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Corn Cutting in the 21st Century

Discussion in 'Foot Surgery' started by Dieter Fellner, Oct 4, 2016.

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  1. Dieter Fellner

    Dieter Fellner Well-Known Member


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    ABSTRACT

    Background

    Plantar corns are a cause of pain and activity restriction. Debridement may give temporary relief of symptoms but a surgical excision may be sought by patients looking for a curative treatment. The following study reviews the effectiveness of surgical excision and the histopathological diagnosis of skin lesions which were clinically diagnosed as corns.
    Methods
    Forty three patients suffering from painful plantar keratosis underwent a surgical excision of the lesion under local anesthetic. Following excision, the lesion was sent for histopathological analysis. The participants were seen for final review on average 19 months later. Recurrence of the lesions and histopathological diagnosis was recorded.
    Results
    In 20 (46.5%) of participants there was no recurrence of the skin lesion whilst in 23 (53.5%) the lesion recurred and was symptomatic. Initial histopathology indicated 22 cases of verruca pedis (51.2%), 19 cases of keratosis (44%), one (2.3%) epithelial cyst and one fibroepithelial polyp. Recurrence was noted in 64% of the verrucae and 79% of the keratosis group.
    Conclusion
    Full thickness excision of plantar skin lesions resolved the condition in fewer than half of the particpants in this study. Over half of lesions diagnosed clinically as plantar corns were in fact verrucae when analysed histopathologically. These findings indicate that bone surgery should only be considered once histopathological diagnosis of the lesions has been established. Full thickness lesion excision under local anesthetic may however be considered as a treatment option for sufferers of painful plantar corns as it is more effective than scalpel debridement and does not require specialised equipment.Podiatrists should consider full thickness excision under local anesthetic as the second line of treatment when routine debridement fails to relieve pain sufficiently.

    Felix M Lopez, FCPodS, Specialist Podiatric Registrar
    Timothy E Kilmartin, FCPodS, PhD Consultant Podiatric Surgeon
    PODIATRY NOW Vol 19, Number 10 | October 2016
     
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  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    I want to congratulate Mr. Lopez for this excellent work with important implications for the management of the plantar foot lesion.

    I would ask the author to include demographic data to know more about the patient population managed in this way i.e. age, sex, lesion location etc.

    I also would have liked to see a correlation with the clinical diagnostics signs & symptoms and observations and the histopathological findings. For example, the classical dermatoglyphic pattern, presence or absence of capillary bleeding and the 'pinch' test. It might be argued it is entirely possible for the experienced clinician to make a distinction between tyloma and V.pedis, for example. The accuracy of the observations might be enhanced with a dermatoscope.

    There is an interesting practical ,complication in the application of the findings, in the US. In the absence of class findings, the Podiatrist will not receive remuneration for his work, if the lesion is a tyloma, but can expect payment if this is a VP. This is of importance to the doctor practicing in the Medicare system, where bills have to be paid, for services rendered.

    Lastly, the histopathologist cannot always accurately distinguish between the tyloma and its' variants and VP since the microscopic features can significantly overlap. There is, therefore a risk of a false positive histological diagnosis.

    I will be interested to know what other's might have to say about this study, the findings of which remain very important.
     
  4. Dieter Fellner

    Dieter Fellner Well-Known Member

  5. In over thirty three years of practice, I can't recall a single patient who I would refer for surgical excision of a plantar HD, where conservative management has failed.
     
  6. Dieter Fellner

    Dieter Fellner Well-Known Member

    Mark,

    My experience is somewhat different. Many patients would be referred from the county's podiatry services for a surgical consultation of the recalcitrant plantar foot lesion. Those lesions would have the typical appearance of a tyloma / IPK. We would evaluate and convince ourselves there is a problem with the metatarsal parabola or an associated hammertoe, to provide a mechanical explanation for the lesion. There may well be a structural factor to contribute and the surgical remedy would be some form of bone work i.e. osteotomy, osteoclasis, ostectomy, hammer-toe repair etc. And, in many cases the patient would benefit ... but not always. There is a failure rate of around 27% ... let's say 1:4 patients did not respond adequately. And the surgeon is left scratching their head. Perhaps we did not shorten enough or elevate enough or ....

    This paper provides for tremendous insight .... the plantar lesion can be VP or a mixture of tyloma and VP. Fabulous work ....
     
  7. bob

    bob Active Member

    Hi Mark.
    That raises a valuable point. I have found that the majority of generalist podiatrists that I come across do not refer for surgery when their conservative treatments fail. Instead, they tend to try multiple treatments with less evidence base than surgery (if that is possible) whilst bad-mouthing surgical outcomes to their patients.
    I am not saying that you do that, but your post struck a chord with me. I wonder why corn cutting podiatrists never seem to refer a patient to have the corn/ verruca or underlying bone to be cut when their scope of practice fails? As Dieter has indicated, possibly not the best pathology to pick for an offshoot thread, but you shall hopefully take my discussion point in the manner in which it was intended.
    Respectfully,
    Bob
     
  8. Dieter Fellner

    Dieter Fellner Well-Known Member

    An interesting point. In the US the corn cutting Podiatrist attempting non-operative treatments is of course the same Podiatrist who might provide a surgical remedy, as necessary. In the UK, the NHS podiatry clinics seemed only too happy to consider the surgery referral instead of having the patient back in their over-booked clinics every 4-6 weeks. Does this reflect a different approach between the private and the NHS Podiatrist?

    On the positive side, although some statistics will tell you 1:4 patients do not get the anticipated relief, 3:4 will find that definitive cure. The paper I cite should provide a useful mechanism to increase the percentage of satisfactory outcomes. It might be added, that a plantar lesion can be a more sinister pathology - and only an excision and histology report will provide the definitive answer. Not a common occurrence ,but also by no means unusual, and a potentially fatal oversight.
     
    Last edited: Oct 12, 2016
  9. Hi Bob

    I've regularly referred patients for surgery when I think it's indicated for a whole raft of conditions, but never for excision of plantar HDs or VPs as I've on the most occasions managed to resolve these conditions to either the patient's or my own satisfaction. That said, I often refer recalcitrant ID lesions where the underlying bone structure has been determined by x-ray to be contributory. The other factor in referring for platter excision is post operative scar formation, which I know can be minimised by good surgical technique, but that is variable of course! Just like conservative podiatric management!

    Best,

    Mark
     
  10. blinda

    blinda MVP

    Hi Dieter,

    I agree, Felix and Tims` paper is an excellent piece of work. I had a chat with Tim about this a few years ago when he started needling the VPs and we agreed that misdiagnosis of VPs as `neuro-vascular corns` frequently occurs. Probably due to their lack of thrombosed capillaries and pain on both direct and lateral squeezing. Felix and Tim stated in their article; "51% of excised skin lesions were misdiagnosed as plantar corns when in fact they were verrucae. The inaccuracy of clinical diagnosis is alarming..." Indeed.

    Also of note;"Recurrence occurred in 53% of the verrucae pedis group..." This concurs with Ivan Bristows` suggestion that excision/surgical procedures do not address latent viral particles in adjacent tissues, thus recurrence after apparent resolution is high.

    I`m not sure that I agree with you that histopathology cannot accurately distinguish between common garden variety of corn and HPV tissue. Of the samples that I have sent in the past (I haven`t done so for years, as I can usually clinically identify the various types of VP), the report stated "viral particles present". Pathologic features can determine (amongst other findings) viral infection of the basal layer (which is where the virus incubates for approx 8 months after inoculation before invading keratinocytes) and vacuolated prickle cells (which is evidence of keratinocyte DNA alteration by the virus in order to replicate). Whereas, a corn is the visible and palpable result of a `clumping` of corneocytes that exhibit incomplete differentiation on histopathology, due to heightened inflammatory cytokine activity from physical stress to the epidermis.

    It has often been said to Ian Reilly and I during our CPD days that practitioners have had some success with needling `corns`. There`s an underlying reason for that.
     
  11. davidh

    davidh Podiatry Arena Veteran

    Very interesting point Bel.
    Regards,

    David
     
  12. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hi Belinda,

    I too recall, fondly, the teachings about VP and the extended margin of likely verrucoid tissue beyond the clinically visible periphery.

    And I don't disagree that in a perfect specimen histopathological markers can provide for confidence in diagnosis. Not all samples present in this fashion and there can be histological overlap between the two lesions. Histological signs can be indicative but not always definitive of lesion characteristics. This is information provided by a dermatopathologist. I first read this information in an article or book (alas,many years ago, and I don't have the reference now) which first alerted me to this potential problem.

    I would be interested to know the epidemiology of the cases studies to know if any inference can be made from variables e.g. age. Conventionally we think about the VP to affect a younger patient. If the verruca diagnosis can equally affect the older patient, this will be useful information. I am advised such information was available but the editors of the journal took that out for publication.
     
  13. blinda

    blinda MVP

    Yes, an appropriate sample would have to be used for accuracy and I agree, there are some histological similarities between a corn and VP, but histological process and subsequent diagnoses has significantly improved in recent years and are important indicators in determining HPV sub-types that have the DNA potential to malign.

    Interesting point you raise regarding epidemiology. I suppose it could be assumed that with increased exposure - ie age - then acquired adaptive immunity would render the older population at less risk of manifesting some types of HPV. But, I think I will contact Tim, and see if he is in a position to offer any further information...

    Enjoying this thread!
     
  14. Dieter Fellner

    Dieter Fellner Well-Known Member

    Belinda,

    I will take your word for the advances in histo analysis. I already reached out to Tim/Felix, and awaiting a response to know if I can see the original article.
     
  15. blinda

    blinda MVP

  16. Dieter Fellner

    Dieter Fellner Well-Known Member

    Thanks for the link Belinda. I got a structured course, with exams, in histopathology at NYCPM. We would stare at slides through the microscope for weeks on end, of all different tissues and organs in health and disease. Was that useful? Yes and no ... like many skills, unless there is a continued effort, with practice, the information slips away.
     
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