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Any Advice on Neurolysis for Morton's Neuroma ?

Discussion in 'Foot Surgery' started by Canada Foot Guy, Mar 6, 2011.

  1. Canada Foot Guy

    Canada Foot Guy Active Member


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    Will begin treating a patient for chronic recurrent interdigital neuritis next week (3-4 webspace). X_ray and MRI support diagnosis. Patient is female 45, healthy, no allergies and no meds.....has tried all conservative to no avail - but will NOT stop wearing neuroma-inducing footwear, would have preferred that is she was willing to change footwear and we could have attempted corticosteroid injections..but alas - even the most beautiful ortho-wear gave her the willies....so we are left with killing the nerves or surgery...have opted for neurolysis after reviewing Dr. Dockery's research...
    any advice on the procedure or experience with outcomes ? the mixture of marcaine, epi and dehydrated alcohol is being prepared by a sterile compounding pharmacy as we speak...
     
  2. Catfoot

    Catfoot Well-Known Member

    Canada Foot Guy,
    If this lady is not willing to help herself or co-operate with you, why are you continuing with treatment?

    I think there is a thread on this site about non-compliant patients.

    I am sure admin will be able to find a link for you.

    I, personally would be wary, as if she does not have the outcome she wants she could well lay the failure at your door.

    So it's your call.

    regards

    Catfoot
     
  3. Canada Foot Guy

    Canada Foot Guy Active Member

    Catfoot, you bring up an excellent point - I will specifically amend my already, excessively detailed 2 page, small print, consent form for injections and operative treatment to more specifically address this procedure and potential outcomes....I do not think my role is judge and jury here...only neural executioner..:).....I will however read these posts/forums that you are referring to ..thank you.....:)
     
  4. Catfoot

    Catfoot Well-Known Member

    Hi Canada Foot Guy,
    Glad to be of help.
    Sadly, in this world of increasing litigation we pods must be very sure that patients are advised of all possible outcomes, that we have informed consent *and we must be sure that we have the appropriate documentation completed.

    regards

    Catfoot

    * in UK we have to make sure that the patient has informed consent to treatment, I am not sure what the law is in Canada, but I would assume it follows the same basic principles.
     
  5. In patients such as these, I inform them that their shoes are the cause of the pain but will try metatarsal pads cortisone injections and try to get them into a wider shoe. If this does not relieve their pain, then I have no problem offering them a surgical neurectomy procedure since, in my hands, these surgeries are routinely successful. However, I also let the patients know that if they were to change their shoes, they could easily avoid the surgery.

    Make sure, in your preoperative dictation, that the following sentence is placed within the chart:

    "The patient was fully informed that a change in shoegear away from stylish dress shoes to more roomy shoes would greatly increase her chance of avoiding the need for surgical removal of the intermetatarsal neuroma and the patient is fully aware that continued use of stylish dress shoes after surgery will greatly increase the chance of her having chronic pain in her feet for the rest of her life."

    You must protect yourself from these patients and this type of notation in the chart will go a long way toward making it very clear that the patient's shoe choices are the cause of her pain, and not your treatment.
     
  6. Canada Foot Guy

    Canada Foot Guy Active Member

    Dr. Kirby,

    Thank you very much for your expert input. It is much appreciated. Also thank you for the wording. My patient wishes to go through with this procedure. I will keep you posted on the results...Kind Regards

    Gary Boardman D.Pod.M.
     
  7. Admin2

    Admin2 Administrator Staff Member

  8. Lee

    Lee Active Member

    Hello Catfoot,
    I the UK we practise 'valid consent' rather than informed consent. If you work for the NHS, have a look at your trust's consent policy which invariably refers to obtaining valid consent.
    See:
    http://www.medicalprotection.org/uk/factsheets/consent-basics
    and
    http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103653.pdf
    for further reference. I can't say that I'm by any means an expert on this, but I have noticed that a lot of published work on consent comes from the US and may not be entirely applicable to UK law.
    Cheers,
    Lee
     
  9. SarahR

    SarahR Active Member

    Hi Gary!
    I had a patient who did 3 neurolysis injections at a different clinic (some ortho clinic in hamilton) and ended up in more pain than she'd been in before.

    Make sure you put that on the form/discussion that there is a possibility of increased pain especially if the injection sequence is terminated before complete destruction of the nerve.

    Sarah
     
  10. Nat

    Nat Active Member

    Make sure you let the patient know that increased pain is common post-injection, particularly after the first injection, and it persists several days before it gets better.

    My experience has been that if there has been no improvement in symptoms by the third injection, then there won't be any improvement after seven injections. I therefore terminate sclerosing treatment after three injections if there has been no improvement from pre-treatment levels, then recommend surgery.
     
  11. Canada Foot Guy

    Canada Foot Guy Active Member

    Thanks Sarah and Nat,

    nothing better than getting the benefit of a senior members experience
    Much appreciated !

    CFG
     
  12. Gibby

    Gibby Active Member

    I agree with Dr. Kirby-
    Good advice, as recurrence is a concern, especially if there are compliance issues. Lots of women buy and wear narrow heels, even if the shoes cause pain.
    I seldom need to perform surgery on patients with neuromas; the older treatments seem to work extremely well. Correct custom orthoses, sometimes a simple metatarsal pad, and injection therapy almost always works- I use a mixture of Lidocaine, Marcaine, with Celestone and Kenalog. Simple excision if injection therapy is unsuccessful. I have read about the neurolysis, but have never done it. Also heard of a podiatrist using some kind of cryotherapy machine. Same doc often uses a laser- (?) Sounds scary to me.
    I figure if it isn't broken, don't fix it.
    I cannot think of a reason to do neurolysis when injection/orthoses and infrequent simple excision works so well. Maybe the recurrence rates are lower? Let us know how it goes...... Well, it's back to work- Mardi gras is officially over.
     
  13. SarahR

    SarahR Active Member

    Gary,
    Tony has been quite willing to come out to our colleagues offices and mentor with soft tissue surgeries. If your neurolysis fails, this is an option for having the neuroma excised and learning opportunity.
    Sarah
     
  14. drsarbes

    drsarbes Well-Known Member

    Neurolysis vs excision;

    regardless of what studies you may have read, in my humble opinion, success in neurolysis for Morton's neuromas is very practitioner dependent.

    As for the patient not wanting to help herself re: shoe style...... I see no difference in this as compared to a runner that has foot pain only when running that doesn't want to give it up; or a hockey player with pain with skates but not shoes not wanting to stop skating.

    Some people put an emphasis and "importants" on certain aspects of their life (perhaps how they dress) that others put little thought into. Let's not be so quick to judge.

    Steve
     
  15. Canada Foot Guy

    Canada Foot Guy Active Member

    as it turns out, I am taking a little extra time reviewing the imaging while I am still waiting for the compunding pharmacy to mix my cocktail...:)...will keep everyone posted
     
  16. Catfoot

    Catfoot Well-Known Member

    Hi Lee,
    I don't work for the NHS, I'm in private practice.

    The last whole day seminar I attended last year, on this topic, was using the words "Informed Consent" but I think we are talking about the same concept, just a difference in semantics.

    In the NHS, employees is protected by the Vicarious Liability of the Employer, but those of us out in the field do not have that umbrella.

    There was a case before the HPC recently where a Podiatric Surgeon was taken to task and one of the allegations is that they did not have informed consent. (The hearing actually found that there was "no case to answer")

    regards

    Catfoot
     
  17. Berms

    Berms Active Member

    Good point Steve. This is what makes podiatric sports medicine very challenging at times.
     
  18. Canada Foot Guy

    Canada Foot Guy Active Member

    status update - meds came in but patient put off procedure for a few months
     
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