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Dr. Davis & Dr. Z

Posted by Sheila S on 1/07/03 at 01:45 (105003)

Hello again.... I went to the Orthopedic Foot/Ankle Specialist yesterday evening. (sorry, on neuroma, 2 surgeries, sclerosing, etc. still very painful). He took xrays said the foot looked normal, did alot of feeling around and feels it's still neuroma - probably or possibly, the nerve wasn't cut short enough to retract away from the pressure area of my foot.

He would recommend another surgery with plantar incision. However, he said the success rate on that is only about 75%. I'm concerned about yet another surgery with no real good success rate. Also, he did not feel that any other tests would reveal anything; and his question was, if an MRI shows a neuroma then great, but what if it doesn't, than what? Since that was a very good question I didn't decide to have the test (at this time). I asked about cryoablation but they don't do cryosurgery there.

Any thoughts on the plantar incision success rates and cryoablation??

Thanks!
Sheila

Re: Dr. Davis & Dr. Z

Dr. Z on 1/07/03 at 20:47 (105061)

Here is what I know about cryoablation. Very poor results with cases that have had neuroma surgery.
It sounds like the orthopedic guy did a very good examine. I agree with
him. Surgical excision from the bottom is the correct approach. I would do if I have tried everything

Re: Dr. Davis & Dr. Z

Ed Davis, DPM on 1/07/03 at 22:40 (105068)

Sheila:
Removal of the neuroma from a plantar approach sounds reasonable. No advantage to cryoablation. Why does he place the success rate at only 75%? (my suspicion is that he is just being cautious).
Ed

Re: Dr. Davis

Sheila S on 1/08/03 at 04:27 (105079)

Hi Dr. Davis, thanks (yet again!) for your response. You are the one that suggested from the beginning that there was still a neuroma in the same place, or even possibly an adjacent space. You explained to be that you had seen bi-lobed and tri-lobed neuromas and the lobe could NOT be seen from a dorsal incision... consequently I did alot of study on that aspect, and felt your ideas of another lobe (or nerve not cut short enough) were most likely on the nose.

The Ortho doc said the clicking I still have is a great indicator; and his best test was to inject the nerve with zilocaine (or some such) which he did. He angled the needle directly to the met head and was dead-on hitting the spot that hurts the most. For about 3 hours I was totally, completely, pain free. Do you agree with that theory also? (He did mention the slight possibility of 'phantom pain' but didn't feel this was the problem because of the clicking - and if the injection worked then that would also rule out phantom pain.)

I know I saw some photographs on the web of the surgery and they showed the nerve removed stretched out over top of the incision - to show the length removed. And I remember thinking at the time that neither of my docs removed that much ADDED together (I asked to see). The first doc removed maybe a 1/4 inch of nerve, the second doc only removed a lump with little tissue attached. So it seems reasonable the nerve wasn't cut short enough.

Now, I'm concerned about getting the utmost best surgeon to do the surgery. Any ideas there? I'm scared of the Ortho doc since he said the success rates are so low (by the way, he named some world-famous Orthopedist who does alot of this, when talking about success rates, but I can't for the life of me remember his name); and my Podiatrist that did the 2nd surgery does not do plantar incisions.

I'm willing to travel to have the surgery just to be assured the doctor is HIGHLY experienced, knowledgeable, etc. etc. and is my very best chance at getting this problem fixed.

Any help would be hugely appreciated. Many thanks!

Sheila

Re: Dr. Davis

Ed Davis, DPM on 1/08/03 at 14:59 (105107)

Sheila:

I understand your concerns considering your experience. This is not a complex procedure, requiring a very high level of skill. Again, I have to wonder why the ortho surgeon came up with the 75% figure -- suspecting that was due to caution. As far as someone who 'does a lot of this,' that would be a bit hard to believe as there simply are not a lot of cases out there requiring a plantar approach. I certainly can come up with some 'big names' in my field if you don't mind the travel.
Ed

Re: Dr. Davis

Sheila S on 1/08/03 at 16:45 (105116)

Some 'big names', actually, more importantly, someone experienced in plantar surgeries - at least to some degree, would be wonderful. I don't mind travelling if I can get someone experienced to do the surgery.

You can send the names to my email if you like, (email removed)

Thanks!

Re: I have a Dr. Plantar approach for you

Dr. Z on 1/08/03 at 21:50 (105139)

The plantar approach is the much easier procedure to to perform then the dorsal approach. I do know someone who does it all the time instead of the dorsal approach. He is very good with this approach. We were all taught the dorsal approach but this podiatrist only does it the plantar approach. So if you want to travel and go to him I will hook you up with this guy. He has been doing the plantar approach for over twenty five years.. Is that enough experience.

Re: a complication...

Sheila S on 1/09/03 at 03:14 (105145)

Dr. Z, 25 years is quite enough experience. lol

However, NOW, I would like to gather your opinion (and Dr. Davis) on this:
another doctor said 1) if the neuroma thread was hidden under the met head, there would be no Mulder's click. 2) if it was a neuroma somewhere in this area it SHOULD show up on an MRI and SHOULD show up on an Ultrasound. He said they are actually quite easy to see on ultrasound if the viewer is experienced. His suspicion is that it is not a neuroma but a tear or other damage to the metatarsophalangeal joints.

IF tests can't prove that it IS another neuroma or nerve cut too short, are there some tests that CAN prove it's NOT something else?

Sheila

P.S. I have been given the name of Dr. Banks in Georgia, which isn't that far away. Any thoughts?

Re: a complication...

Dr. David S. Wander on 1/09/03 at 08:27 (105150)

Sheila,

I completely agree with Dr. Davis regarding doctors that perform 'a lot' of these procedures. Even in a busy practice, I'd be very concerned with a doctor that boasts about doing these procedures all the time. Many neuroma's don't require surgery and are relieved with conservative care. The advantage of a plantar approach is that there is usually much better visualization of the structures. I never call any surgery 'simple', because all surgeries carry risks. I would certainly seek a surgeon that has experience with the plantar approach and discuss your concerns with him/her. Dr. Alan Banks in Georgia has an excellent reputation and is a very experienced surgeon and should be an excellent choice.

In my opinion, a Mulder's click is a very unreliable sign that can also occur with an intermetatarsal bursa, and is not necessarily unique to a neuroma. I certainly wouldn't use Mulder's sign/click as a definitive answer. Ultrasound is an excellent modality if it is being performed by someone with A LOT of experience. An MRI (with contrast/gadolinium) is also an excellent test to determine if a neuroma exists, but may not show a small entrapment further back. Once again, this is best read by a radiologist with an expertise in musculoskeletal MRI.

Unfortunately, despite all clinical signs, symptoms and expensive tests, the only DEFINITE way to determine what is causing the pain is surgical intervention. In your case I do agree that a plantar approach should be the most beneficial in visualizing all the structures, and Dr. Alan Banks should be an excellent choice. Good luck.

Re: Dr. Davis & Dr. Z

Dr. Z on 1/07/03 at 20:47 (105061)

Here is what I know about cryoablation. Very poor results with cases that have had neuroma surgery.
It sounds like the orthopedic guy did a very good examine. I agree with
him. Surgical excision from the bottom is the correct approach. I would do if I have tried everything

Re: Dr. Davis & Dr. Z

Ed Davis, DPM on 1/07/03 at 22:40 (105068)

Sheila:
Removal of the neuroma from a plantar approach sounds reasonable. No advantage to cryoablation. Why does he place the success rate at only 75%? (my suspicion is that he is just being cautious).
Ed

Re: Dr. Davis

Sheila S on 1/08/03 at 04:27 (105079)

Hi Dr. Davis, thanks (yet again!) for your response. You are the one that suggested from the beginning that there was still a neuroma in the same place, or even possibly an adjacent space. You explained to be that you had seen bi-lobed and tri-lobed neuromas and the lobe could NOT be seen from a dorsal incision... consequently I did alot of study on that aspect, and felt your ideas of another lobe (or nerve not cut short enough) were most likely on the nose.

The Ortho doc said the clicking I still have is a great indicator; and his best test was to inject the nerve with zilocaine (or some such) which he did. He angled the needle directly to the met head and was dead-on hitting the spot that hurts the most. For about 3 hours I was totally, completely, pain free. Do you agree with that theory also? (He did mention the slight possibility of 'phantom pain' but didn't feel this was the problem because of the clicking - and if the injection worked then that would also rule out phantom pain.)

I know I saw some photographs on the web of the surgery and they showed the nerve removed stretched out over top of the incision - to show the length removed. And I remember thinking at the time that neither of my docs removed that much ADDED together (I asked to see). The first doc removed maybe a 1/4 inch of nerve, the second doc only removed a lump with little tissue attached. So it seems reasonable the nerve wasn't cut short enough.

Now, I'm concerned about getting the utmost best surgeon to do the surgery. Any ideas there? I'm scared of the Ortho doc since he said the success rates are so low (by the way, he named some world-famous Orthopedist who does alot of this, when talking about success rates, but I can't for the life of me remember his name); and my Podiatrist that did the 2nd surgery does not do plantar incisions.

I'm willing to travel to have the surgery just to be assured the doctor is HIGHLY experienced, knowledgeable, etc. etc. and is my very best chance at getting this problem fixed.

Any help would be hugely appreciated. Many thanks!

Sheila

Re: Dr. Davis

Ed Davis, DPM on 1/08/03 at 14:59 (105107)

Sheila:

I understand your concerns considering your experience. This is not a complex procedure, requiring a very high level of skill. Again, I have to wonder why the ortho surgeon came up with the 75% figure -- suspecting that was due to caution. As far as someone who 'does a lot of this,' that would be a bit hard to believe as there simply are not a lot of cases out there requiring a plantar approach. I certainly can come up with some 'big names' in my field if you don't mind the travel.
Ed

Re: Dr. Davis

Sheila S on 1/08/03 at 16:45 (105116)

Some 'big names', actually, more importantly, someone experienced in plantar surgeries - at least to some degree, would be wonderful. I don't mind travelling if I can get someone experienced to do the surgery.

You can send the names to my email if you like, (email removed)

Thanks!

Re: I have a Dr. Plantar approach for you

Dr. Z on 1/08/03 at 21:50 (105139)

The plantar approach is the much easier procedure to to perform then the dorsal approach. I do know someone who does it all the time instead of the dorsal approach. He is very good with this approach. We were all taught the dorsal approach but this podiatrist only does it the plantar approach. So if you want to travel and go to him I will hook you up with this guy. He has been doing the plantar approach for over twenty five years.. Is that enough experience.

Re: a complication...

Sheila S on 1/09/03 at 03:14 (105145)

Dr. Z, 25 years is quite enough experience. lol

However, NOW, I would like to gather your opinion (and Dr. Davis) on this:
another doctor said 1) if the neuroma thread was hidden under the met head, there would be no Mulder's click. 2) if it was a neuroma somewhere in this area it SHOULD show up on an MRI and SHOULD show up on an Ultrasound. He said they are actually quite easy to see on ultrasound if the viewer is experienced. His suspicion is that it is not a neuroma but a tear or other damage to the metatarsophalangeal joints.

IF tests can't prove that it IS another neuroma or nerve cut too short, are there some tests that CAN prove it's NOT something else?

Sheila

P.S. I have been given the name of Dr. Banks in Georgia, which isn't that far away. Any thoughts?

Re: a complication...

Dr. David S. Wander on 1/09/03 at 08:27 (105150)

Sheila,

I completely agree with Dr. Davis regarding doctors that perform 'a lot' of these procedures. Even in a busy practice, I'd be very concerned with a doctor that boasts about doing these procedures all the time. Many neuroma's don't require surgery and are relieved with conservative care. The advantage of a plantar approach is that there is usually much better visualization of the structures. I never call any surgery 'simple', because all surgeries carry risks. I would certainly seek a surgeon that has experience with the plantar approach and discuss your concerns with him/her. Dr. Alan Banks in Georgia has an excellent reputation and is a very experienced surgeon and should be an excellent choice.

In my opinion, a Mulder's click is a very unreliable sign that can also occur with an intermetatarsal bursa, and is not necessarily unique to a neuroma. I certainly wouldn't use Mulder's sign/click as a definitive answer. Ultrasound is an excellent modality if it is being performed by someone with A LOT of experience. An MRI (with contrast/gadolinium) is also an excellent test to determine if a neuroma exists, but may not show a small entrapment further back. Once again, this is best read by a radiologist with an expertise in musculoskeletal MRI.

Unfortunately, despite all clinical signs, symptoms and expensive tests, the only DEFINITE way to determine what is causing the pain is surgical intervention. In your case I do agree that a plantar approach should be the most beneficial in visualizing all the structures, and Dr. Alan Banks should be an excellent choice. Good luck.