Neurovascular corns treatment

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Hi
I`m a Podiatrist working in an NHS trust in Wales.
I am currently collecting data regarding how many patients we see with Neurovascular corns.
On avaerage they`re seen every 3-4 weeks for minimal debridemant as they are too painful.
I`m trying to find more information on the different treatments we could offer. I`ve heared of WP Ointment, and hydrocolloid dressings. I was interested in finding out about surgical debridement with a tibial block
Ha anybody done this? and was it beneficial?

Thank you

 

I referred my pt with a R/PMA/4 NV corn for surgical excision with the tibial block. However he has 5 NV corns in total all on the PMA. This being the worst one, we decided to try it. He is seen by me every 4/52 and he wanted to try it. This was about a year ago now and it's worse than it was before, possibly due to scar tissue. I don't recommend for an NV corn on a prominency. Didn't work in this instance.

 

Hi,
I see a gentleman every 4 weeks for debridement and have recently been using potassium hydroxide 5% solution whilst debriding and then clean it off and apply silver nitrate after finished debriding. It seems to be making a huge difference. The client managed a whole 15 minutes without wincing!!
Lucy

 

Posting in another thread reminded me - look up Gary Dockerys work on sclerosing alcohol injections for plantar lesions of this kind - might give you some more insights!

 

Hi
I too have many pt`s who suffer with NV corns, its very frustrating that we cant seem to offer a long term solution.
I have heard of potassium hydroxide 5% being applied to the lesion prior to debridement, also another post mentioned the use of phenol application to the site for 5 mins prior to light debridement.. hope this helps

 

For me the priority would be to remove the forces damaging the local tissue. Until this is done everything else is a relative waste of time.

After that, during treatment, give an injection of local anaesthetic to allow you to debride the area maximally and do the best enucleation you can.

A successful enucleation will mean that:
you transect a few capillaries and amputate a few nerve endings (amputed nerve endings do not transmit pain impulses);
The quality of your enucleation will be equal to that of a simple hard corn;
The patient suffers no pain during enucleation;
You suffer no stress during the enucleation;
the patient is happy to return for follow up treatment.

The success or otherwise of your treatment is dependant upon ensuring that the forces applied to the living tissues are within the level of tissue tolerance, ie the forces don't cause tissue damage. There are two aspects to that. The first is ensuring that the forces applied to the area are within the level of tissue tolerance and the second is to ensure that the reduction of the str.corneum is such that the thickened, denser str.corneum doesn't contribute to tissue damage.

If you can't modify the forces succesfully you may as well carry on doing what your doing or add a bit of this, eg silver nitrate or a bit of that vitamin A, etc, etc. The chances of producing any real benefit will be just about zero but at least you will get the feeling that you are doing something more useful.

Good Luck,

Bill

 

Hi,
The previous post by wdd was spot on.
All of the neurovascular corns that I have had to treat usually have a poor deflective component to the treatment. However the patient usually has a long history with many failed, or poor treatment attempts. The first thing I often have to do is build up a level of confidence with the patient. They are pretty sore when they come in and always wont let you remove the whole corn. Firstly I debride as much as I can. Then apply acid, as for warts. Then deflect with the thickest material I can to take pressure off the area. The acid softens up the area removes some of the corn in a much more painfree way than debriding. The amount of acid and its concentration depends on the individual. Review weekly until gone with the same treatment. By now you are really improving things, they are very happy, so now you can get them into orthotics easily.

A note on orthotics. The more you can deflect pressure off the area the better. Its all about the pressure, forces etc.

I recently tried this treatment approach with a patient and they had an allergic reaction to the salicylic acid. They then on the review told me that she was allergic to the acid. She had forgotten, her twin sister reminded her when her foot started burning (not just where the acid was but everywhere) apparently later in the day. I solved this by using hydrogen peroxide 20 volume. This softens the area, turning it a whitish colour, makes it less sensitive and cooler (according to patient). It is a very slow debride though and only worthwhile in these rare cases. All you do is keep applying very liberal amounts of hydrogen peroxide whenever the corn gets tender to debride until you have to stop then deflect. The more deflection the better.

The quickest way though, if you can, is to give a local anaesthetic. Once numb very carefully debride the nv corn. Then deflect. If you can deflect well enough with orthotics, felt etc you will get loads of referrals from this patient forever due to the poor treatment history. I wasn't taught any of this at uni.

I love treating these things.
All the best
Peter.

 

Yep, I wasn`t taught that at undergrad level either. As a profession, we certainly underultilise the use of LA. We have the indepth knowledge of anatomy and physiology of the lower limb, in addition to holding the privileged position of rendering what would ordinarily be a painful procedure, painless with LA. This includes enucleation of NVC`s, so why don`t more pods use it?

Just my thoughts.

Bel

 

When LA first came in there were practitioners who refused to use if to treat true onychocryptosis, ie where a spike of nail has penetrated the flesh. They considered that using LA was admission of poor technique! It's a little like a surgeon of the pre-anaesthesia school refusing to use general anaesthetic because his technique was so 'good' that he could amputate a leg in 15s anyway (frequently including a couple of his assistant's fingers for good measure).

If you have a patient with an painful involuted, possibly cryptotic toe nail do you automatically and immediately use LA or do you try to treat it first without LA and only if it's unbearable resort to LA? Why the delay?

Although you weren't taught to use LA to aid in the management of this specific condition you were taught how to enucleate and you were taught how to administer LA to allow pain free surgery.

Is there some reason why it should only be nails surgery that is pain free?

Is there some ethical issue here that I can't see?

Do American podiatrists give LA to facilitate the enucleation of so called neurovascular corns or any other type of painful corn come to that?


Bill

 

Bill, not sure who you are directing your questions to, but I agree completely. That was the point i was trying to make. I`ll use LA for spikes, NVC`s, VP`s and nail avulsions.

Bel

 

Hi Bel,

Sorry if it seemed that I was directing my questions at you specifically or if there seemed to be any implied criticism in them. That was not my intention. My questions are aimed at the broad community of PA users hopefully including some whose training was not influenced by the British system.

Bill.

 

You`re alright, Bill. It`ll take more than that to penetrate my thick skin. :drinks

 

Might it be useful to begin routinely using LA to facilitate enucleation?

Bill

 

How much time has the corn the KoH solution to stay over the corn before the debridment?
I'm working with urea 50% cream in occlusion before to treat it...easier for debriding but the patient it's still wincing!

 

how much time do you let on the corn the H2O2 before the debriding?

thanks
FA