April 2014

Study Examines Minimally Invasive Neuroma Decompression

By Brian McCurdy

Can an emerging minimally invasive decompression technique be beneficial for neuromas? A poster abstract presented at the American College of Foot and Ankle Surgeons (ACFAS) Scientific Conference says the technique holds promise and is less time consuming and cumbersome than an endoscopic technique.

   The retrospective case study focused on 16 patients with neuromas who had failed conservative therapy. Out of 23 decompressions performed, the study notes that only one patient had recurring symptoms and the remaining patients’ symptoms had fully resolved in an average of 20.6 days. Patients bore weight in surgical shoes for a week after the procedure before returning to normal shoegear.

   Abstract co-author Leslie Niehaus, DPM, notes that the decompression technique is based on the minimally invasive technique of Stephen Barrett, DPM, without the costs of the instrumentation. He notes the 1 cm incision in the web space usually heals very well.

   “This allows a quicker recovery to shoes and work. The success rate has been very good, around 85 percent. We do see a few that need to have the open procedure later but very few,” says Dr. Niehaus, the Director of the Alliance Community Hospital Podiatric Residency Program in Alliance, Ohio.

   However, Dr. Niehaus does note the decompression procedure’s learning curve, saying it is a “blind” procedure that surgeons perform by touch and anatomical knowledge. He notes the nerve as well as the adjacent tendons can be damaged without proper surgical technique. Dr. Niehaus adds that the procedure would not identify or biopsy true tumorous masses.

   Abstract co-author Alisa Ludwig, DPM, concurs. She says poor surgical technique may damage intrinsic muscles, can cause hammertoe deformity and if one does not release the entire deep transverse ligament, the procedure will fail. In the long-term, Dr. Ludwig believes patients will fare very well if one believes that the compression was the cause of the pain. She says the patient bears weight after the surgery so there is no fibrosis of the deep transverse ligament. Dr. Ludwig also maintains that this should be a permanent correction. She recommends emphasizing the importance of appropriate shoe gear after the procedure.

   As Dr. Ludwig points out, patients with a positive Mulder’s sign and Lachman test tend to have better results with the minimally invasive neuroma decompression. Dr. Niehaus adds that patients with the classic entrapment symptoms without gross deformity of the web space from an obvious space-occupying lesion are good candidates for the minimally invasive decompression. He says ultrasound or magnetic resonance imaging can help determine if an open technique is indicated. The minimally invasive surgery is not ideal for patients with bulbous lesions or a positive Sullivan’s sign, notes Dr. Ludwig, a second-year resident at Alliance Community Hospital.

   Dr. Niehaus notes minimally invasive surgery is not a new idea and surgeons have done it with various techniques such as cryotherapy, sclerosing therapy and platelet rich plasma. He points out that the surgery can be an option for patients with neuromas who do not wish to have the standard open techniques.

How Effective Is Ultrasound Debridement For Wounds?

By Brian McCurdy, Senior Editor

Ultrasonic debridement can effectively remove necrotic tissue from wounds, according to an abstract submitted to the Symposium on Advanced Wound Care Spring (SAWC Spring).
The study focused on 35 patients, 14 of whom had complicated post-op wounds and 21 of whom had chronic wounds. Patients received from one to eight ultrasound treatments over 12 weeks. Using Bates-Jensen Wound Assessment Tool scores pre- and post-treatment, the study researchers noted a decrease in necrotic tissue.

   Kazu Suzuki, DPM, CWS, has been using a low frequency ultrasound device daily in his wound care center for several years and the advantages include much less pain in comparison with sharp debridement. Many of his patients specifically ask for ultrasound rather than a regular scalpel. The combination of ultrasound with saline irrigation as an ultrasound medium allows Dr. Suzuki to debride irregular-shaped wounds and the wound bed more thoroughly. In addition, he notes ultrasound debridement provides near sterilization of the wound bed and can promote faster wound healing.

   “The end results are a very clean wound that is impossible to obtain with only a scalpel and saline flush,” says Dr. Suzuki, the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers in Los Angeles.

   The disadvantages of ultrasonic debridement, according to Dr. Suzuki, include the cost of the technology and a lack of reimbursement coding.

   Dr. Suzuki most often uses ultrasound debridement for acute hematomas (in irrigating and evacuating hematomas), as well as skin tears and lacerations. He notes the modality is helpful in large venous ulcers, which often have an irregular shape, and any neglected chronic wounds with a thick layer of devitalized tissues and biofilms.

   The Symposium on Advanced Wound Care Spring/Wound Healing Society (SAWC Spring/WHS) meeting will be held April 23-27 in Orlando, FL. For more info, visit www.sawcspring.com .

Does A Gastroc Recession Enhance Plantar Fasciotomy?

By Brian McCurdy, Senior Editor

Surgery can be a viable alternative for patients whose plantar fasciitis does not respond to conservative therapy. A poster abstract recently presented at the ACFAS Scientific Conference examines the effects of combining plantar fasciotomy with a gastrocnemius recession.

   The retrospective study focused on 472 patients who failed conservative treatment for plantar fasciitis. The patients were divided into two groups: those who had plantar fasciotomy alone or those who had a plantar fasciotomy with gastrocnemius recession. Thirty-five patients completed a modified Foot Function Index questionnaire and the survey results demonstrated no significant difference in regard to the addition of the gastroc recession to the plantar fasciotomy.

   Abstract author George Rivello, DPM, contends that since the reasons for plantar fasciitis are multifactorial, it is difficult to draw a direct cause and effect relationship from a tight heel cord to chronic plantar fasciitis. He speculates that is why adding a gastrocnemius recession to a plantar fascia release in his study did not seem to provide much additional pain relief in the long term.

   H. John Visser, DPM, says the theory behind gastrocnemius recession for plantar fasciitis is that its contraction instills a plantarflexion force in the calcaneus, putting further strain on a taut plantar fascia and aggravating the symptoms. He feels the problem with gastrocnemius recession and plantar fascia release is that the weakness created by lengthening causes increased weightbearing forces directly through the calcaneal tuberosity.

   Dr. Rivello, a second-year resident at Scripps Mercy Hospital Podiatric Residency Program in San Diego, notes that only 10 percent of patients with plantar fasciitis will continue to be symptomatic at 10 months after some form of conservative treatment. Before pursuing surgical treatment, he suggests exhausting conservative measures such as injection therapy, night splits, non-steroidal anti-inflammatory drugs, orthoses and even cast immobilization.

   In his study, Dr. Rivello points out that no pain scoring was available before the surgery so the study could not determine whether there was baseline improvement in both groups or if the groups were appropriately matched for preoperative pain scores. He notes future research would ideally be a prospective case comparison study of the two treatment groups of plantar fascia release and isolated gastroc recession.

   Plantar fasciotomy is most effective in a subtle cavus foot, notes Dr. Visser, the Director of the Mineral Area Regional Medical Center Residency Program in Farmington, Mo., and the Director of SSM DePaul Residency Program in St. Louis. However, he notes plantar fasciotomy is unnecessary in patients who can tolerate the symptoms of plantar fasciitis, which mostly improve in one year.

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