Excision of Neuroma

[UIC]

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A really cool video of Dr. Patrick DeHeer excision of a neuroma. Looks like fun

[YOUTUBE]s70YfQgCwW8[/YOUTUBE]

 

[PADPM]

Neuroma surgery is not traditionally performed by most docs from a plantar approach for "virgin" neuromas, though it is sometimes done this way, and I have performed it this way for "virgin" neuromas. The most common method for first time neuromas is a dorsal approach.

The major advantage of the plantar approach is the excellent visualization of the "neuroma", and the disadvantage is a plantar incision which always has the potential of a painful scar on the weight-bearing surface and some restrictions regarding weight bearing post operatively.

However, the plantar approach is often the procedure of choice for patients who have already had a prior neuroma surgery performed that failed, for patients that have developed a stump neuroma or sometimes for patients that have failed sclerosing alcohol injections, since the neuroma in these cases tends to be smaller due to the "shrinking" effect of the alcohol injections.

But the bottom line is that as a surgeon, you must pick the procedure that works the best for YOU and most importantly, you believe results in the best outcomes for your patients.

 

[sideways]

what was the flexion at ~1:00?

 

[NatCh]

what was the flexion at ~1:00?

Normal response to noxious stimulus (it was a pain reflex).

 

[NatCh]

the disadvantage is a plantar incision which always has the potential of a painful scar

The painful plantar scar is always the big fear that people cite, but when I've done plantar incisions the scar always comes out very flat and almost invisible. I've never had a complaint about a troublesome plantar scar. I can't say the same thing about my dorsal incisions though. Has that been your experience?

 

[PADPM]

Actually, that's why I stated "potential" scar. Fortunately, it seems that my experience has paralleled yours, and plantar scars have healed very nicely.

I'm sure that similar to me, you make sure that whenever possible, the incision is not actually directly below a weight-bearing surface. In the case of a neuroma excision, the incision is between the metatarsals, not below the metatarsals.

However, I have had more complaints of dorsal scar discomfort and fibrosis than plantar scar problems. Maybe the plantar scar issue is an urban legend!

 

[NatCh]

Actually, that's why I stated "potential" scar. Fortunately, it seems that my experience has paralleled yours, and plantar scars have healed very nicely.

I'm sure that similar to me, you make sure that whenever possible, the incision is not actually directly below a weight-bearing surface. In the case of a neuroma excision, the incision is between the metatarsals, not below the metatarsals.

However, I have had more complaints of dorsal scar discomfort and fibrosis than plantar scar problems. Maybe the plantar scar issue is an urban legend!

For neuroma plantar approach I make the incision in between the metheads but in residency we did Hoffman procedures via plantar approach directly beneath the metheads (scared all of us residents due to painful scar fears). Even then, none of the patients as far as I know ever complained about the scar, which fairly well disappeared. Nonetheless, I usually use a dorsal approach for virgin neuromas anyway.

I tend to think the painful plantar scar is urban legend, but perhaps one of these bright students or residents can pull up an article examining the issue of plantar versus dorsal scar formation.

 

[PADPM]

I've never performed a Hoffman via a plantar incision. Of course many of the patients requiring this procedure have R.A., and subsequently have fat pad atrophy/trophic skin. Therefore, I presume you would have to choose these patients cautiously when performing a plantar incision.

 

[krabmas]

For neuroma plantar approach I make the incision in between the metheads but in residency we did Hoffman procedures via plantar approach directly beneath the metheads (scared all of us residents due to painful scar fears). Even then, none of the patients as far as I know ever complained about the scar, which fairly well disappeared. Nonetheless, I usually use a dorsal approach for virgin neuromas anyway.

I tend to think the painful plantar scar is urban legend, but perhaps one of these bright students or residents can pull up an article examining the issue of plantar versus dorsal scar formation.

No literature, but similar to the palm of the hand, the sole of the foot heals well when the patient is able to maintain NWB.

 

[NatCh]

No literature, but similar to the palm of the hand, the sole of the foot heals well when the patient is able to maintain NWB.

True, but I've found they don't even require NWB -- just protected WB in an aircast or p/o shoe. I do use heavier gauge suture material though.

 

[krabmas]

True, but I've found they don't even require NWB -- just protected WB in an aircast or p/o shoe. I do use heavier gauge suture material though.

I agree that the pt could probably WB if they are sensate. I would not trust the neuropathic patient to WB w/ a plantar incision even in a total contact cast.

 

[347932]

I can't remember the last Neuroma I excised. I now do the sclerosing injection series and have done this for the past four years or so. It has virtually eliminated the need for operative excision and I've had extraordinarily good results with the series.

Neat vid though! I know Dr. DeHeer quite well. He's an excellent surgeon, a very bright practitioner and a super nice guy. He was also one of the Podiatrists that spent time away from his private practice to help with disaster relief in Haiti.