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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. David J 12345

    David J 12345 Member

    Dieter
    Thanks for the reply, it's funny but we don't really adopt that technique in the UK. As an RN prior to Podiatry it was common to see Oral Surgoens, Medics and Aneasthetics just infiltrating areas for sutures and minor skin surgery and lesions. Ethyl Chloride was often used also. When I asked why we never use LA subcutaneously it was you should always do a forefoot or ankle bloc. It always seemed a little extreme to me. I wonder how many practitioners in the UK use subcutaneous LA as a technique. Is it available and what are the clinical risks of using this technique??

    Regards

    David
     
  2. Dieter Fellner

    Dieter Fellner Well-Known Member

    David,

    Yes, it's possible the more common practice of regional and ankle blocks in UK podiatric surgery has influenced this LA technique for the needling method. Perhaps that's because the anesthesia courses are run by podiatric surgeons? I don't know, but I would hazard a guess.

    Also, of interest, the vast majority of surgery in the US is performed under twilight sedation / MAC (monitored anesthesia care) with LA, or GA. While the regional blocks are also performed, there's maybe somewhat less of an emphasis i.e. if a patient looks uncomfortable the anesthesiologist will step in.

    And, I agree - during my hospital residency, I would commonly see the use of SQ / LA for a variety of applications in other disciplines, also in the ED. There's certainly no reason why anyone cannot or should not apply the method, as demonstrated in Dr. Kirby's excellent video.

    This is a safe technique with few risks - nerve blocks likely carry a greater risk. One common sense caveat: avoid an intra-epidermal injection which may cause skin necrosis (which, ironically in the case of the VP may not be a problem either)
     
  3. David J 12345

    David J 12345 Member

    Dieter
    You're right, interestingly competancy springs to mind. In the U.K. would our insurers insurance we spend an afternoon in a holiday inn paying £500 to be deemed competed to deliver this method. In the absence of surgery it should really be the method of choice. Clean, less risk, relatively simple. Job done. That video of Dr Kirby was excellent on both administration and VP puncture. Interstly what is the success rate of this?

    David
     
  4. Dieter Fellner

    Dieter Fellner Well-Known Member

    David,

    Based on Dr. Ivan Bristow's work it's around the 70% mark.
     
  5. David J 12345

    David J 12345 Member

    Dieter
    Is there a SOP for needling in your NHS establishment. Is plantar infiltration using LA used in the NHS as opposed to blocs tibial blocs. It seems clean, fast, less risk less hassle all round. In private practice I fell we are becoming more risk averse. You can be insured for anything. It's when they come to pay out that the problem. I'm still impressed with that YouTube clip!! (maybe I need to get out more). I can't find any NICE guidelines on the practice.
     
  6. David:

    I use ethyl chloride spray for all my patients' injections. It is fairly quick, helps numb the skin and decreases the "fear" of needles for many. Local infiltration makes much more sense to me for verrucae needling. Many times the plantar infiltration may be done from a dorsal skin stick where the skin is less sensitive. Even plantar skin sticks aren't too bad as long as the skin is numbed well. The key with local infiltration to minimize pain is to push the local anesthetic in slowly so that there is not a sudden expansion of tissues which tends to cause more pain. Plantar infiltrations are not painless, but, to me, they are a far superior and less risky way of doing verrucae needling.
     
  7. Dieter Fellner

    Dieter Fellner Well-Known Member

    David,

    I left the NHS in 2008 and I am now in New York. I can't pretend to have kept up with NHS bureaucracy - I'd simply discuss and consent a patient for it, NHS or private. No procedure is ever risk free but you can reassure your patient the risks are contained.
     
  8. blinda

    blinda MVP

    We offer a refresher for the various LA procedures, including local infiltration and blocks, during our CPD day. It`s up to the practitioner (after the usual risk vs benefit assessment) and patient, which technique they use. As far as I am aware, there are a handful of NHS departments which offer verruca needling, but I am not privy to their protocols.
     
  9. JaneyT

    JaneyT Member

    Hi again,
    just had a little look at the kirby video, appears by the huge flinch from the patient that ethyl chloride is not completely effective for numbing! Why would using liquid Nitrogen lead to court cases? cryotherapy is widely used for treating the verruca anyway. I would presume that applying too much ethyl chloride would have damaging effects also?
     
  10. Dieter Fellner

    Dieter Fellner Well-Known Member

    Janey,

    I can't agree it's a 'huge' flinch ...lol - NO injection will ever be completely pain free! The topical refrigerant controls this to a manageable level. The plantar skin is very sensitive.

    Liquid Nitrogen is simply too aggressive. Look at the freezing temperatures achieved by LN v EC. Bottom line, I have never known anyone use, or recommend, LN as a topical refrigerant. You will be applying the freezing agent to adjacent healthy skin to infiltrate beneath the VP. Applying too much EC could also cause frost bite but it's much less likely - you apply for 20-30 seconds or until you see the superficial freeze develop.

    Each method has pros & cons. You decide, with knowledge of your patient, the optimum approach.
     
  11. Dieter Fellner

    Dieter Fellner Well-Known Member

    Today I followed up on my patient - we tried a couple more cryosurgery sessions first. Because of the 5 year history, and complete lack of response to EVERYTHING tried before, I felt it prudent to first biopsy the lesion. Today I took two punch biopsies, one from the center and one from the periphery.

    So happens, our office has the Madajet Needle Free injector. It's a phenomenal tool for raising a wheel of anesthetic. Topping up, for complete local infiltration is a breeze afterwards. My patient is a little skittish but tolerated the proceedings very well. I now look forward to the green light from the pathology report to go ahead with the needling.
     
  12. blinda

    blinda MVP

    Totally agree on obtaining definative diagnosis prior to treating any lesion that raises the slightest concern, whether needling or other.

    A couple of months ago, a patient was referred to me for needling after her GP had tried cryo and sal acid. I didn't like the appearance, although it was certainly 'verrucous' but the onset was very rapid and she had a history of chemotherapy for ovarian Cancer...Biopsy and subsequent excision revealed acral melanoma mascarading as a plantar wart. One very happy pt as there are no metastases found.
     
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