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I have been asked to research this as a possibility of this being a procedure.

This may be a preferred method of treatment to counter the use of corticosteroid due to the fact that this may cause fat pad atrophy due to leakage into the plantar area. I have not been given any more info a part from this.

Any ideas of how to search for this? Any info that people may have? Have tried google with no real results.

Thanks in advance...

Hi GarethNZ:

Well, it would be endoscopic procedure since there is no joint.

Anywhere you can form a "space" you can insert a scope. In the foot non-joint scopes have been used at the Achilles attachement, os trigonum, plantar fascia, etc.... as well as within tendon sheaths (tenoscopy).

Teach a surgeon to use a scope and he'll come up with new ways to use it (or the orthopedic company will!)

I have heard of decompressing the nerve, i.e., just cutting the transverse intermet. ligament with the endoscope, but not really removing the neuroma. It doesn't seem as though it would be that difficult to remove it.

I would suggest perhaps searching for ENDOSCOPE and Morton's neuroma. You'll probably get some 8th cranial nerve hits as well.

Hope that helps.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Steve,

Thanks for you reply...not good form with terminology there! Had looked up the definition or arthroscope, thinking that is is there definition of the tube for any surgical procedure whether endoscopy or arthroscopy...anyway!

I'll do some searches and get back too you...

Kind regards

Gareth

There was something called the Kobyguard system being talked about a few years ago, but I do not know of anyone using it at this time - might be worth a google though

regards

simon

Hi Simon

The Koby Guard is actually just a blade and tunneling device that allows one to cut the intermet. ligamet from the interspace. (they have one for the planatar fascia as well)

My take on this device is that if ALL you are going to do is cut the ligament then you can easily make a small incision OVER the interspace and cut it with your blade of choice. I was never sold on why this device was needed.

It will "decompress" the nerve, whether or not this translates into relief of symptoms is another question.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Hi Steve,

Absolutely, that was my reaction at the time of the presentation. I don't know anyone who bought into it for exactly the reasons you mention(not to say some practitioners don't find it helpful!).

s

The procedure you are discussing is known as the EDIN procedure which stands for Endoscopic Decompression Intermetatarsal Neuroma. The procedure was developed by AM surgical for use with their system. In fact I am quite friendly with the president of AM surgical. Recently Am surgical sold their foot an ankle products to Wright Medical who markets the system. The system is better known for use in Gastroc recession procedures. Technically the procedure is rather easy to perform, but IMHO, it can be accomplished just as easily using a #62 blade through the dorsum of the foot.

The Kobeguard system was merely a modification for office use and involved a tunneling device with a capture jig to insert their special blade which was little more than a #62 blade on a flexible plastic handle. The systems were very affordable, although the price for the blades is high, although not as costly as the AM surgical blades which run about $500 each.

Right now several complanies are working on an endoscopic tarsal tunnel release system, but due to the position of the ankle, safety of the procedure is a big issue. Developing specific equipment for this will probably make the procedure cost prohibitive.

Speaking of AM Surgical. Has anyone used their system for an endo gastroc release? Thoughts?

The AM surgical instrumentation for endoscopic gastroc release was originally marketed by AM surgical and the rights to it were sold to Wright Medical. The device is rather easy to use and there are only a few potential issues. Most important of which is the possibility of sural nerve damage. If the incision is made 4 finger breadths above the flair, and in a proximal to distal manner, there is little potential for damage.

You should easily be able to get approximately 1.5 cm of length using this technique with minimal dissection. I suggest you cast the patient for a period of 4 weeks post op. Several others report there is a loss of "explosive" power following the procedure and it should be reserved for less active patients and a conventional TAL done for younger more active patients.

Summer

Dear All,

I believe it was Dr Stephen Barrett who developed this procedure. He was also one the two Podiatrists in the USA who developed the Endoscopic Plantar Fasciotomy (EPF) procedure back in the 90's. Although I have taken both of Dr Barrett's courses I only continue to perform EPF when indicated. I have found that a Neuroma Decompression can be carried out using a small stab incison into the skin and with soft tissue dissection and identification of the intermetatarsal ligament, it can be transected and the nerve decompressed. I have personally found that Endoscopic nerve Decompression was more tramatic and in half the cases a nerve resection would be required at a later time.

Robert Chelin DPM
Canada

Hi Robert:

"continue to perform EPF when indicated."

Wondering what your success rate is.
How does your post op routine differ when you remove the nerve.
Do you code for a nerve decompression?
Thanks
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Dear Steve,

There are no coding issues in Canada for Podiatrists. Patients pay us directly in most cases and then they seek reimbursement from the insurance comanies or they pay themselves if there is no coverage.
As far as EPF I have had grea success but with avaiablity of Extracorporeal Sockwave Therapy (ESWT) in Canada I have not had to perform nearly as many
EPF.
As far as the neuroma surgery. When doing nerve decompression it usually involves one suture for closure that is removed in a week. The dressing is much smaller and they can put on a running shoe immediately. When performing a full dissection as you know sutures in longer unless closure by subcuticular. They need to keep drier longer and I place them in a post op shoe for 3-4 weeks minimum. It also will take longer to return to extra ciricular activity.


Robert

Summer,
I was under the impression that a gastroc release or EGR would have a less debilitating effect on the triceps surae strength versus a TAL? With the EGR I thought you are only releasing the gastroc aponeurosis at the "gastroc run out?" Thus, you'd leave the soleal aponeurosis intact helping to retain some of the "explosive" power. A TAL affects the entire muscle group. How could a TAL be better for younger patients, if you consider the risks of Achilles over-lengthening, rupture, scarring, etc all associated with TAL surgery?

Can you shed some more light as to why a TAL would be better for younger patients?

Thanks.

Dear members,

Please find below some of the articles generated by a brief Medline search into this topic. They include a review, a retrospective study, and a preliminary cadaver report. All articles are published by the same principal author (Barrett), as referred to by Robert above. The abstracts and references for these articles are pasted below in chronicle order, however I was unable to obtain electronic full-text access through my library account.

Review (note author’s contact details):


Retrospective study (no control for confounding variables):


Preliminary cadaver report:

Regards,

Andrew