April 2014

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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.

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