Dr. Rampertab has performed over 4,000 procedures now and finds that the success rate for certain patients is reasonably predictable. Although the overall success rate for UltrCryo hovers around 97% with those patients relating 100% relief of symptoms, the success rate for patients who have had even a single Alcohol injection drops dramatically to 50-60%.
After treating more than 200 patients with a history of Alcohol injections for the treatment of Neuromas and Plantar Fasciitis, Dr. Rampertab finds that these patients account for the vast majority of patients who see less than optimal relief of symptoms after UltraCryo. Of these 200 or so patients, only a little over half have had complete relief of symptoms after the first UltraCryo. Most of the remaining patients had a repeat UltraCryo procedure and again about half found that they had complete relief of symptoms after the second procedure. Of the remaining 50 or so patients, half were doing well enough that they were satisfied with the remaining pain level. The remaining 25 or so continued to have significant pain. Most of these patients went on to have open surgical excision of the nerve and about half had a satisfactory healing course with minimal symptoms. The remaining dozen or so patients continued to have significant pain.
Dr. Rampertab feels that the reason for these findings is definitely the Alcohol injections and the effects that the Alcohol has on the nerve structure. Dr. Rampertab does not advocate Sclerosing Alcohol treatment for any conditions of the foot. By its definition, (sclerosing means "to turn to bone") alcohol injections cause soft tissue atrophy (shrinkage and hardening). As it is a fluid and fluid flows to the path of least resistance, there is no way to keep the medicine in a particular spot when you inject it. It flows throughout the tissues. This same process of sclerosing causes changes within the nerve tissue including the structures needed for the normal healing of the UltraCryo procedure. This hardening of the surrounding tissues of the nerve cause the freezing to not have a predictable effect on the nerve.
Because of these findings, Dr. Rampertab tries to make patients fully aware of the greater chance of failure of the UltraCryo procedure on patients who have had one or multiple Sclerosing Alcohol Injections. Given that a significant number of those patients did respond favorably with over half being symptom-free after the first procedure, it should still be considered the treatment of choice, but if the first procedure fails and there is very little relief, it may be best to start considering open excision of the nerve.
Dr. Rampertab tries his best to educate other Foot and Ankle Specialists about the adverse effects of Sclerosing Alcohol Injections. More and more Phoenix area DPM's have discontinued the use of Alcohol Injections after discussions with Dr. Rampertab.
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The basic principle involves the accurate positioning of the cryoprobe onto the affected nerve branch and applying extreme cold. An iceball is formed around the nerve causing a prolonged block in nerve conduction.
The pain relief is almost immediate. The block is completely reversible. There is minimal recovery time needed. The majority of patients are able to resume full activity level the next day. Actually, they are able to do much more than prior to the procedure within days of having the procedure done.
What are the benefits of having the cryo procedure done?
- Long term pain relief
- Reversible nerve block
- Reduction in drug usage post-operatively
- The ability to repeat the procedure
What are the conditions that can be effectively treated with Cryoanalgesia (cryo)?
- Plantar Fasciitis-acute and chronic symptoms
- Nerve entrapments of the foot-including Morton’s Neuroma
- Tarsal Tunnel syndrome
- Achilles Tendinitis
- Entrapment neuropathy caused by scar tissue post-operatively
- Painful symptoms of Diabetic neuropathy
- Chemotherapy-induced neuropathy
- Neuropathy of unknown origin
- Pain from amputation neuroma and stump neuroma
Cryoanalgesia (cryo) - The Procedure
A significant amount of time is spent during the pre-procedure work-up discussing the etiology of the patient's problem and discussing the various conservative and surgical options. All necessary diagnostic tests and procedures are performed to determine the exact diagnosis and when it is determined that the patient would benefit from the procedure, the risks, complications and expected post-op course and expected post-op results are discussed in great detail. All questions are asked and answered.
Day Of Procedure
The procedure is done in-office under local anesthesia. To alleviate any fears, it should be noted that in a comprehensive poll, 100% of patients have said that they would have the cryo procedure performed again, if necessary, and related no unpleasantness.
After a local anesthetic injection in the area where the incision will be made, a second deeper injection is placed directly onto the nerve branch where the procedure will be performed. After the foot is prepped for the procedure, a small two to three millimeter incision is made in the skin and the cryo probe is placed through the incision and directed to the nerve. Using ultrasound, the probe is guided to and placed onto the nerve branch and the procedure is performed. The actual procedure takes approximately seven minutes per nerve branch. No stitches are needed. A small compressive dressing is applied.
The patient keeps the dressing clean and dry and intact for three days. After removal of the dressing, no post-op care is needed. The patient may return to full activity to tolerance, usually within three days.
80% of our patients relate 80% improvement in symptoms within a few days of the procedure.
Azcryo receives patient referrals from other Podiatric Surgeons when all their treatments have failed.
A powerpoint presentation of a lecture given by Dr. Rampertab to the attendees of The Western Podiatric Congress presented by the California Podiatric Medical Association discussing the surgical procedure is available for viewing.
UltraCryo is Ultrasound-guided Cryoanalgesia. The UltraCryo-trained surgeon uses an Ultra-high resolution magnifying Ultrasound to guide the Cryoprobe into place on the various nerve sites. In the hands of an experienced Cryosurgeon, the Ultra-high resolution Ultrasound allows for extremely accurate Cryoprobe placement leading to extremely high success rates after the Cryoanalgesia procedure. For all indications that UltraCryo is used, the success rate is as high as 98% in the hands of the most experienced Cryosurgeons. Of the more than 150 Cryosurgeons in the country, only a very small handful use Ultra-high resolution Ultrasound guidance of the Cryoprobe.
Using UltraCryo allows the Cryosurgeon to actually see the nerve structure as well as the vascular (blood vessel) structures nearby. The Ultrasound is used in Pulsed Doppler mode allowing for visualization of even the smallest vessels. This allows for proper precise positioning of the Cryoprobe on just the nerve trunk. Using UltraCryo allows us to visualize the iceball as it is formed. We can use the Ultrasound's high resolution to measure the size of the iceball. This allows us to accurately predict and control the size of the area of nerve we are performing the prolonged conduction block on. We can also measure the location of the nerve in relation to the nearby vessels and bony structures.
Ultrasound images taken during the UltraCryo procedure can be saved and may be used in the rare event that the procedure needs to be repeated. Those images from the previous procedure allow us to look back at the structures that may have contributed to recurrence of the pain or in rare instances, procedure failure. The use of the UltraCryo allows us to see the involvement of scar tissue and bony prominences in the entrapment of the nerve.
All of the above apply to Neuroma with a few exceptions. Most patients with a Neuroma relate fairly immediate relief with strappings and custom orthotics. In those that do not see this significant improvement early on, the argument for UltraCryo is compelling. More than 80% of patients undergoing the procedure for Neuroma symptoms relate more than 80% relief within hours to days of having the procedure done. The other significant exception is that having the procedure done allows the patient to spend less time in their orthotics. This is very important to women who are required to wear dressy shoes and higher heeled pumps to work and can only wear their orthotics in the evenings and weekends. The UltraCryo provides immediate relief and sustained relief with less frequent orthotics wear.
When all forms of non-surgical treatment fail to bring relief to your foot problem, your foot doctor may suggest surgery. As with most surgical procedures these days, the most complicated foot surgeries can be done in an outpatient setting. It is very rare for a patient to be put in the hospital overnight for a foot surgery.
Pre-operative and post-operative teaching is performed prior to surgical correction. This encourages patient compliance and decreases the risk of complications. Most foot surgeries are done either at surgery centers or in the day surgery unit of many of the area hospitals. These facilities are equipped with the personnel that may be needed if an emergency should arise. The foot doctor and the anesthesiologist work closely to determine what type of anesthesia is best for the patient. In most cases, we choose IV sedation. This is a safe method in which the anesthesiologist gives the patient a sedative in the veins and keeps the patient comfortable and unaware of the surgery. The anesthesiologist is trained in knowing the proper dosages that the patient may need and has the proper monitoring equipment on hand.
As in all types of surgery, infection is rarely seen. The rate of infection in the surgical community has remained at less than three cases per one hundred surgeries, or 3%. Most surgeons find that it is actually lower in reality. Dr. Rampertab’s infection rate in outpatient settings as well as in-office procedures is less than 1%. For the Cryoanalgesia procedures performed in the office surgical suite, it is more like one per thousand procedures.
With proper surgical technique and post-operative instruction, swelling is rarely a problem. The patient is instructed to reduce walking or standing as much as possible for the first three days. This is when most swelling will occur. If proper instruction is followed, the patient may be walking in as little as two to three days. This is usually dependent on the type of surgical procedure performed. When bone surgery is performed, the amount of time off the feet may be slightly longer.
- You may have nothing by mouth after 12 Midnight the day before surgery. No food, no beverages, no smoking.
- Medications will be discussed with the doctor.
- Have someone drive you to and from the surgery center.
- Arrive at the surgery center one hour prior to scheduled time.
- The Nurse or Anesthesiologist will start an IV through which all medications will be given. They may have to do lab work, EKG or X-rays.
- You will be given IV sedation in the surgical room. This will keep you comfortable throughout the procedure. You will also be placed on monitors upon your arrival to the surgical suite, i.e. oxygen, EKG, blood pressure, etc.
- For those patients that will require General Anesthesia, you are given IV sedation to put you to sleep and you will be kept asleep by the Anesthesiologist.
- After the procedure, you will be taken to the PACU. You will stay there for 1/2 to 1 hour.
- Upon getting home, eat something, take your meds, get comfortable, elevate your foot and leg at the level of your heart. If you are lying in bed, have a pillow or rolled-up blanket under your foot or leg. If lying on the couch, set your foot onto a pillow or the arm of the couch to keep it higher. Apply ice as directed.
- Expect some bleeding the first time you get up. Remain in bed except to go to the bathroom until your first post-op visit. This appointment will be made the day of your pre-op visit.
- You will have had surgery, some pain is expected. Pain is the body's way of telling you that you are disturbing normal healing. If your foot hurts, stay off of it.
- If you have any questions, please call the office.
See the following links for information on the side effects of cortisone injections in soft tissues and joints.
Custom Functional Orthotics are devices scientifically constructed in a laboratory from a neutral position impression cast of the feet after a careful range of motion study and biomechanical exam has been performed on both lower extremities. They are used to correct or accommodate and improve function of various foot deformities which are producing symptoms and inflammatory processes such as tendonitis, capsulitis and fasciitis. Orthotics are very effective in treating these inflammatory processes and preventing the inflammation from recurring or becoming chronic and disabling. Their use prevents the need for prolonged physical therapy, immobilization and in many cases, surgery.
The newest orthotics available are casted for with plaster, but the plaster cast is then sent to a lab where the inside of the cast is read by a computer cad program. The orthotics are then fabricated from high polymer plastic or semi-rigid foam that is never heated. This allows them to be stronger and more rigid while still remaining relatively thin. They may then be covered with a soft topcover when appropriate. These computer generated devices can be made to fit into any shoes, including dress flats and heels up to 1 ½ inches in heel height. Any shoes with over that heel height would not accommodate an orthotic well enough to do any good.
Custom orthotics are the conservative treatment of choice for most foot problems. That is because most foot conditions are due to poor foot function and biomechanical faults. Custom orthotics correct these faults. Some examples of conditions treated with custom orthotics include Achilles Tendonitis, Bunions, Calcaneal Apophysitis, Hammertoes, Joint Capsulitis, Neuroma, Peroneal Tendonitis, Plantar Fasciitis, and Plantar Fibroma.
Shoe and Orthotic specialty stores are popping up everywhere. These stores carry imported shoes that may not be found in conventional shoe stores and tout the ability to make custom orthotics. Several national chains of these stores can be found in every major city. These franchises advertise heavily and claim to be able to treat a variety of medical and biomechanical conditions of the feet. The advertising and sales tactics of the stores worsened some years ago when The Centers for Medicare Services (CMS), in their infinite wisdom, decided that they would accept and pay claims by these stores for Diabetic Shoes and Diabetic Inserts.
Once the Orthotic Stores had the ability to bill Medicare directly instead of being the middle man everything changed in the Diabetic Shoes and Orthotic industry. Prior to this happening, typically the Doctor saw the patient, deemed it necessary that the patient wear special Diabetic Shoes due to certain deformities of the feet or certain other conditions that may cause foot problems and then wrote a prescription for those certain shoes and inserts for the special needs of his/her feet, and sent the patient to an Orthotic and Prosthetic Specialist who fitted the patient for those particular shoes and inserts. This is no longer the chain of events. Now, the patient may see an ad in a local newspaper touting the fact that Medicare pays for one pair of shoes per year and the patient can take advantage of that by going into the store directly. The patient may now seek care directly from the shoe salesman. No need for a medical work-up.
In most cases, the people taking advantage of this benefit are older. They intend to go to the store for the special shoes advertised. Once they are in the store, they fall prey to the hard-selling clerks who explain that they should have more than one pair of shoes and also various over-the-counter inserts. It is not unheard of to have a patient come into my office after having spent one thousand dollars for shoes and orthotics they did not need. They have already spent one thousand dollars out-of-pocket and have not yet seen a medical professional.
It is hard to understand why people choose to seek care in a shoe store rather than going to see their medical doctor or seek the advice of a foot and ankle specialist. While most health insurances will cover a visit to the doctor’s office, the visit to the neighborhood Orthotic Store is strictly self pay. Additionally, all of these stores have a no refund/store credit only policy. That means if you buy a pair of shoes or orthotics and find they do not fit well after a few days, you can return the item, but only for store credit. You must then choose something else in the store to buy.
The ability to service Medicare patients allowed the stores to then start advertising to other people. They propound the ability to make Custom-Molded Orthotics for everyone. They tout special computer systems that analyze foot structure during gait and design special orthotics. In reality, the orthotics that are dispensed at these stores are off-the-shelf devices that are bought in bulk. They are fitted according to shoe size never taking into account differences in structure from feet to feet. I am appalled when patients present and take these orthotics out of their shoes and are certain that they are custom molded. I then turn the device over and show them the European sizing on the back. These same devices that can be ordered from a Foot Specialist’s office for as little as $25 a pair are being sold for $280 a pair at the Orthotic Stores. Additionally, if the patient continues to have pain and goes back to the store, often they are told that although the orthotics fit well, they need a different type. They are then sold a second pair of orthotics that are also over-the-counter. This is hard to imagine but it is happening every day. The Chain Orthotic Stores are reaping huge profits. Their ad campaigns are extensive and very successful.
Because these stores carry various types and brands of shoes found nowhere else, their ads will make unrealistic claims about special shoes that are designed to do various things. Some examples: shoes that specifically treat Plantar Fasciitis, shoes that specifically treat Hammertoes, shoes that treat Tarsal Tunnel Syndrome, shoes that give you a workout while you do your everyday walking, shoes with springs in the heels or the entire sole of the shoes, shoes with rocker (rounded) bottoms that will energize your feet and legs and many more. If you want to see more, just read their ads. None of these claims are true. There are no such benefits to these shoes.
There is no evidence of these unethical practices being challenged in the near future. For now, this is a large problem facing all Doctors of Podiatric Medicine. Most will not or cannot (financially) advertise as much as these stores. Therefore the “sale” of medical services is lost to the Orthotic Shoe Store.
The bottom line:
The people at the Orthotic Shoe Store have very little medical knowledge. They are, after all, shoe salesmen who work on a commission basis. They intend to make the biggest sale they can. Buyers beware.