Post tibial block for deep ennucleation

We measured pre-treatment, immediately post-treatment and at six weeks. I really can't recall why six weeks was chosen. I think it may have been based on Redmond et al. (1999) assertion that symptoms could return at six weeks post debridement, or Potter and Potter's (2000) study of regrowth patterns?. Or it might just have seemed like a reasonable length of time. If we wanted to do a good time series study then weekly or even daily pain scores may have been better but I'm not sure why it would have been more "palatable" though to measure every week? As this was not really the thrust of the study, three measurement points were taken. I think that at the time the usually return period for patients undergoing routine callus debridement was 12 weeks.

Yeah, but this should have been true of both groups, since there was no sig diff in pain pre-treatment or immediately post treatment. We did not standardise footwear as this would have been impracticable, nor did we record smoking habits.

The only study I know of that Tony was involved in was of scalpel debridement in isolation, published in JAPMA 1999.

Paul, i am not aware of any research that has attempted to do this. All of our subjects were otherwise healthy so i would assume that the lesions were mechanical in origin.

Personally I'd be more concerned regarding the statistical power of this and the other studies on debridement.

 

Wow:
Lots of interest over an IPK!
Think what might happen if we had something INTERESTING to discuss, like a coliform verrucae !

I see the posts have turned from Dx to Treatments to Treatment success -

If I have a patient with an IPK of chronic duration and a closet full of orthotics I usually do a metatarsal osteotomy (assuming the metahead is plantarflexed relative to the adjacent mets)
This usually solves the problem.

I allow the patient to light one up after surgery!!!!!!


Steve

 

Wow, love the discussion... Great thread... i will watch the smokers with interest and debride / enucleate the HD's of all the non smokers anyway

 

So you are denying care to smokers?

The paper you posted in the undergraduate research thread is interesting, showing that debridement of callus was no better than "sham debridement" and did not significantly influence plantar pressures. I know corns and callus are not the same and I'd love to see these kind of studies repeated for corns. We may or may not be able to extrapolate.

Bob, we only looked at diffuse callus and only used blades to debride. How do you assess the quality of debridement, BTW? The only way we could work out to ensure consistency across all subjects would be to use ultrasound scanning comparing thickness of normal plantar skin with the debrided area.

The question is, how many studies showing debridement is no better than a sham and/ or that it has the potential for making things worse do you think we would need before chiropodists/ podiatrists/ podologists (call yourself what you wish) the world over hang up their scalpels for these hard skin problems and start trying to treat calluses and corns by some other means?
:sinking::deadhorse::sinking:

 

Yes, in the presence of a plantarflexed metatarsal (or a Weil if it's relatively long for example), but with no obvious underlying bony problems, a closet full of orthotics and when a patient's been through a multitude of conservative options including podospray, granuflex, etc... I'm very cautious to offer surgery. As you've said before Steve, if the diagnosis remains unclear (other than there's a clinically painful persistant IPK) what are we going to offer? I have done lesion excision previously with OK results, but I made sure they had been through all of the above and a short series of debridement under anaesthetic (max 3 times with a 6 week interlude). Even then, I've warned of a high chance of recurrence. And as said before, smoking cessation advice was given at various stages (although I recognise this to be just a correlation in the clinical population I was treating, I felt the holistic benefits were significant, even if the IPK isn't really linked).

Thanks Simon. The quality of debridement issue was not something that I was questioning in a serious manner. Perhaps if you were to perform a similar study you could get an experienced clinician in who has many years of teaching and clinical experience to worry about how feathery the callus debridement might be? (the last question was also just a joke)

Your final paragraph is interesting. Did you present your callus debridement results at the UK national conference? If so, how well received was it? I know podiatric surgeons in the UK have a national audit of their results, and heard that a similar audit may be rolled out for conservative podiatry so maybe this will help to answer some of these questions as the results come back?

 

This was not presented in the UK, it was presented in Spain. I would love to see an audit on this. However, audits are problematic as they don't control for placebo, gratitude effects etc. Moreover, we have a public perception problem: when the public visit a chiropodist they expect to have their "corns cut" because this is what chiropodists do. Now, try telling your 80+ year old patient with oedema flowing over the top of her court shoes ("they're good shoes, they're van dal"- yeah, right:bang that you are not going to cut her corns, but rather you are going to use an insole, but first she'll need to habitually wear a different kind of shoe; then stay in business.:sinking:

 

Interesting, the Cochrane review for hallux valgus surgery used to conclude something along the lines of one third of patients were dissatisfied with the outcomes of surgery (this review has been pulled for being too old). How many dissatisfied cases does it take for a surgeon to hang up their bone saw?

 

Now back tethered to the computer and very interesting to read all your comments, almost all useful (!) and food for thought regarding my future management of this difficult set of problems.
I realise it's all gone a bit intellectual, but just to go back a bit - I also used to belong to the school of thought that there was no such thing as a neurovascular corn. In this particular case though, while reducing the most painful HD, Iattempted to reduce a tiny area which appeared slightly darker than the surrounds, and despite the tibial block (which was, to all intents and purposes, complete) the patient flinched suddenly, describing the sensation as being like an electric shock going right through her body. The corn is composed of a collection of lobules(ie more like a bramble than a grape) and this nerve appears to present between the lobules. Thus I am led to conclude that this HD indeed has a neural element that is causing pain! How do we then describe it?
I have also noticed that the type of HDs that do tend to be intractable and very painful have this lobular appearance under the magnifier. Has anyone else noticed this?
Thanks very much to all who took the trouble to post, much appreciated.

 

not to sound argumentative, but your tibial block cannot have been complete if your patient felt pain during the debridement.

 

Well spotted George, and not argumentative at all! What about the rest of it though?

 

Steve

Ouch! What type of surgery do you use it for??

LoL Dave

 

Sorry to be unsophisticated but I find giving the patient a bunch of cut out 5mm felt pads to use in between visits is often a good solution to reduce w/b pain and to resolve the corn over 6 months or so. Perhaps she would be allergic to the adhesive?? .

Dave Smith

PS I have found this also works well for overweight alcoholic smokers with COPD who can't afford orthoses because they spend too much on fags, booze and take aways and holidays to Ibiza and Torremelinos.:boohoo::santa:

 

Loads and loads and loads and loads and loads and loads and loads and loads and loads and loads and loads and loads and loads and loads and etc........

Getting pretty good results these days, I thank you!

 

The last two posts by Dave and Bob made my day. Cheers Gentlemen :drinks: I'm off to IBIZA.

 

A wart.........


:morning:


PS - I have an idea, biopsy it and send it to pathology - just satisfy all our curiosity.

 

Glad you said that, I was thinking exactly the same thing :morning:

If you can't get a biopsy do the lateral pressure versus direct pressure test- see which hurts more, if it's lateral squeeze, my money is on the wart.

 

Hmmmm, I have indeed seen this lobular manifestation. I wouldnt describe this as a corn. Did you note that the lesion, post callus reduction, is more `spongy` to touch than your usual HD? I`m thinking along the same lines as Simon and Paul....VP or at least where there once was a VP. Local infiltration of the area (making sure you infiltrate behind not just in the lesion) and histology of the mass is definatley in order. Bet my bottom dollar it comes back `viral particles detected`!

 

Doh! Thanks for waking up my remaining brain cell. To be fair it doesn't look anything like any VPs I've ever seen before, but will certainly send sample for analysis. Watch this space...............

 

Good grief: lots of point scoring going on here.
When I trained, an HD with vascular elements and that was painful to debride even slightly was described as a neurovascular HD. Everyone knows what it means and I'm not sure that debating semantics is particularly useful.

Back to the original point: have you considered Marigold therapy for the patient? It might keep the lesions at bay for longer than pure debridement alone and is good for HNV in that it is not a painful procedure. A patch test would establish whether the lady is allergic to the paste.
I'd also consider a biomechanical examination and - if you can get the lady to change her footwear - a suitable orthosis.

As for the smoking: you can advise all you like, but unless the woman WANTS to quit, she won't.

 

Why can't you do both? Enucleate the HDs as well as looking at the biomechanical/orthosis angle?
I've been reading this forum for about a month and am suprised at how much it is dominated by the "biomechanics is the answer to everything and other aspects of podiatry are inferior and we shouldn't be doing them" view.

 

You can do both, so long as the patient is willing to play along. If this forum is dominated by biomechanics, it's probably because the people who post here most frequently are interested in biomechanics; you can do something to change that. Try starting some threads which have nothing to do with biomechanics, but since we live within the gravitational field of the planet earth, forces impact on everything we do. If I put an emollient on the skin it changes the material properties of the skin... biomechanics is not a sub-specialisation, it impacts on all aspects of podiatry, perhaps this is why it is discussed so much here.

 

Indeed, case in point: I can cite a couple of studies that show that debridement of callus may result in deterioration of the lesion/ increased pain. Can you identify any studies that show that insoles may similarly result in a deterioration of the lesion / increased pain?:santa:

 

Charlie

You wrote

I agree, tilted womb, insomnia, immorality, insanity, intractable plantar keratosis, anything with the prefix 'in' and haemorrhoids to name just a few, but I don't think Charlie will go along with that!!:santa2::craig:

Just a bit of fun there, but have you ever come across a corn that didn't have a mechanical aetiology? wouldn't reason suggest the opposite might be true and removing the mechanical stress might be a good idea?.

Dave:drinks

 

Simon

Sounds very counter intuitive, I've never had some one tell me that their corn was more painful once it was removed. I have loads of customers who have come to me for years and do not have painful corns any more. Perhaps the ones that didn't return did so because they got worse. This is the problem with inductive evidence, even tho the argument may be valid the outcome may still be still false. Deductive reasoning would give me a far more convincing result in this case I think.

all the best Dave

 

The evidence suggests that while there is an immediate relief of pain / improvement in appearance, both the appearance and pain may deteriorate over a period of time. You could argue that these lesions may have deteriorated or got more painful anyway.

Dave, your patients come back to you for many reason, among these reasons are that they believe that if left untreated the pain will return and they wish to prevent the pain from returning (from whom did they get this idea?) and because the pain has returned. The ones that didn't come back may have no pain anymore or may think you're ****. Collect the audit data, then you'll have a better understanding, without having to philosophise too much

 

No charlie70, we are not debating semantics here. Every word has a precise meaning. It is the facts that we are debating. That might be particularly useful.

 

It is by definition not possible. A heloma durum is hard callous. Callous is not innervated tissue. Why would it have a blood or nerve supply. Hence the term or definition neurovascular HD is a misnomer and by pure definition cannot exist.

What you were taught is dogmatic at best. I can't prove they don't exist, but I have never seen one and it appears on these forums plenty of people are in the same boat as me.

Those they say they do exist and have seen them are either:

a) In a minority and these lesions are extraordinarily rare

b) Wrong - they are other lesions.

I laid the challenge out there a few posts back - someone find one, take pictures then biopsy it for me. Its not hard to prove!

Heck, if I could find one I would do it immediately and post the results here for everyone to see putting this puppy to bed once and for all. Trouble is in 12 years of practice I have never seen one, so statistics say I probably won't in the next 12....it could be a vry long wait for my results!

Dare I ask for any peer reviewed randomized controlled trials backing the use of Marigold therapy for anything?

 

Lol - at least you made me smile.
I'm not anti-biomechanics: yes, of course its intrinsic to a lot of what we/I do. BUT is is still very subjective (biomechanics "specialits" even within our small department frequently disagree about treatment methods and sometimes the diagnosis) and does not always yeild the results we hope it will. I don't see it as the be-all and end-all of Podiatry. I'm a generalist and quite proud to be one. I do everything: routine work, bio clinics, nail surgery, triage/assessment. I do send a few cases off to the specialists when I've had no sucess....its a pity that the patient so often comes back to me with no improvement. You can see why I'm a little sceptical?

Also, to all those blithely suggesting the OP "send tissue off for analysis" - good idea! But not often an option for those who work in the NHS primary care: I wonder how much access private practitioners have to labs? All we can do is refer to dermatology with the suggestion they send a tissue sample for analysis: whether they do or not is entirely their own decision and they don't even have to share the results iwth the referring Podiatrist.
Not great, but that's the reality.

 

I wish there were a smiley of someone holding up a handbag and saying "ooh, get you!"
Well, in 18 years of practice (do we get points for years of practice and/or the number of patients we've seen? :wacko , I've seen plenty of lesions that look like HD's with occassionally a black spot that bleeds if you touch it. They hurt like hell, come back within 4 weeks and are quite difficult to get rid of. And, given the patients at other clinics across this patch who are getting routine treatment every 4 weeks or so for "HNV" or "fibrous HD", they're not THAT much of a minority.
We've tried all sorts on these patients: radiolase, acids, anaethesia + proper enucleation - they've all had bio assessment and orthoses (none of which have worked). We had someone train in Marigold therapy and do some sessions about 2 years ago: unfortunately they went on maternity leave before they could audit hte results. Of those referred to her from my clinics, one has not had the lesions return, 3 had the lesions return after about 6 months and one found it made no difference.... not enough to constitue a trial but enough to make me not dismiss it out of hand as a treatment. I'll be interested to see what the results of the internal audit for next year show.

The "HNV"'s and/or "fibrous corns" are also patently NOT VPs.

Its an interesting point you raise: are they HNV or some other lesion that we haven't identified? I think I'll contact the dermatology unit at the hospital and see if they'd consider testing tissue... if they do, we may make some headway. Thanks for that suggestion.

 

I wish there were a smiley of someone holding up a handbag and saying "ooh, get you!"
Well, in 18 years of practice (do we get points for years of practice and/or the number of patients we've seen? :wacko , I've seen plenty of lesions that look like HD's with occassionally a black spot that bleeds if you catch it with the scalpel. They hurt like hell, come back within 4 weeks and are quite difficult to get rid of. And, given the patients at other clinics across this patch who are getting routine treatment every 4 weeks or so for "HNV" or "fibrous HD", they're not THAT much of a minority.
We've tried all sorts on these patients: radiolase, acids, anaethesia + proper enucleation - they've all had bio assessment and orthoses (none of which have worked). We had someone train in Marigold therapy and do some sessions about 2 years ago: unfortunately they went on maternity leave before they could audit hte results. Of those referred for Marigold from my clinics, one has not had the lesions return, 3 had the lesions return after about 6 months and one found it made no difference.... not enough to constitue a trial but enough to make me not dismiss it out of hand as a treatment. I'll be interested to see what the results of the internal audit for next year show.

The "HNV"'s and/or "fibrous corns" are also patently NOT VPs.

Its an interesting point you raise: are they HNV or some other lesion that we haven't identified? I think I'll contact the dermatology unit at the hospital and see if they'd consider testing tissue... if they do, we may make some headway. Thanks for that suggestion.

 

You only get points for years of practice if you realize your mistakes and rectify them. Practicing for "X" years and making the same mistakes repeatedly doesn't qualify anyone for experience points.

Yes they are called verrucae or more commonly warts!

You must live in an extremely special part of the world. I ask a simple request. Photo posted here pre-debridement and post debridement and biopsy results.

Stimulating an immune response does not "always" elicit eradication of the lesion (from this point on called the WART).

Why would it, its most likely a wart!

But if I took your methods of belief on board I would believe in Santa Clause, the tooth fairy, little green men from mars and also reflexology (sorry had to get a jab in there!).

Where is the evidence - surely there is "something" that makes you recommend Marigold therapy other than "my mates reckon its tops"?

Don't get too excited because even if they show its God's gift to these lesions, its worthless without a peer reviewed RCT.

How so? Please explain?

That is all I ask.......I would happily biopsy one if I could only find one!!!!

 

Right mate, despite your fast-held assertion that the lesions are WARTS, they look nothing like "warts", don't behave like "warts" etc etc.
Hence my belief that they are not "warts".

No, I don't believe in Santa Claus etc and find your assertion that if i don't agree with you I must be delusional strange at best.

If I was able to get someone to biopsy the lesions, I would. However this is not an option available to us for something that is not malignant. You're welcome to hop on a plane and come do it, if you like.

As the has degenerated somewhat, I'll leave this thread here.

 

Charlie - why don't you contact your local podiatric surgery unit? If you make contact, I'm sure any case that may need a biopsy will be gratefully received and assessed. Merry Christmas.

 

I´ve followed along a bit here and will try not a take sides.

Charlie I know that you have said the Biopsy is not a option but for a learning experience if would be great to have Photos- before after debridement , results of Biopsy etc. And answer to what IT is.

It might make agreat learning experience for you , me everyone.

You might be right and Paul etc will have learnt or you maybe wrong and you will have learnt something as well. Thats the great thing about the forum I can come on a say I think this and other will correct me if I´m wrong Then I will have learnt and others who read along also would have learnt.

It sometimes gets a bit personal but I find swearing at the computer helps.

 

No merely stating a fact - I don't have any evidence that Santa Claus, little green men etc... exist so I don't believe in them. However my 3 year old tells me Santa does indeed exist (she is slowly turning me around, but as I explained to her Daddy needs a peer reviewed, double blinded RCT to really believe!)



I don't care whether you agree/disagree with me - I am just asking for evidence - I want to learn and if these lesions do actually exist like so many people have apparently seen I want to see them also (I feel a little left out I think).

Don't leave the thread over my post. By leaving you are merely proving your own point above. You don't agree with my sentiments, so you run away? Hardly worth leaving over me thinks. No personal issues here - lets just keep it evidenced based and professional.

 

All

With regard to the notion that an NV corn is a misnomer here is an interesting discussion of Clavus http://emedicine.medscape.com/article/1089594-overview with further discussion on work up and differential diagnosis. It is interesting to note that none of the differential diagnoses(DDX) listed include anything called or described like a neuro-vascular corn. The point is that even tho the definition of clavus is lesions caused by mechanical forces the DDX are not. Therefore one might imagine that anything similar to a clavus but not caused by mechanical forces, might be described and yet the NV corn is not there. Infact it appears that the only thing that is described in this way is in fact a wart of some kind or perhaps neuro vasular ulcer.

Clavus
Clavus is a thickening of the skin due to intermittent pressure and frictional forces. These forces result in hyperkeratosis, clinically and histologically. This extensive thickening of the skin may result in chronic pain, particularly in the forefoot; in certain situations, this thickening may result in ulcer formation. The word clavus has many synonyms and innumerable vernacular terms, some of which are listed in the Table below; these terms describe the related activities that have induced clavus formation.

This is the name and bona fides of the author.
Clavus
Author: Nanette Silverberg, MD, Assistant Clinical Professor, Department of Dermatology, Columbia University School of Medicine; Director of Pediatric Dermatology, Department of Dermatology, St Luke's Roosevelt Hospital Center, Maimonides Medical Center and Beth Israel Medical Center
Contributor Information and Disclosures
Updated: Jun 26, 2009

Cheers Dave

 

Dragging this thread back up. Does anyone have, or know where I could find, the literature written by Craig Camasta on "Smokers Corns".

Also does anyone know of any literature on the debridement of these lesions under local aneasthetic? There doesn't seem to be much, if any, on the effectiveness of debridement under LA on the level of pain these lesions cause.

 

Hello

Just high jacking this interesting little thread. I would like to do post tib blocks for such painful corns' that crop up from time to time but i have no experience of doing a post Tib block . Would love to learn but unsure where to start.

I am a NHS and private practitioner - no scope in my current band 6 role for training and not sure where to go privately to get a post grad training in this field so i can crack on.

Many thanks

John

 

Hate to be the one to point the elephant out in the room, but:
SMOKING= poor peripheral blood flow = overly responsive nerves = more pain than usual.
The vascular component (or lack of) is the real issue here.
I too have had Aboriginal clients, rheumatoid arthritis clients, and PVD clients with HD's that appear in this manner - but the common denominator is always the vascular component.
That said, I concur, get them to cease smoking & their pain threshold increases. But then cigarettes are a narcotic, & in my humble esperience, most of my clients on some form of narcotics do have significantly altered pain thresholds.
The ironic part is, most smokers tell you they feel smoking helps them "manage" their pain.

 

If the vascular component is the "real issue" why do so often the lesions start to "resolve" when they cease smoking? This has been discussed on these Boards before.