Patient with problem scar

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Hi out there - first posting. Insights invited on the following ;
lady (08.08.52) with bilateral congenital calcaneal hypoplasia - childhood surgery for ? purpose leaving lateral plantar scarring approx 15cm - scar tissue thick and vitreous. Approx 20 years ago, consultant orthopaedic opinion was permanent relief only possible by bilateral amputation ! Patient declined this course. Now on heavy pain medication - Neurontin (gabapentin), Amitryptilline, Lyrica - attends at 8 week intervals for extensive debridement of scar tissue. Recent review by another orthopaedic consultant - he could do nothing and suggested referral back to the consultant who advised amputation 20 years ago. There must be something less radical, surely ? Has anybody come across similar and if so, were there alternatives to the suggested amputations/ keep taking the tablets ?
CWK, Dublin, Ireland.

 

Re: Insights please

Hi Mr C.W.Kerans,

:welcome: to Pod' Arena,

Has your patients used the following product?

UK & Ireland :

follow the link for further details.

http://global.smith-nephew.com/master/united_kingdom_19591.htm




Ireland Corporate Information:
Directors: Mark G. Henderson, Paul R. Chambers (British)
Registered Number: 8596
Registered Office: Molyneux House, Bride Street, Dublin 8

I hope this may be useful. I have used this product on problematic scars in the past & have been pleased with its success.

Regards,

 

Re: Insights please

Twirly,

Thanks for the information about cica-care, and I'll follow up on this. Getting the scarring, which is like glass embedded in the plantar skin, healed would be great, but the underlying bone problems remain. I haven't seen X-Rays of what the osteology remaining looks like but it seems to be a mess. Is there a specialist anywhere in the British Isles who is noted for reconstructive foot surgery ? The lady in question is pretty desperate.

CWK, Dublin

 

Re: Insights please

Hi again CWKerans,

Might be a good idea to post a new thread on the main forum,

I am aware of a few UK Podiatric surgeons who frequent the Arenas hallowed halls from time to time.

Click on forums. Go into foot surgery & at the top of the screen locate 'start new thread.'

Then your question will be flagged up for all to browse.

Cheers, :drinks

 

Mr Kerans

The patient you describe appears to be on medication for neuralgia/neuropathy. So I am going to make the assumption that based on your description, the sural nerves, or branches of the same, have become entrapped in the scar tissue.

Without any x-rays, or clinical photographs, it would appear that the scar tissue and possible nerve entrapment explain the degree of pain this person is enduring. I will assume there is nothing wrong with the calcaneus itself, or some other form of peripheral neuropathy is at play.

Hence, I would be considering assessing this person further for a sural nerve release (eg Tinel's signs, nerve conduction studies), with excision of the scar tissue and more appropriate closure. A podiatric or plastic surgeon could be consulted for this procedure, if your orthopaedic colleagues are unhelpful.

Intractable nerve pain is very, very, very (did I say 'very') rarely an indication for amputation...

LL

 

Hello,

have you tried inserting an acupuncture needle into the scar tissue itself?

Sometimes works, as a form of pain relief, though not always.

 

I agree with Lucky.

I think that this poor individual should have a throrough assessment including MRI, nerve conduction studies etc. If these reveal no nerve entrapment syndrome then it might be possible to try a number of therapuetic options including hyalauronic acid injections (Martin Harvey in Tamworth U.K. and Akbal Rwanda in Maidstone U.K.) Ultimately I suspect that bone and plastic surgery will be required and it may be kind to point out that nothing is going to give 100% relief although it should certainly be possible to improve things. All this will be expensive and I suppose that it is worth trying Twirly's suggestion first but amputation should, in my view, not be considered for a long time (very very very....very per LL!)

Bill Liggins

 

CWK:
I agree with LL on this.

It is always helpful when seeking advice not to make assumptions.
For instance, you make the assumption in your initial post that the pain is from a surgical scar.
I doubt very much that orthopedics would suggest an amputation for a painful scar.
20 years ago they may have offered amputation for "causalgia".

LL is correct, you should first assess the patient and come up with an underlying etiology for the pain prior to selecting a treatment.

When does it hurt? (on or off weight bearing or both?)
Character of pain (sharp, dull, intense)
Is the pain localized or radiating?
Can you duplicate the pain with pressure? If so, where?
Does local debridement help? Completely? Somewhat?
What was the initial surgery for?
Any other medical concerns?
What is the patient's occupation?
What's the patient's gait like?

All this would help us help.

Thanks

Steve

 

If further detailed assessment suggests that some of the trouble is generated by local shear forces on scar tissue on the heel then this at least is not a "neurological" source of pain and can be modified by external physical factors. An easy thing to try is a suitably shaped orthoses covered with 6mm gel that is used as socket lining in prosthetics.(the gel needs to be the version that has fabric bonded to both sides other wise you can't glue it to anything) I have used it to good effect for feet with problems form shear stress.
regards Phill

 

Thanks to all colleagues for replies to my posting re problem scarring - food for thought in all. Will try the cica-care approach initially and see what, if any, improvement develops. Thanks again.
CWK, Dublin.

 

Hi CWK:
If the scar is 20 years old don't expect a miracle from a product like cica care.

I think it's important for you to evaluate the source of pain first.
My 2 cents

Steve