New Study Emphasizes Cryosurgery For Painful Foot Neuromas

By Brian McCurdy, Associate Editor

Practitioners traditionally use cortisone or alcohol sclerosing injections, orthotics, surgery or other modalities to treat foot neuromas. Now you can also use precisely targeted ice injections as a minimally invasive surgical procedure for relieving painful neuromas in the foot. New research on this modality was recently reported at the Annual Meeting of the American College of Foot and Ankle Surgeons (ACFAS). Freezing these neuromas is proving very effective as an alternative to surgery for treating neuromas that fail conservative methods, according to study authors Lawrence Fallat, DPM, FACFAS and Eric Caporusso, DPM. In the study, Dr. Fallat used this procedure to treat 31 neuromas in 20 patients. All had failed conservative treatment and some had had unsuccessful neurectomies. The study authors evaluated the patients for one year, gauging pain ratings and patient satisfaction. Eighty-three percent of the patients in the study said the cryosurgery provided significant pain relief, 39 percent said they were pain-free, and 90 percent said they would have the procedure performed again. “Cryosurgery should be considered as a viable treatment for symptomatic neuromas of the lower extremity,” emphasizes Dr. Fallat. “It is fast and convenient and has no post-op disability.” He also adds that patients do not need stitches after the procedure. So how does the procedure work? “With the advent of sophisticated gas expansion needles, we can freeze painful tissue with a 3-mm probe,” notes Dr. Fallat. He says during this six-minute procedure, which you can do in your office, nitrous oxide gas is passed and withdrawn through the probe tip to lower tissue temperature to minus 70ºC. A 5-mm ice ball that forms at the tip of the probe destroys the local nerve tissue. There are a few caveats, though. Some patients in the study said they did not benefit from the procedure, but they all had a previous neurectomy. According to Dr. Fallat, scar tissue from those surgeries may have prevented complete penetration with the probe. Therefore, he says you should avoid using cryosurgery for these patients as the “freezeball” cannot penetrate the scar tissue. While cryosurgery does not get rid of neuromas, it reduces patients’ sensitivity and makes the condition less painful, according to Dr. Fallat. He says patients “consider this a victory.” “My overall assessment of the cryosurgery for neuromas is that it should be added to the list of acceptable treatments for this condition,” says Gary Dockery, DPM, the Founder and Director of the Northwest Podiatric Foundation for Education and Research. “However, it is still a surgical procedure, even if it’s listed as ‘minimally invasive surgery.’” Dr. Dockery notes that chemical neurolysis provides more effective results in terms of “pain-free” patients. While the cryosurgery study found that 39 percent of the patients were pain-free after the procedure, Dr. Dockery notes that his 1999 study of chemical neurolysis found that 82 percent of his patients were pain-free. Still, both Drs. Fallat and Dockery believe cryosurgery does provide another option in the arsenal for foot neuromas and should be considered before the more invasive neurectomy. “The failure rate of neurectomy exceeds 20 percent, and neuromas can recur,” explains Dr. Fallat. Follow-Up Results From Study Show Promise For OrCel The results are in and they seem to be promising for a six-month follow-up study of all 36 patients involved in a venous ulcer pilot trial for the skin substitute OrCel. The results, which were submitted in a final report to the Food and Drug Administration (FDA), show 71 percent of the patients treated with a non-frozen version of OrCel achieved 100 percent wound closure compared to 37 percent for the control group. This represents a 92 percent improvement using OrCel to treat hard-to-heal ulcers over standard of care therapy. In addition, the rate of wound closure for the OrCel-treated group was double that of the control group and the group treated with OrCel consistently required fewer days to heal. “Those patients who have received treatment with OrCel have been very pleased in that their chronic wounds have healed with treatment,” notes Scott Lipkin, DPM, who has enrolled three patients in OrCel’s open label venous leg ulcer trial and has been involved with its diabetic foot ulcer trials. “Patients are happy with OrCel treatment in that it is painless, safe and it works. Patients treated for venous ulcers have noted a marked decrease in pain after OrCel application.” David G. Armstrong, DPM, says his group at the Southern Arizona Veterans Affairs Medical Center is beginning enrollment in both the OrCel venous stasis wound trial and the diabetic foot wound trial. He says time will tell what he and his group find. “Certainly, (OrCel) is attractive because of its unique cryopreservation qualities,” points out Dr. Armstrong. “It can be stored for a longer period of time than Dermagraft or Apligraf. Whether this is ultimately important or not or what the eventual results turn up remains to be seen.” According to Ortec International, the manufacturer of OrCel, the controlled pilot study that generated the new data involved 36 patients and eight centers. Patients were prescreened to ensure inclusion of only hard-to-heal ulcers. The study excluded ulcers which showed more than a 30 percent improvement to standard of care therapy. The median size of the ulcers treated for both the OrCel and control groups was 4.5 cm, with the median age of the ulcers being nine months for the OrCel group and 10 months for the control group. For more information on OrCel, which has received previous FDA approvals for treating epidermolysis bullosa and donor sites in burn patients, visit Ortec’s Web site at — B.M. Are Lasers The New Wave In Removing Warts? Wart removal has gotten a “facelift” with the introduction of lasers to treat verruca plantaris. Podiatrists are citing lasers for improved treatment results, as well as increased efficiency. One such laser used by podiatrists is the Ceralas D 980 nm diode laser. According to the manufacturer Biolitec, you can use the laser to treat different types of warts as it enables you to perform one-step cutting and coagulating, and decreases recurrence risk. The 980nm wavelength gives podiatrists precise, controlled soft tissue ablation and hemostasis that fosters effective results. Michael D. Drager, DPM, has found much success with the Ceralas D laser, using it alone as a first line therapy. His patients have found this type of treatment more effective than topical treatments and “generally do not experience pain.” Dr. Drager says patients begin to see results within four to six weeks after treatment has begun. Dr. Drager says the laser is “ideal for mosaic, flat, plantar warts,” adding that no dressing change is required and you don’t have to contend with an open wound. Biolitec notes that you can also use the laser to treat vascular lesions and moles, in general incisions and wound care, although Dr. Drager warns against using laser therapy on bigger and deeper lesions. —Gina DiGironimo Production Editor Web Site Pick Of The Month If you’re looking for a referral service that helps your practice grow and ensures your financial assets, you should check out This site provides doctors and advisors the opportunity to discuss current economic issues and the site’s independent advisory team can offer cost-effective solutions to enhance your practice. Designed as a referral exchange and educational center, the site provides a range of services from a “Discussion Forum” to Archives to “Ask An Advisor.”

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