Is injecting adjacent inter-metatarsal spaces with ethanol risky?

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In the “Hughes et al” paper attatched on ethanol injection for neuromas it states on P 1537


“As we stated in the Results section, in our series
in the three patients who had surgery, we
found the procedure was technically more demanding
because of the degree of fibrosis
present. Macroscopically the neuromas and
proximal extension appeared fibrotic as did the
neurovascular bundles in one case. The latter
raises a potential problem with toe vascularity
when injecting consecutive web space neuromas,
but this was not borne out in practice.”

Yet in the selection protocol it states

“Forty patients were excluded because
they had two lesions in the same foot . . . . . . .
multiple lesions in the same foot were initially treated surgically
in our local practice at the time of the study,
hence their exclusion from this series.”

So I am trying to figure out exactly what is being said here.

My read on this is from reading the paper is:

P1 The sclerosing action of the ethanol is likely to shrink neuroma volume by creating a more fibrous lesion.

P2 This action could cause technical difficulty in preserving the vascular integrity of supplied toe(s) if surgery was subsequently indicated in “failed” cases.

P3 Adjacent toes share a common vascular supply.

C Do not inject 2 or more adjacent inter-metatarsal spaces with ethanol because theoretically the toe supplied by vessels from both adjacent spaces have elevated risk of subsequent ischemia if needing surgery.

P= premise C = conclusion

Did everyone else reach the same conclusion?

Whilst this seems a valid arguement it is not clear if the treatment failures in this study were because the lesions before treatment were so highly fibrosed that they lacked capacity to be "shrunk".

If I am understanding this correctly, potential problems theoretically could be mitigated since fibrosed lesions are distinctly hyperechoic on diagnostic ultrasound exam compared to typically hypoechoic lesions which likely contain more water content. The study however doesn’t discuss this.

If, as it seems to me, the arguement is sound, then we should avoid injecting adjacent lesions if the sonographic appearance is hyperechoic in at least one of the spaces until further evidence is forthcoming.

cheers

Martin

The St. James Foot Clinic
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