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Neuroma Management

General

Most patients with plantar digital neuritis/neuroma (a painfully enlarged nerve) complain of a sharp shooting pain affecting the ball of the foot, radiating into the toes.  Some patients also experience numbness.  The symptoms are often brought on by wearing tight fitting shoes and normally occur after prolonged walking or driving.  The pain can often be relieved by taking the shoe off and resting. The cause of neuromas is not clear, although local irritation has been suggested.

 

 

Diagnosis

The diagnosis is made by the examining the foot in combination with your description of the symptoms.  Sometimes the diagnosis is less clear cut and an injection of local anaesthetic or an ultasound scan may be required.

Treatment options

Conservative care

• Wide fitting shoes
• Insoles
• Anti inflammatories and analgesics
• Local steroid injections

Surgical Management

This involves excision of the thickened nerve.

Day surgery

You are admitted to the hospital on the day of your operation.  Professor Tagoe will confirm your consent form and mark the surgical site(s). Dr Nathwani (anaesthetist)  will also see you to discuss your anaesthesia.

Anaesthesia

Most patients elect to have their operation carried out under local anaesthetic with sedation, under the care of Dr Nathwani Consultant Anaesthetist.

There are different depths of anaesthesia from sedation through to a general anaesthetic.  Sedation provides reduced consciousness with most of your reflexes left intact and spontaneous breathing. This means that your airway is secure and there is no need to place a tube into your throat. As well as sedation a local anaesthetic block at the level of the ankle is performed to render the surgical area anaesthetised. This allows us to keep the amount of drugs used to a minimum.  The sedation wears off within a few minutes of the end of the operation, without the accompanying drowsiness and nausea, which is sometimes associated with general anaesthesia. The operation is pain free and patients remember nothing of the experience at all.

Local Anaesthesia

Professor Tagoe will anaesthetise your leg via an injection in the back of your knee (Popliteal block). 

As the anatomy behind the knee varies a little from person to person we use a nerve stimulator to locate the nerves. This sends a small electric current down the needle which stimulates the nerve. This means that the muscles controlled by the nerve begin to contract and relax causing the foot to ‘flick’. Whilst this is a strange sensation, it is not uncomfortable and helps us to deliver the anaesthetic with precision.

Local anaesthetic at the level of the knee not only blocks sensation but also movement of your foot.  This is temporary lasting for 24 to 36 hours and has the advantage of providing long lasting pain relief and numbness. 

The operation

The standard incision is on the top of the foot over the site that is painful.  The incision is about 4-5 cm in length and is placed on the top to reduce the likelihood of a painful scar on the sole of your foot.  The surgeon will use a dissolving suture to close the skin.  The operation normally takes about 20 minutes.

Discharge

Before you leave the hospital you will be given a post operative shoe and shown how to partially weight bear using crutches.  Post operative painkillers will be dispensed by the nurses. 

You should arrange to go home via car or taxi with an escort.  You are advised to have someone with you for the first twenty four hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48hrs (essential walking only). It is important that you do not interfere with the dressings and keep them dry.  You can buy a purpose made waterproof cover to keep the leg dry, from your pharmacy.  Professor Tagoe will see you for a dressing change 3-4 days post surgery, most patients can then return to walking to tolerance around the house.  You will be seen by the nurses 10 days following the surgery when the dressing will be removed and the suture tags cut.  The physiotherapist will instigated range of motion exercises and help you return to a trainer and facilitate your walking.  From this point on you can wash your foot.  A gradual increase in your activities will reduce the likelihood of local scarring aiding your recovery.   Once out of the post operative shoe you can drive your car as and when you feel safe.

Outcome

After this type of surgery you will have permanent numbness between the relevant toes.  However, we hope to improve or eliminate your pain. A published departmental audit reported a 94% satisfaction rate.

Possible complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.  Outlined below are the common problems or those rare complications with serious outcomes.  In cases where we don’t have accurate audit, we have used published results from the podiatric literature.  These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
• Thick and or sensitive scar – no audit data is available.
• Adverse reaction to the post operative pain killers.  1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue.  The incidence is 1 in every 83 operations*
• Delayed healing of soft tissue   No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition.  Deep vein thrombosis incidence is 1 in every 900 cases.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident.  This normally requires management by specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.

Specific complications following neuroma surgery

• Reoccurrence of symptoms.

• Localised scar tissue, this normally resolves with post-operative massage or physiotherapy

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre operative screening of your health allows us to determine whether you are fit for surgery.  It is important that you disclose your full medical history.  If there is a question mark against your health then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post operative instructions which include resting and elevating the operated leg.  Keeping the wound clean and dry until advised otherwise is essential.  Please ask the nurse or Professor Tagoe if you are not sure what to do.
• Having a healthy diet is important; this provides the nutrition required for healing.
• Smoking is associated with a 20% increased risk of delayed or non healing of bones.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
• Post-operative mobilisation will be advised, this helps improve the flexibility, strength and stability of your foot.

Podiatric Surgical Training
3 year:	Degree in Podiatry
2 year:	General Podiatric Practice
2 year:	Diploma in the theory of podiatric surgery
2 Year	Surgical training programme (Podiatric Surgical Trainee)
	Final fellowship examinations
3 year:	Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery Consultant Podiatric Surgeon

Secretaries:

Marina Nichols:
08700 410448
Email: marina@thetagoeclinic.co.uk