananberg wedge [or a first met clip] and it goes away. I rarely operate on them now.

    In years past I also got great results with sclerosing alcohol, without ultrasound guidance. If you can numb the nerve with local you can hit it with the sclerosing agent too.

    I'm in the Dr Gottlieb camp on this one.

    Dennis

  • I HAVE READ EVERYTHING ABOVE, AND AGREE VIRTUALLY WITH EVERYTHING WRITTEN; WITH THAT SAID, HERE IS MY PROTOCOL AFTER 14 YEARS:

    1.  RICE, NSAIDS, WIDER SHOEGEAR, LO-DYE, MODIFY ACTIVITIES.

    2.  XRAYS REVIEWED W/ PT, DIAGNOSTIC BLOCK, EMPHASIZE #1, RECOMMEND ORTHOTICS.

    3.  CORTICOSTEROID INJECTION, REPEAT IF SOME RELIEF REPORTED X2 MORE.  MILD ANALGESIC OF CHOICE, IF CANDIDATE, IF VERY PAINFUL (PAIN IS PAIN, SO TREAT IT).

    4.  AFTER DUE COURSE OF CONSERVATIVE TX, IF NEUROMA SMALL, INTERMET LIG RELEASE (ENDOSCOPIC). I HAVE NEVER HAD A PROBLEM ROTATING THE INSTRUMENTATION (AM JUSTLIN'S) AND VISUALIZING THE NEUROMA FROM WHERE THE INTERMETARSAL LIGAMENT WAS JUST TRANSECTED; TAKE A PICTURE.  IF THE NEUROMA IS JUDGED TO BE RATHER LARGE, THEN ONE CAN CONVERT TO OPEN.  SIMPLY EXTEND THE INCISION AND RESECT.

    5.  IF NEUROMA IS LARGE (i.e, palpably, MRI, US image), RESECTION VIA APPROACH OF CHOICE- GOES QUICKER VIA PLANTAR APPROACH; AFTER YEARS OF DORSAL APPROACH, I BECAME PLANTAR CONVERT- IT POPS RIGHT OUT AT YOU!  PUT THEM IN A WEDGE SHOE TO OFF-WEIGHT FOREFOOT; SUTURES STAY IN LONGER (OBVIOUSLY, 'CUZ PLANTAR SKIN TAKES LONGER TO HEAL).

    5.  IF PT ADVERSE TO SURGICAL OPTION, OFFER SCLEROSING INJECTION THERAPY; USE STRONGER CONCENTRATION DEPENDING ON SIZE, E.G., 6-8 %.  MUST HIT IT AND JUST PROXIMAL TO IT; PT MUST SAY OUCH, AND TELL THEM IT WILL HURT, BUT LESS AND LESS EACH INJECTION AT 7-10, NOT MORE THAN 14 DAYS APART (BUT I'VE HAD THEM SKIP AND INJECTION AND STILL CONTINUE WITH SUCCESS).  I UTILIZE ULTRA-SOUND GUIDED NOW TOO; IT ACTUALLY HELPS, AND IT DOCUMENTS THE CLINICAL INJECTION PROCEDURE AS WELL.

    wg

  • Quote:

    Dear Dr Gottlieb Just came across your article on how I learned to love FHL and Dr Dananberg. I also was intrigued by his articles and spent some time with him in New Hampshire.Two non consecutive days. I also think he is a genius the way he thinks so independently.I use manipulation and have read all of his articles. The purpose of this email follows. I live in a depressed area and would like to use low dye taping for my poorer patients. The problem I have is the relatively short time the tape stays on. Could you give me some idea of how you tape or did tape when you added a kinetic type felt wedge to the low dye taping.  It will help me help some of my poorer patients Thanks Arthur Lukoff


    Arthur, thanks for your input and question.

    I found that there were three secrets for making the tape stay on for a week or so. I will give my Dad credit for them.

    One was to clean the foot first. We used a whirlpool on everyone for every visit. Then allow the foot to dry well [we were treating other patients during this time]. This removes the natural oils and sweat and the dirt that they attract. This step makes a huge difference. I know use alcohol and/or soap and water to remove the oils.

    Second secret is tape spray. Lots of Pedi PreTape or whatever adhesive spray is on the market now. This makes the surface of the foot receptive to the tape. It also acts as a barrier for the tape to adher to instead of skin. Prevents irrittation and the tape stays on.

    Third is what I call the 'holey bandage' technique. Religious patients love this pun, G-d bless them. I cut multilpe oblong holes into the tape substance. This increases the pliability of the tape so it forms and molds to the foot better. More importantly it provides a way for moisture to escape and the foot and tape to dry off well after bathing. Yes, bathing.

    Fourth [yeah, I think I said 3 secrets, this is more of a whisper] is that I used Elastikon tape. It has/had [does J&J still make this?] multiple pores that helped it dry out. And I seem to recall that it stretched better than the other tapes did.

    When taped the way described above I tell my patients to take showers, not baths. Then stand on a folded towel and rock back a forth a few times to help drain and dry the tape and pads. Done properly the tape and padding will typically last a week. I've had patients manage to keep it on wayyyy toooooo looonnnngggg.

    Low Dye taping worked best for me, use the technique that works best for you as long as it holds the heel with the appropriate padding [usually a varus wedge cut from an adhesive horsehoe felt pad for the hindfoot and a varus kinetic type wedge for the forefoot]. Once the patient likes the support you can then mold for an appropriate orthotic. I don't know what the going rate is these days but in 2003 I used to charge $550.

    Dave Gottlieb, DPM  my own personal thoughts and opinions only, no one else

  • Dear Dr Gottlieb Just came across your article on how I learned to love FHL and Dr Dananberg. I also was intrigued by his articles and spent some time with him in New Hampshire.Two non consecutive days. I also think he is a genius the way he thinks so independently.I use manipulation and have read all of his articles. The purpose of this email follows. I live in a depressed area and would like to use low dye taping for my poorer patients. The problem I have is the relatively short time the tape stays on. Could you give me some idea of how you tape or did tape when you added a kinetic type felt wedge to the low dye taping.  It will help me help some of my poorer patients Thanks Arthur Lukoff

  • Quote:

    Great input everybody!

    For the V.A.podiatrists on here, how can I acquire the dehydrated alcohol? Since I am no longer in the private sector,I am having trouble getting things into my clinic which were commonplace in my office. Cantardin for warts is a big one! I miss that stuff, but I can't get it within the V.A.



    Alex,

    I have not ordered it here at the VA in Seattle, however did order it once at the VA in San Antonio a couple of years ago.  All I did was talk to the pharmacist and tell them the concentrations I needed and they prepared it for me.  But I was required to order it for a specific patient and use was on that individual patient alone (therefore I kept it labeled and locked in my office with the patients information).  When I finished the injections I was to discard of any remaining injectable. 

    Not sure if you've talked to your pharmacist there, but I would believe that would be the first step and then they may require the same in regards to ordering it for a specific patient's use.

    Hope that helps.

  • Great input everybody!

    For the V.A.podiatrists on here, how can I acquire the dehydrated alcohol? Since I am no longer in the private sector,I am having trouble getting things into my clinic which were commonplace in my office. Cantardin for warts is a big one! I miss that stuff, but I can't get it within the V.A.

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