Laser Foot Surgery
When the carbon dioxide radio-frequency-excited surgical laser was introduced in Canada in 1983, everyone thought it would become the treatment of choice for foot problems. The laser is an effective tool but it is not a panacea for foot problems: its best applications are for treating verrucae, porokeratosis and ingrown nail.
Because these lesions can be stubborn, treatment of verrucae is frustrating for both patient and practitioner. Warts used to be treated on a repetitive, palliative basis or removed surgically. Though dermatologists still use liquid nitrogen on plantar warts, the patient may still wind up in a podiatrist's office after several treatments. The most effective form of treatment for warts seems to be the CO2 laser.
Mosaic verrucae or single lesions can usually be vaporized with only one treatment. There is no need to inject a local anesthetic directly into a lesion; the posterior tibial block or dorsal mayo block suffices. Because it is so precise, the laser cauterizes small blood vessels: there is less bleeding than with traditional surgical approaches, no burning, so tissues adjacent to the verrucae are unaffected (causing less edema and surgical trauma), and it sterilizes as it vaporizes.
The procedure requires a local anesthetic. Despite a dorsal injection and gentle techniques, young children still do not like the idea of a needle in their foot, so a routine palliative approach is preferable. The operative site must be kept very dry and covered with sterile dressings for four or five days. The procedure also involves a weight-bearing area; biplane accommodative padding is used to limit pressure on the surgical site, but the wound can become tender depending on the patient's activities. Obviously, the more they can rest and elevate the foot, the better. The Provincial Medical Plan does not cover this procedure, although many insurance companies are now covering foot surgery.
Although chemical matricectomy is successful when used in combination with a partial nail border removal, the laser is another tool that can be used to perform this procedure. The procedure is very similar to older techniques after the offending nail border is removed, the matrix is vaporized with the laser.
There is less postoperative pain, swelling and discomfort for the patient when the laser is used, though it was already minimal with chemical matricectomy.
Ingrown nails can recur with the laser; the rate of recurrence is about 5%. An overly aggressive approach with the laser can also delay healing.
These nucleated, deep corns respond well to treatment with the laser. While in the past they have often been excised, this technique causes more postoperative pain and edema.
The laser can vaporize these lesions right down to their cone-shaped apical base. There is usually no bleeding and patients are able to walk comfortably with accommodative dry sterile dressings.
Patients still have to keep the operative site dry for four or five days. In the presence of biomechanical imbalance or plantar flexed metatarsal, there is a greater possibility for these lesions to recur, in which case the biomechanics of the foot have to be addressed.
Other Uses For CO2 Lasers
Onychomycosis used to be treated with the laser; the nail would be removed and the mycotic nail bed vaporized with the laser. While this worked well, new and effective antifungal oral medications allow treatment without any surgical procedure.
The laser works well in the treatment of neuromas. The laser cuts the nerve smoothly and microscopically, rather than with a frayed edge, so the risk of a "stump" neuroma which can lead to recurrence is lessened.
Myths about lasers
Lasers do not vaporize bone. Since bone does not have the water content of soft tissue, lasers cannot be used to surgically treat bunions and other bone deformities. Though some podiatrists will use a laser to make the incision prior to traditional bone work, they should not claim that laser is effective in the treatment of bone problems.
Is it worth having a laser in your practice?
The laser is an excellent tool in treating some common podiatric problems, one that can help both patients and practitioners. Patients appreciate leading-edge technology in the treatment of their problem, so they might opt for a podiatrist- that can offer them this new approach to the treatment of common podiatric problems.
Lloyd Nesbitt DPM
Canadian Footcare Practice, June 1999, Vol. 4, No. 1
June 1999 by Lloyd Nesbitt, D.P.M.