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The Treatment of Verrucae Pedis Using Falknor’s Needling Method: A Review of 46 Cases

Discussion in 'General Issues and Discussion Forum' started by Dieter Fellner, Nov 15, 2016.

  1. Dieter Fellner

    Dieter Fellner Well-Known Member


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    I am dealing with a 24 yo female with three reclacitrant plantar warts of five years duration on her right forefoot in spite of extensive previous treatment attempts with chemical therapy, electrocautery, surgical excision and, most recently a series of five cryosurgery attempts.

    I saw her for the first time yesterday and I discussed with her dry needling ala Falknor's method. I stumbled across the online, excellent article from Dr. I Bristow and our own Belinda Longhurst. Well worth a read, and a technique well worthy of consideration. Dr. Kirby is also acknowledged.

    The lesions appear typical for plantar warts and look benign from a clinical perspective but we also discussed biopsy.

    http://www.mdpi.com/2077-0383/2/2/13/pdf
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Dieter Fellner

    Dieter Fellner Well-Known Member

  4. blinda

    blinda MVP

    You`re too kind, Dieter.

    Farina Hashmi and her team have just completed an RCT on this - I am not privy to the results as yet (because I am on the ethics and steering committee only), but the trial can be found here; http://bmjopen.bmj.com/content/5/11/e009406.full
     
  5. Dieter Fellner

    Dieter Fellner Well-Known Member

    Belinda, thanks for the link. Let's see what happens. Whatever the outcome from the study, needling will likely remain a worthwhile option esp. when other treatments have magnificently failed. I feel bad for such a patient. Understandably there is a sense of despondency when yet another treatment is proposed.
     
  6. Dieter:

    Needling is such a simple and relatively painless procedure with almost no risks that I can think of. I would think that the patient would be somewhat excited in a potential cure with another treatment for her vp lesions, rather than despondent. With that being said, I always tell patients that no verrucae treatment is 100% effective and that, sometimes, when one treatment doesn't succeed, another one might cure the lesions.

    Here is the original Podiatry Arena thread where I first introduced Falknor's needling technique to the readers of Podiatry Arena over 7 years ago. By the way, the use of an 18 gauge needle was a mistake at the initial posting...I use a 25 gauge hypodermic needle for the needling.

    https://podiatryarena.com/index.php?threads/mosaic-verrucae-help-with-treatment.25720/
     
  7. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin,

    I agree ... only this patients has had several uncomfortable (i.e. painful) treatment episodes in the past. There are three discreet plantar lesions. The prospect of several injections in the ball of her foot is daunting. I don't want to overstate her condition of despondency, she was certainly receptive to my suggestion.

    About the 25g / 18g issue: does it really matter? The idea will be to 'mush' up the VP 'good & proper'. An interesting modification was suggested by another contributor - crimp the needle 2mm down from the tip. Seems to make sense to obliterate the hollow needle tip when the idea is to implant viral protein tissue SQ.
     
  8. Dieter:

    If one of the verrucae lesions looks older and larger than the other, then you can just needle this "mother wart", which is what I do for mosaic verrucae. If they are close to each other, I will do them all with one plantar injection with ethyl chloride freezing to decrease the pain of the plantar injection. If the patient is really scared and nervous, give her 5 mg Valium tabs and have her take one about 30-60 minutes before the start of the procedure. Then the patient comes in almost happy, rather than scared to have the procedure. Pre-procedure Valium often works wonders for those patients who have "needle-phobia".
     
  9. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin: agreed. I'd use Diazepam 5-10mg on my UK patients for similar reasons - when we don't have the luxury of IV sedation (in Old Blighty, for the most part) and rely totally on LA for all our surgery. I spent a couple of hours going through the previous threads ... beats Ethyl Chloride for brain numbing. BTW Ethyl Chloride is super-expensive. Found alternatives (also fine spray, with freeze capacity to -60F) for a fraction of the cost.
     
  10. [​IMG] [​IMG]
    I use Gebauer's Ethyl Chloride Fine Pinpoint Spray. Even though it costs $50.00/bottle, my patients love it and ask for it every time I need to do an injection. I probably get about 100 sprays out of each bottle so at 50 cents an injection, I wouldn't consider it "super-expensive".
     
  11. W J Liggins

    W J Liggins Well-Known Member

    I'm intrigued. Why not simply use a tibial block (and send patient to the waiting room whilst it takes effect?)

    All the best

    Bill
     
  12. blinda

    blinda MVP

    That`s what I do, Bill. Often see a patient in between whilst LA is taking effect. Patients usually remark that they feel no pain at all.
     
  13. blinda

    blinda MVP

    I think that`s what Mark Russell does. Amarite, Mark?
     
  14. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin: cheapest price I can find from Henry Schein is $258 for 4 (3.5oz) or $80 for one bottle. Perhaps you're getting a better price. The EC alternative is $18 (Amazon) whatever works best for you, I guess.
     
    Last edited: Nov 18, 2016
  15. Dieter Fellner

    Dieter Fellner Well-Known Member

    Bill: this is discussed extensively on the sister thread.

    Check out Kevin's YouTube video :



    He demonstrates the injection technique with ethyl chloride. It's simple and effective and one of the pearls of practice I picked up from Podiatry USA. The topical refrigerant is very popular here and makes light work of a painful injection. I also used the tibial nerve approach but there is always that risk of nerve trauma. Getting good plantar forefoot anesthesia is hit & miss and this can take a long time to develop good anesthesia. That said we also regularly used ankle blocks for our elective surgical cases and rarely (but occasionally) had some residual effect from the tibial block - it's a numbers game and the more you do the more likely you'll eventually get a problem. I am reminded of my UK colleague who was sued for a tibial nerve laceration following such an injection.

    Once you get comfortable with the topical it does make a lot of sense and avoids some risk.
     
    Last edited: Nov 18, 2016
  16. Interesting...on my Henry Schein account they list 4 bottles for $199.00. Don't why it's cheaper for me??
     
  17. Dieter makes an excellent point. I have come too close to a few posterior tibial nerves with a hypodermic needle during PT nerve blocks over the past 30+ years and these patients can have parasthesias, or even worse, for over a year sometimes if the nerve is hurt bad or the patient jumps when the needle is close to the nerve.

    In addition, patients easily walk and easily drive home after ethyl chloride and local plantar infiltration, which PT nerve blocks, causing complete foot numbness, increases your medical liability if they fall or try driving with a numb foot and get into an accident. I'll continue using ethyl chloride, thank you. Works great, is much quicker, and patients tolerate it very well.
     
  18. Dieter Fellner

    Dieter Fellner Well-Known Member

    I'm guessing your office manager is flirting with the HS rep .....:oops:
     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    ethyl chloride.png

    What I found in the HS online product catalog ....
     
  20. W J Liggins

    W J Liggins Well-Known Member

    Each to their own I suppose. One of my registrars did a study several years ago which reviewed approximately 1,700 patients who had undergone ankle block anaesthesia - he was actually looking at the incidence of DVT with ankle cuffs, and the result was nil -. As an incidental finding he also reviewed cases of neuropraxia/paraesthesia and the result was nil. These were all National Health Service patients and the podiatric surgeons involved were very experienced in ankle block anaesthesia.

    All the best

    Bill
     
  21. Dieter Fellner

    Dieter Fellner Well-Known Member

    Bill: do you have the reference for that paper?
     
  22. W J Liggins

    W J Liggins Well-Known Member

    Hi Deiter. I don't think that he ever published. It was done by Julian James and he collected his data from all the then podiatric surgeons in the country (not all of them replied). Shortly afterwards I had a separation from the Society so I did not follow it up.

    Cheers

    Bill
     
  23. Bill:

    When I first started doing Falknor's needling technique about 20 years ago, when my practice was much less busy (10-15 patients a day) I was using a posterior tibial nerve block, which took much longer to get complete anesthesia. However, now, seeing 25-35 patients a day, I simply don't have the time to wait for a PT block to take effect and, honestly, haven't noticed that patients complain more about my ethyl chloride freezing-plantar injection technique than they did about the PT block. That being said, in my situation, my ethyl chloride freezing-plantar injection technique seems far superior for my specific practice situation and has never caused any pain the next day. In addition, my ethyl chloride freezing-plantar injection technique leaves the rest of the plantar foot with complete and full sensation for my patients to be able to walk out of my office with a sensate plantar foot and with a sensate plantar foot while driving back to their home in lawsuit-happy California.

    Like you said, each to their own.:)
     
  24. Dieter Fellner

    Dieter Fellner Well-Known Member

    Bill: that's a pity since this type of information can be a great resource to the profession. I'm curious, though, how this information was collected. If this was a survey based on PASCOM I will be just a little cynical about the results. When any survey reports a 0% incidence over 1700 patients, my cynicism threshold is lower still. Time for more coffee ;)
     
  25. Dieter Fellner

    Dieter Fellner Well-Known Member

    Kevin: I think you need an Associate, willing and able to relocate (with a view to partnership) .... :cool:
     
  26. No room in the practice currently. The orthopedic surgeon I work with (we've worked together now for 30 years) and I fill up all three exam rooms in the office every day of the week. Maybe when he retires....don't know when that is either!
     
  27. Dieter Fellner

    Dieter Fellner Well-Known Member

    Ke
    Kevin: clearly you need to relocate and expand ... (kidding). The partnership with Orthopedics is a very sound business and professional model. I have always enjoyed working alongside our Orthopedic colleagues. My residency program (Montefiore) is an integral part of the Orthopedic service.
     
  28. W J Liggins

    W J Liggins Well-Known Member

    Hi Deiter. I share your concerns re: zero percentages which sound statistically suspicious. As I mentioned, not all those surveyed answered and I suppose it is human nature, regrettable though that may be, to not report problems.
    All the best (have a pint instead of coffee). Bill
     
  29. Dieter Fellner

    Dieter Fellner Well-Known Member

    Bill: agreed, it's not only the under-reporting but the methodology in such a survey. Did all those 1700 patients have a venous duplex to r/o definitively a DVT? I'm guessing: no. You can only see what you're looking for. Did the Podiatric Surgeon ask searching questions about paresthesia / numbness etc? Was an attempt made to perform a rudimentary neurological exam. Or did he rely on a patient flagging up symptoms of concern or simply palm it off ... who can know. I'll take a Bourbon (in place of the pint) .... it suddenly got very cold in New York City.
     
  30. JaneyT

    JaneyT Member

    Hi there,
    I'm new to the needling technique, having attended a course by Belinda Longhurst and Ian Reilly last September. This week I have attempted 2 posterior tibial blocks (my first!!) for vp under the 4th mpj area, neither of which was successful. I ended up doing local infiltrations, ouch! In trying to figure out why I couldn't get the block to work I came across this thread, so I was wondering how long roughly does anaesthesia usually take in this location? I initially injected 2ml, then waited 5 mins, tested, injected some more, tested sensation, waited a bit more (about 15mins in total), gave up! I'm pretty sure I got the position right, marked it out, as I was taught, halfway between MM and calc. Perhaps didn't inject enough to begin with? But now I'm thinking I simply didn't allow enough time? My inexperience showing!
    Any help/suggestions welcome!
    cheers
    Janey
     
  31. W J Liggins

    W J Liggins Well-Known Member

    Hi Janey. Try dorsiflexing and abducting the foot, palpating the posterior tibial artery a little superior to half way between the MM and calc., inject a few mm. inferior to that and but crucially aspirate (dental self aspirating syringes are best) and beware of pt. paraethesia. You will find that some patients - seemingly females in particular - have a fat pad over the area which makes palpation difficult, also the nerve splits at different levels in different patients so try going superior if it fails the first time.

    All the best

    Bill
     
  32. Dieter Fellner

    Dieter Fellner Well-Known Member

    I agree with Bill. Always best when you can palpate the nerve. Relying on topical landmarks and measurements is always an approximation. Anatomical variations can throw a curved ball. Also helps to use a doppler to identify the PTA, note direction of probe, mark the skin and inject just a little posterior to the mark. Advance the needle until you meet bony resistance. Withdraw circa 1/4" , aspirate then infiltrate. Try to mentally visualize the nerve and fan out the fluid. Don't be shy and use 5-7 cc as required. This is a relatively large nerve. Bupivacaine can be slow to work. Not unusual to have to wait 10-15 minutes or more. You can expect the skin to pink up from the vasodilation effect. The nerve block can be somewhat unpredictable. Alternatively or concurrently get familiar and comfortable with the Ethyl Chloride local infiltration technique. It's predictable and quicker and there's no risk of nerve trauma. Depending on the location of the VP you can also try injecting dorsal plantar.
     
  33. JaneyT

    JaneyT Member

    Thanks guys!
    I palpated the artery and angled injection downwards trying to target the lateral branch. We got local flushing and anaesthesia but not anywhere near the front of the foot! I guess I'm really nervous of hitting the artery.
    Silly question: how can I palpate a nerve? I thought it would be too fine to feel.

    Can freezing the tissue be achieved with niquid nitrogen rather than ethyl chloride?
    Thanks
     
  34. Dieter Fellner

    Dieter Fellner Well-Known Member

    If you get a chance, get on a cadaver course so that you can dissect, visualize and palpate this nerve. It's much larger than you might think. On a skinny patient apply firm pressure and you can roll the nerve quite easily with your thumb. Look for that in every patient you see. That way you will have an appreciation for it.

    Don't aim to hit the lateral branch, I doubt it's possible to isolate the medial from the lateral branch. The solution has to circumstantially cover the nerve to be sure to block the nerve impulse. I suspect in some cases it's a partial coverage that's why there is a failure. Be mindful of the fact the medial ankle structures are contained in their own bundles separated out by fascial compartment. You need to be off by only a few mm to find yourself (or the solution) in the wrong space. That's why it's also a good idea to fan out and cover all the bases.

    Please don't use liquid nitrogen - you'll risk a localized frostbite and this may cause skin ulceration. Ethyl Chloride or another skin refrigerant is the way to go.
     
  35. W J Liggins

    W J Liggins Well-Known Member

    Don't press the nerve too hard. As Deiter says, visualise it and roll it - personally I find an index finger more sensitive than a thumb, but that may simply be personal preference. The neurovascular bundle is quite large here and in a less than 'adipose' patient you should quickly find it with practice.

    I wholeheartedly agree with Deiter - avoid liquid N2 at all costs - the only way is the courtroom from there! - and do find an anatomy dissection course. Medical students only dissect one foot between two, so there is usually a free foot per cadaver. Not all medical schools in the UK still carry out cadaver dissection but it is well worth the travel to find one.

    All the best

    Bill
     
  36. JaneyT

    JaneyT Member

    You guys have been really helpful, thanks for that. You have reminded me of things that I did know once upon a time but got lost when I was just doing general treatments. I did do dissection at uni, but it freaked me out so I stopped going!
    Back to the drawing board for me then :)
     
  37. blinda

    blinda MVP

    Hi Janey,

    If you're ever in my neck of the woods, you're welcome to come and observe a tib block or two and then numb my foot?
     
  38. JaneyT

    JaneyT Member

    Would love to Bel, thanks! I will get in touch on your email :)
     
  39. David J 12345

    David J 12345 Member

    That so impressive. Now, I'm going to get shot down in flames but why is this not common practice in the U.K. even when using other modalities.
     
  40. Dieter Fellner

    Dieter Fellner Well-Known Member

    David,

    I think it's simply a question of working practices and familiarity with techniques. I have worked both sides of the Atlantic. When I was in the UK it's highly likely I also wouldn't have considered this useful alternative. I simply wouldn't have had confidence that this alone would help or work too well.

    I soon found, in the US , the practice of using a skin refrigerant is very common. Many patients will expect it, anytime they get a 'shot'. I recall, as a US student, giving a patient a cortisone shot for Morton's neuroma. I'd never before considered using ethyl chloride ... the patient got his shot, without it, but looked at me aghast asking "Hey doc, what happened to the spray!"

    The Attending, observing the proceedings later gently advised me that American patients have an expectation to get that skin numbed before the needle. Point is, once you start to use it, regularly, you get comfortable and have confidence in the technique. Heel injections, neuroma, plantar skin, ankle injections etc etc.
     
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