Whilst you can safely continue taking most drugs during cryosurgery, there are a few which can interfere with the procedure. You should only ever change your medication after first discussing this with your GP or the specialist who has prescribed them. Below is a list of the medication that could influence the healing process. Please contact us if you require further information. Aspirin Although patients can generally continue taking aspirin if they wish to, there is a small risk that this medication may cause increased bleeding during cryosurgery. However, if you are taking aspirin without a serious reason to do so, we would suggest that you abstain for a week before the procedure. Clopidogrel This is an antiplatelet drug which is often prescribed for heart and other vascular conditions. This drug should not be taken during cryosurgery and we would recommend that you stop taking it 10 days before the procedure. We strongly advise that you discuss this with your cardiologist or GP first. Warfarin It is not considered safe to have cryosurgery for Morton’s neuroma whilst on Warfarin, particularly if you are taking an amount which causes your INR to rise above a level of 2. Generally speaking, for cryosurgery we want your INR to be between 1 and 1.5. Patients on Warfarin would need to convert to low molecular weight heparin a few days before their operation to reduce the risk of adverse bleeding. We are happy to liaise with your GP or haematologist to facilitate this, and an expert opinion from these individuals may be required before the procedure can take place. Methotrexate This drug is often used to manage rheumatoid arthritis and other forms of inflammatory arthritis. Opinions vary between rheumatologists and some are quite happy for cryosurgery to take place without adjusting your Methotrexate dose. However, we always recommend that you discuss this with your Consultant Rheumatologist first. Methotrexate belongs to a group of drugs called DMARDs (disease-modifying antirheumatic drugs). There are others in this group, and we can give specific advice via if required. Rivaroxiban This is a relatively new type of blood thinning drug that has to be stopped two days before cryosurgery can safely take place.
Cryosurgery involves freezing the neuroma by inserting a very thin needle-like probe. In simple terms, the nerve tissue is largely destroyed by an ice ball that attaches to the nerve. However, some parts of the nerve remain and this allows for regeneration in a way that would not be possible if the nerve was cut away. This is why permanent numbness is generally not a feature of cryosurgery. Cryosurgery causes vascular damage to the capillaries around the nerve (endoneurial capillaries). This in turn results in a reduction of a fatty sheath around the nerve (“demyelination”) and subsequent "Wallerian" degeneration of the central part of the nerve (the “axon”). Because the connective tissue around the nerve (the perineurium and epineurium) is preserved, there appears to be far less incidence of stump neuroma, a well-recognised complication of open surgery (Richardson et al 2014).
The cryosurgery procedure itself is generally not painful as patients receive a local anaesthetic. This anaesthetic is usually injected into the ankle and top of the foot, not at the site of the neuroma. Here the skin is relatively soft, and the injection is generally not too uncomfortable.
Patients tolerate the injection very well and this is reflected by other studies. Barrington et al. (2014) explored patient willingness to undergo a repeat peripheral nerve block in the event of any further surgery that they may require. The study reviewed 9,969 surgical procedures with a response rate of 61.6%. 94.6% of patients were willing to have a repeat nerve block if required. At the Morton’s Neuroma Centre, the vast majority of patients cope very well with the injection and describe only mild to moderate discomfort.
Your entire appointment will be one hour. This includes the time it takes for your foot to go numb following the administration of local anaesthetic.
We recommend that you travel home on the back seat of a car so you can keep your foot elevated. You should rest for 24 hours but can then return to work. You should avoid longer periods of walking (short walks of 10 minutes or so should be fine).
It is very important that patients keep their foot and dressing dry for the three days. The patient can then remove the dressing after this time. Generally, the small incision will have completely closed. However, if there is still an open wound, a dressing should be re-applied, and patients should contact us for further advice.
We generally recommend that you wait two to three months but this does vary from patient to patient. It also depends on the type of sport – patients should discuss this directly with the Centre for specific advice.
You should give the procedure three months to work. However, the response to treatment does vary from patient to patient. The most important thing is to 'listen to your body' and to do as much or as little according to your comfort levels. If you have little to no pain after two to three weeks, then you will clearly be able to do more than if your foot still has some tenderness.
Some patients bleed and bruise a little more than others. Pain thresholds also vary from patient to patient and some patients may be more sensitive to surgery. Cryosurgery sometimes results in the formation of a blood blister (haematoma). This will vary in size and so may take longer to break down in some patients than others. It also can account in part for the difference in recovery time from one patient to another.
The incidence of complication is very small. One of our recent audits involving 101 patients showed no incidence of infection or other significant complication .
No. Cryosurgery has been used to treat various conditions for over 25 years. Use of cryosurgery to treat Morton's neuroma has good reported success rates. More evidence is needed, however, and this is why we formally audit our results.
Those who have not seen success with open surgery may respond to cryosurgery. In these cases, we freeze the distal hypersensitive part of the remaining nerve. This may be imbedded in scar tissue or present as a stump neuroma.
We often treat patients who have already received one or several steroid injections. A single previous injection will not necessarily reduce the chance of cryosurgery working. However, multiple failed injections can lead to complications such as soft tissue wastage, which can reduce the potential benefit of cryosurgery.
Most insurance companies do cover cryosurgery at our Centre. It is best to call us to discuss this.
Patients can have reduced sensation in the toe, but this does not usually last indefinitely.
This depends on your specific circumstances, however often we prefer to treat a single neuroma at a time. We can perform diagnostic injections to identify whether more than one neuroma requires treatment. We prefer not to treat two feet at the same time as this can slow down recovery.
A bursa and neuroma usually present together, and cryosurgery can be used to successfully treat both. However, if a very large bursa is present then a steroid injection may also be needed.
Many patients do not appear to have recurrence after cryosurgery, however this is possible. We are committed to principles of clinical governance and evidence-based medicine. We continue to audit our results so we can provide patients with the latest information on cryosurgery. Our data shows that recurrence rates are very low.
We have performed what is likely to be one of the most extensive audits on cryosurgery for Morton's neuroma worldwide. Our success rates are at least 70 per cent. One key benefit of cryosurgery is its low complication rate, and this is why it should be considered prior to open surgery. Despite this, there is generally a shortage of good medical studies on the success of cryosurgery for Morton’s neuroma, and to date there are only three published papers on this topic. You may be surprised to learn that there is no good evidence to show that cortisone is effective in the long-term management of the condition, despite its routine use in the treatment of Morton's neuroma. Open surgery has recorded complication rates of up to 40 per cent. Dr. Fallatt et al. (2002) concluded that the results from cryosurgery for Morton's neuroma were comparable to open surgery, but with fewer risks of complication and a significantly shorter recovery period. He reported that 90 per cent of patients would choose to have the procedure done again under similar circumstances, with 38.7 per cent gaining total relief, and 42.5 per cent partial relief at one year. Fallatt did not use ultrasound to guide the procedure, nor did he use a validated patient health survey, instead relying on a 10-point visual analogue (VAS) scale. Patients were reviewed for one year following the procedure. Friedman et al. (2012) reviewed 20 patients, 15 of whom experienced a positive response. However, the sample group consisted of patients with various kinds of nerve related pathology and only five patients were treated for Morton's neuroma. The study reported that one patient experienced no benefit, another experienced mild relief and three were reported to have had marked relief. The paper emphasised the importance of using an ultrasound-guided technique, and most patients received either oral or intravenous (IV) sedation. All received IV antibiotic prophylaxis prior to the procedure. The follow-up time was short and inconsistent with patients reviewed once at four weeks and then at six weeks, 10 weeks and 56 weeks respectively. A validated patient reported outcome measuring tool was not used and some, but not all, were assessed via a pre- and post-operative VAS score. Hodor et al. (1997) discussed the application of cryosurgery for Morton's neuroma citing one successful case study.
It is true that the procedure is more established in the United States than in the UK. Equipment costs are high and mastering the procedure requires a significant investment in time and training. Expert knowledge in ultrasound and minimally invasive surgery is also required. Mr McCulloch, the primary Consultant Podiatric Surgeon at the Centre, has a master's degree in diagnostic ultrasound. He is a senior lecturer on the subject and has many years of experience in performing minimally-invasive medical procedures of the foot and ankle.
No. Our Centre is led by a Consultant Podiatric Surgeon with a long NHS pedigree. Mr McCulloch has performed a vast array of different surgical procedures, ranging from nail surgery to complex flat foot reconstructions and midfoot amputations.
No. The Centre is able to offer the full range of procedures including radiofrequency and open surgery.
We would certainly recommend that you consider cryosurgery before open surgery, and usually also before radiofrequency. This is because of the reduced risk of complication and shorter recovery time. The medical literature shows that open surgery has a reasonable success rate of about 75 per cent, with resection of the Morton's entrapment (J. Jerosch et al. 2006). Other papers (Womack and Richardson 2008) published data in direct contradiction to these success rates. In their series of 120 patients who underwent resection for Morton's neuroma, 50 per cent had a good or excellent result, 10 per cent had a fair result, and 40 per cent had a poor outcome. One of the reasons for leaving open surgery as a last resort option lies in the 25-35 per cent risk of developing post-surgical pain and an unsatisfactory outcome.
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