Foot neuroma surgery
Conservative treatment does not work for many patients and minor surgery usually is necessary. Two surgical procedures are available. The surgical removal of forefoot neuromas is a relatively simple procedure. The surgery can be preformed using a local anesthesia in the doctors office or with intravenous anesthesia (twilight anesthesia) in an outpatient surgery center. The dorsal approach involves making an incision on the top of the foot. This approach permits the patient to walk soon after surgery because the stitches are not on the weight-bearing side of the foot. The podiatrist maneuvers the instruments carefully through many structures and cuts the deep transverse metatarsal ligament, which typically causes most of the nerve compression. This procedure can lead to instability in the forefoot that may require attention in the future. Following administration of anesthesia, a skin incision is made on the top of the foot in the location of the neuroma. This is most commonly in the area between the second and third toes or between the third and fourth toes. The second procedure involves a plantar approach, in which the incision is made on the sole of the foot. The advantage of the plantar approach is that the neuroma can be reached easily and resected without cutting any structures. Most surgeons prefer to make the skin incision on the top of the foot for several reasons. If the skin incision is placed on the bottom of the foot the patient may be required to use crutches for up to three weeks. Additionally, it takes longer for the skin on the bottom of the foot to heal. In the event that a thicken or irregular scar forms during healing, it may cause pain while walking. When the incision is made on the top of the foot the neuroma is easily found between the long bones (metatarsals) behind the toes. After the nerve is identified it is cut and removed. Once the surgery is completed a gauze dressing is applied. This bandage stays in place until the surgeon sees the patient on their first post-operative visit. On the first post-operative visit the surgical site is inspected and a new dressing is applied. The sutures are removed in 10 14 days following the surgery. During this period of time the foot must remain dry to reduce the risk of infection. The patient should limit their activities and keep their foot elevated above the heart as much as possible. A post-operative shoe is worn which allows the patient to do limited walking. The patient should not walk with out the post-operative shoe. Once the sutures have been removed the patient may bath the foot and attempt to wear a roomy stiff-soled walking shoe. It generally takes three weeks from the time of surgery before the walking shoe can be worn comfortably. The time required to be off from work will depend upon the type of work being preformed and the type of shoe that must be worn. If the patient can work with their foot propped up and elevated with limited walking they may be able to return to work within a week of surgery. It is generally recommended that the patient not return to work until they can wear a normal shoe comfortable. Patients who have jobs that require prolonged standing, walking, kneeling or climbing may be off from work for as long as four to six weeks. The surgical area contains very small blood vessels, nerves, and muscles and complications can occur. Once the neuroma is removed, the empty space may fill with blood, resulting in a painful hematoma. There is a risk for infection, necessitating careful monitoring by the podiatrist and patient. If the incision site becomes warm or red within a day or two after surgery, or if the patient runs a fever, the surgeon must be contacted immediately. Recurrence is another possibility. The stump of nerve remaining after resection can begin to grow again. If this occurs, the nerve grows in width and length, creating a burning pain that can be treated by injection or further surgery.
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