Interview with Ron McColloch, Podiatrist at London Podiatry Center

Today I have an interview with Ron McCulloch. See below for the interview and details. I actually got in touch with Ron because his centre treats Ledderhose but it also uses Cryotherapy. He has not yet used cryo to treat plantar fibroma's but has not ruled out used it for this purpose in the future.

 Bio: 

Ron McCulloch is the principal Podiatric Surgeon and Director of the London Podiatry Centre. During his many years as a specialist Podiatric Surgeon, he has performed thousands of successful foot operations.

Ron McCulloch is Consultant Podiatric Surgeon at London's Homerton University Hospital.He lectures extensively both on the national and international circuit and helped to develop podiatry in the Middle East.

Ron McCulloch built a state of the art gait laboratory at The London Podiatry Centre. This is one of the most advanced dedicated podiatric gait facilities in the world. He is a published author on surgical techniques and is one of only two practitioners in Great Britain to offer invasive cryosurgery of the foot. 

This information was taken, with Permission from http://www.londonpodiatry.com/podiatry/staff/

1)    How long having you been treating Dupuytren's and Ledderhose disease?  

About 20 years

2)    Roughly how many Dupuytren's patients have you treated and how many Ledderhose patients have you treated?

 Plantar fibroma formation varies from discreet nodules to multiple lesions. (Of course you know this).  I have probably treated several hundred of these over my career. They are not uncommon.  I cannot recall exactly how many I have operated on probably around 20 or 30

 3)    What treatments have you used for these conditions? Would you recommend the treatment and roughly how successful is the treatment for each condition?

 Conservative care/redistributive orthoses. Injection therapy, mainly steroid. Surgery to excise the lesions. As you know I'm now looking at providing cryosurgery as cases now come along.

 4)    What would your recommendations be to Dupuytren's and Ledderhose patients and do you have any advice you would like to give?

 Always start with conservative care. If this fails injection therapy which involves breaking the fibroma down with a needle and then infiltrating the steroid. After this I would be inclined to try cryosurgery and full wide excision if this fails.

 5)    What do you think of other treatments such as steroid injections, Xiapex, Radiotherapy and cryosurgery (which I see you do for other conditions)? 

 I only have experience with injections and excision.  The key thing with excision is to do a large marginal one to minimise the chance of recurrence.

 6)    What success have you had with cryosurgery for other conditions? 

 I have done almost 100 operations with cryosurgery but these have mainly been for the management of neuroma formation. As of now I have not had to treat   fibroma using cryosurgery as this is a fairly new treatment in our facility. However when the right case comes along I'm sure we will be using this as part of our armoury to treat plantar fibroma formation.

Interview with Dr Spilken, Cryosurgery specialist for plantar fibromas

Today I have another interview with a specialist, Dr Terry Spilken.

Dr Terry L. Spilken earned his doctorate in podiatric medicine in 1979 at the New York College of Podiatric Medicine. He did his residency training at Kingsbrook Jewish Medical Center and Community Hospital. Within a decade, he was back at the College as a member of the adjunct faculty, climbing the podiatric stairway to the position of Dean of Graduate Medical Education and then Dean of Student Services. He has obtained the rank of Associate Professor in the Division of Medical Science.

He has also worked with the International Dupuytren’s society in the production of the book “Dupuytren’s Disease and related hyperproliferative disorders” where he was author on a chapter on “Cryotherapy and other therapeutic options for plantar fibromatosis” where here covered not only several of the options for the treatment of plantar fibroma’s including cryosurgery and surgery but also the associated risk factors, symptoms and inheritance.

You can find more information here

All information above is provided with permission and is available from the above link.

Here I have questioned him on the above subject of plantar fibromatosis / Ledderhose disease:

1) Do you often come across plantar fibroma’s? How common would you say they are in the USA?

Plantar fibromatosis is a very rare condition.  We see it quite often because of our specialization in treating this condition.

2) What are the risk factors for this disease and do you see these in patients, in particular what percentage of patients tend to have a family history of the disease?

The cause of plantar fibromatosis is still unknown.  There is thought that it is an inherited disease.  The necessary genes may remain dormant in the family over many generations.  Besides family history, there is a higher incidence in males.  Patients with these conditions have a higher risk factor: Dupuytren's disease, Peyronie's disease, epilepsy, other seizure disorders, diabetes mellitus, chronic liver disease and hypothyroidism.

3) I understand that every case is different but what course of treatment do you recommend for early stage Ledderhose?

Patients respond to cryosurgery very successfully the earlier in the course of the condition we get to do the procedure.  Cryosurgery has proven to be a very good option for patients and they seem very happy with the results.

b) Other options I have heard of being used early on include physio and verapamil. Do you know of any cases where these have been successful or the success rate? I ask as I have visited 2 physiotherapist who both said this could not be used to help with this condition and have heard poor results about verapamil.

I have not had success with verapamil.  Research is still being done on this treatment but so far the patient comments have been negative.  I don't think physical therapy is an option at all.  I have not come across any success rate doing PT.

4) I see on your website that you perform cryosurgery, what is this and how does it help with plantar fibroma’s? What sort of success rate does it have and can it be repeated?

Cryosurgery is an ambulatory procedure done in the doctor's office.  It involves freezing of nerve cells performed through a small incision, no sutures are required.  An autoimmune response is created with a change in the protein antigenic properties.  We have about an 80% success rate when the fibromas are in the early stages.  For advanced cases, we repeat the procedure several times until we receive the desired effect.

5) What is the procedure and recovery times for cryosurgery?

A small incision is made on the side of the foot under local anesthesia.  A trochar is used to cut into the fibroma.  The probe is then inserted into the fibroma and ice balls are created to destroy the fibroma.  Patients need 24 hours to elevate and foot and keep the bandage dry.  They need to avoid rigorous activity for about 1 week.  It takes 2 months for the full effectiveness of the procedure but the patient is ambulating fully within a few days.

6) I have also seen on the site that you performed ESWT, I have seen reports linking this to treatment of plantar fibroma’s, is this something that you do or know anything about?

(I covered it here http://ledderhose.blogspot.co.uk/2012/04/eswt-treatment-option.html)

I have not used ESWT for fibromatosis.  We use it for plantar fasciitis.

7) In the book chapter you cover surgical treatment of the disease, what are the options when it comes to surgery?

Removing the lesion alone does not work.  In fact, it has a 90% failure rate.  The only traditional surgery that has a good success rate is a complete fasciotomy.  We remove the entire fascia band so there is no fibrous tissue available for a fibroma to form.  There is a very long recovery time for this painful procedure.  The patient is left without a plantar fascia that can affect their ambulation in the future.  That is the reason why cryosurgery has been so popular as an alternative to this drastic procedure.

8) Do you have any other advice that you would like to give to patients with this condition?

Patients are very educated and do research on their conditions.  That is a wonderful development of the computer age.  The more knowledge the patient gathers the more options they give themselves.  Most doctors are not familiar with plantar fibromatosis and therefore don't know the best treatment choices to offer.  My advice is to keep as current as possible with the options available to them and follow the latest research.

I would again like to thank Dr Spilken for his answers.