Interview with Mr Stephen Bendall, UK Orthopaedic specialist

Today I have an interview with a specialist that I have seen. For me he was an NHS specialist that led the team that tried to help through orthotics and non-invasive measures as, as he states here, surgery is not a great option. See the interview below for a Dr that uses surgery as the last resort to treat Ledderhose disease. 

  

Mr Bendall completed his undergraduate training at Charing Cross Hospital Medical School followed by orthopaedic training on the Charing Cross and St George's rotations. He gained his Fellowship at the University of Maryland and John Hopkins, Baltimore, USA.

He was appointed as a Consultant in 1997 at the Princess Royal Hospital. Mr Bendall's interests include all aspects of foot and ankle surgery and he is also involved in training and research and has recently become an examiner for the FRCS Orth exminations. He is currently the chair to the BOFAS Education Committee and is Chair of the BOFAS MIS Group. Mr Bendall has published a wide range of papers, in particular in relation to ankle and forefoot surgery.

Information and picture above was reproduced with permission from here

1) How long having you been treating Plantar Fibromas?

 I have been treating this condition for fifteen years. 

2) Roughly how many plantar fibroma patients have you treated? And what percentage goes on to need surgery?

I am afraid I have lost count of how many patients I have seen but I would generally see one a month or so. I treat a tiny proportion; my guess would be 30 to 40 cases.

3) How common do you think Dupuytren's and Ledderhose respectively are in the UK? They are supposedly more common in males then females and have been linked to a family history of the conditions, smoking, alcohol consumption and diabetes are these risk factors you see in your patients?

I am not sure of the frequency of this condition within the UK but I agree with your observation that this is more common in men, there are various things that are supposed to be associated with the condition and one sees these risk factors to a varying degree in some but not all patients.

4) When treating plantar fibroma patients what would your order of treatments be? E.g. Steroid injections, orthotics, then surgery?

Regarding how you manage this condition, most patients in fact have little or no symptoms, they are just simply worried about the lump. 

 You are correct that one obviously goes up a ladder of care starting with non-surgical treatment before looking at surgery.

 I am very wary of intervening in an invasive way, either with a steroid injection or with surgery for this condition because it is rare for patients being unable to tolerate the presence of the lumps. It is when one intervenes by doing something physical to the lumps that problems arise.

5) I seem to remember you were not a fan of steroid injections for Plantar Fibromas, why is this?

There is no specific evidence that I am aware of that steroid injection helps or improves this condition

6) In what condition would a patient need to be before you recommend surgery?

Patients usually come to surgery because the lump is intolerable to them or it is very painful. 

7) What is the procedure for surgery? What are the side effects, recovery time and overall success rate in terms of the condition coming back?

The key thing is that the incision to remove the lump is not a small one and has to encompass the whole length of the sole of the foot and one takes away not only the lump but also a margin of what seems quite normal tissue around it to try and reduce the recurrence rate. The published recurrence rate being 10 to 20%.

 In general terms the cut heals over about three weeks or so but the foot will feel sore and tender for the better part of two to three months.

The key thing is that one is interfering with a segment of the plantar fascia and that is an important structure in the foot and one might have to consider wearing orthotics on an indefinite basis after such an operation.

8) What are your thoughts on other treatments that are meant to help with the treatment of these conditions, such as radiotherapy which has been used successfully to treat plantar fibromas and delay Dupuytren's, also cryotherapy /cryosurgery and Xiapex?

I am not familiar with the other modalities of treatment that you mention, radiotherapy, cryotherapy and Xiapex. There is obviously literature with some experience of radiotherapy in Germany but I am not aware of any UK interest in this.

9) Finally any other advice that you would like to give?

Finally the text book, which is Surgery of the Foot and Ankle, is probably the most authoritative text we have on foot and ankle surgery and it quotes “attempted surgical resection is best avoided”. I think that is good advice and certainly is in my experience.

I have seen patients referred to me before who have had attempted resections and these have proved difficult to resolve.

I hope that this has been helpful for you.

With kind regards

Stephen Bendall

The thing that I found most illuminating is that he did not know that there was an interest in the UK for radiotherapy when Dr Shaffer has been treating using radiotherapy for several years and of course it is the treatment that I have had a decent result (so far) with.

I am hoping that I can get Mr Bendall to contact Dr Shaffer. He clearly thinks that surgery is not a great option and perhaps with a bit more knowledge he might think that radiotherapy has some things going for it. I understand that doctors are busy but surely it is in their patients best interests if they are able to keep up to date with all the treatment options available as there may be patients out there that have had surgery that have had it come back worse when perhaps radiotherapy would have worked. 

Other than the above comment I think it was a really good interview and I appreciate, as I do with all specialists, that he found the time to answer the questions.

Interview with Aaron Wolfson, Radiotherapy specialist in Florida

Today I have an interview with Dr Aaron Wolfson from Florida. He uses radiotherapy to treat Dupuytren's and recently Ledderhose. I came across him when a patient I am in contact with was looking for a doctor in Florida and another patient I am in contact with is the patient they mention below. He seems happy with the way that he has been treated and said that the doctor I have interview here follows Dr Shaffer, that can only be a good thing. 

Aaron H. Wolfson, MD, FACR

Professor

Department of Radiation Oncology

University of Miami Miller School of Medicine

1475 NW 12th Avenue, D-31

Miami, FL 33136

Phone: (305) 243-4210

Fax: (305) 243-4363
To see this address On a map 

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

    I have been interested in treating patients with benign fibroblastic diseases (such as desmoids tumors, meningiomas, heterotopic bone, keloids etc) for over 20 years. I have only become interested in treating patients with Dupuytren’s and Ledderhose disease for the past three years. So far I have done four consults and one patient has accepted treatment (currently on a break).

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

    See above. The patient has Ledderhose disease.

3) How common do you think Dupuytren's and Ledderhose are in the USA? They are supposedly more common in males then females and have been linked to smoking, alcohol consumption and diabetes are these risk factors you see in your patients? 

I actually don’t know the answer to this question. I get about three to four calls a year from all over the U.S. for the past three years. You are correct about the risk factors and most I have encountered have more than one usually.

4) Roughly what percentage of the patients you have treated have had a family history of these diseases? 

    The patient I am currently treating has a family member with this disease.

5) You treat with radiotherapy, what protocol do you use (dose, no of doses and gap between the 2 weeks of treatment etc.) and what is the success rate on these diseases with radiotherapy? 

     I use the regimen proposed by Dr. M.H. Seegenschmiedt of Essen, Germany in  which the patient receives once electron beam treatment to the region a day for 5 work days followed by an 8 to 10 week break at which time the patient receives an additional 5 daily treatments (3 Gy per fraction x 10 fractions in total = 30 Gy).

6) Why is radiotherapy a better course of action than other treatments such as surgery? 

    The data from dr. Seegenschmiedt show only about a 10% progression rate with radiation therapy with up to about 50% progression rate with surgery.

7) What are your thoughts on other treatments that are becoming available such as Xiapex? 

    I do not have any experience with Xiapex but I am sure more medications will become available.

8) Finally do you have any advice or other information that you would like to share with Dupuytren's / Ledderhose patients?

  My main advice is to have early detection of the disease in which it is in the nodule stage. It is very difficult to treat the disease in the cord stage.