Preoperative and therapeutic local anesthetics and steroids

In a recent survey that the author conducted among podiatrists, the typical therapeutic injection for inflammatory lesions consisted of 2.25 or 2.5 mL of 1% lidocaine or plain bupivicaine (or, rarely, with epinephrine 1:200,000), 0.5 mL of hexadrol, and 0.25 mL of an insoluble cortisone such as triamcinolone acetonide (Kenalog). It is clear that variation exists and that each doctor has his or her own "cocktail" for therapeusis. The author finds that 1% lidocaine with epinephrine 1:200,000 therapeutic injections alone have a profound clinical effect when used in concert with biomechanic control. These injections are given as a series once a week and then the interphase is stretched out as needed. Because no steroids are used, there is no limit to the number of injections, and so, for chronic entities such as metatarsophalangeal (MTP) joint osteoarthritis, the author has been giving certain patients 6 to 10 therapeutic injections a year for 15 to 18 years, while controlling pain. Because all "cocktails" usually contain some amount of local anesthetic, maybe the podiatric community is using added medications such as steroids unnecessarily. Steroids mask poor diagnostic and technical skills and also infections. Clinicians also should spend time controlling the pedal sympathetics through "chemical sympathectomy." This posterior tibial nerve and artery therapeutic block was developed by Dr. Marvin Steinberg in the 1940s. Treatments are given in 1-week intervals with the first treatment giving 3 to 5 days' relief, the second 5 to 7 days, the third 7 to 10 days, and then 2- and 4-week intervals. Eventually, a comfortable interphase is selected, if necessary. In order for the blocks to work in summation, a vasoconstrictor such as epinephrine is mandatory. Lidocaine is the active ingredient of chemical sympathectomy; it blocks the artery and nerve, including the posterior tibial sympathetics. The posterior tibial sympathetics control 85% of the sympathetics to the foot, including all four muscle layers and the vital structures of the sole of the foot. Epinephrine works at the vasovasorum, nervonervorum, vasonervorum, and nervovasorum to maintain the active medication longer and make the block more effective. This chemical sympathectomy works even better than a lumbar paravertebral sympathectomy.(ABSTRACT TRUNCATED AT 400 WORDS)