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Dear all,

I have a patient whom has a rather large HD under the L1st MTPJ. She does have other cal and HD's which she is happy to have debrided and enucleated. However, she is very anxious about this lesion and rarely lets anyone touch it.

It probably does have a neuro element to it but I feel certain that if it were borught udner control then her quality of life would certainly improve.

Today I suggested to her that the HD be enucleated under LA. I wondered if other pods felt this to be viable? I'm not proposing to do this routinely, just in order to simply bring this lesion under control so future tratement is more effective and less stressful for her.

She is wearing good pressure relieving insoles and sensible footwear.

Any tips or points of view would be most welcome.

Kind regards

 

Hi Page,

L/A is certainly an option.

Another alternative is a product called Salu from Hilary supplies. Self limiting keratolytic.

Makes the lesion more comfortable by softening the H/D & easier to debride.

If you decide to try Salu, I apply a small piece of gauze over the lesion & drip Salu onto the dressing. Leave in place while treating other less sensitive areas (5 mins or so) then debride & enucleate.

Regards,

Mandy.

 

Page,
If there are no contraindications, I don't see why you shouldn't go down the LA route.

CF

 

Hello Page

I think that we are a little too reluctant to see L.A. used for anything other than surgical procedures. In fact, when the Podiatry Association (I'm assuming that you're from the U.K.) originally pioneered L.A., it was stated that it was so doing in order to treat lesions such as you describe which would normally be too painful for the patient to tolerate. L.A. is simply a tool and should be used wherever appropriate. I would suggest that you use a tibial block because infiltration or even field block in that area can be very uncomfortable.

All the best

Bill Liggins

 

Hi Page,

I'm currently looking at using LA to enucleate corns within my department as there are many patients with painfull HDs. I think it is the probably the best way to treat such a pianfull lesion and it puts the patient at ease allowing you to fully enucleate the corn and giving longer relief. I'm pleased to see that your patient has pressure relieving insoles too as there's not much point in doing all that for the lesion to come back.

Luke

 

Dear all,

Thanks for your replies. All very helpful.

I will offer her enucleation under LA for this lesion with a tibial block. I really do feel this is her best option for vast improvement, general control and management.

Thanks again.

 

Page

" i'm not proposing to do this routinely "

why not?

As Bill said LA should be utilised a lot more often. I also agree that you should use a tibial block, you will be insured to perform ankle blocks etc. If your unsure of the technique call up a local pod who uses it often and get some experience ie a pod surg unit. I'm in Lancashire

 

Ditto . Tib blocks are a much underused thing. Dentists give their patients a choice, why shouldn't we?

 

Page,
You may want to weigh your options on this and consider a blunt dissection of the entire mass followed by phenolisation and orthotic aftercare to manage the function and weight loads. I have done this many times over the years and had excellent results with little scaring causing concern

 

Yip... tib blocks get the thumbs up from me...great for neuro-vascular HD`s and needling VP`s :drinks


Cheers,
Bel

 

For singular lesions simple dorsal infiltration saves the complication of the tib block

 

Tis true, I also go in ID for lesions on met heads 2-4 but have found that the pt feels a lot of discomfort during local infiltration if the lesion is slightly proximal to the 1st met head, so now often use tib block.