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Koti M, Maffulli N, Al-Shoaibi M, Hughes M, McAllister J. Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton's neuroma and correlation with intraoperative anatomical variations. J Orthop Surg Res 2022; 17:22. [PMID: 35033145 PMCID: PMC8760656 DOI: 10.1186/s13018-022-02910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Morton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT). Objectives This retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve. Material and methods The study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016. Results The mean pre-operative Giannini score of 13 (0–30) improved to 61 (20–80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin’s criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome. Conclusion Dividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible. Level of Evidence: Level IV - Case Control Retrospective study.
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Affiliation(s)
- Manjunath Koti
- Princess Royal University Hospital, Kings College Hospital NHS Trust, Orpington, Kent, BR6 8ND, UK
| | - Nicola Maffulli
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK.
| | - Muwaffak Al-Shoaibi
- Princess Royal University Hospital, Kings College Hospital NHS Trust, Orpington, Kent, BR6 8ND, UK
| | | | - Jack McAllister
- Chelsfield Park Hospital, Bucks Cross Road, Chelsfield, Orpington, Kent, BR6 7RG, UK
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Arshad Z, Alshahwani A, Bhatia M. The Management of Multiple Morton's Neuromas in the Same Foot: A Systematic Review. J Foot Ankle Surg 2022; 61:163-169. [PMID: 34526223 DOI: 10.1053/j.jfas.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/11/2021] [Accepted: 08/05/2021] [Indexed: 02/03/2023]
Abstract
The optimal treatment strategy for the presentation of multiple Morton's neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. We aimed to summarize and assess the efficacy of current treatment strategies. A systematic review, adhering to PRIMSA guidelines was performed. A computer base search was completed in PubMed, Embase, Cinahl, ISI Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A total of 253 articles were identified, with 7 articles being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, while 2 studies each describe simultaneous excision with 2 separate incisions and delayed excision respectively. There is no strong evidence favoring use of delayed excision or multiple incisions. Further high-quality research is required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.
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Affiliation(s)
- Zaki Arshad
- Medical Student, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom.
| | - Awf Alshahwani
- Trauma and Orthopaedics Registrar (Resident), Department of Trauma and Orthopaedic Surgery, University Hospitals Leicester NHS Trust, Leicester, United Kingdom
| | - Maneesh Bhatia
- Consultant (Attending) in Trauma and Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Hospitals Leicester NHS Trust, Leicester, United Kingdom
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Iborra-Marcos A, Villanueva-Martinez M, Barrett SL, Sanz-Ruiz P. Ultrasound-Guided Decompression of the Intermetatarsal Nerve for Morton's Neuroma: A Novel Closed Surgical Technique. J Am Podiatr Med Assoc 2020; 110:449543. [PMID: 33301594 DOI: 10.7547/19-033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques. METHODS We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery. RESULTS Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1-2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections. CONCLUSIONS The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.
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Abstract
BACKGROUND Morton's neuroma is a frequent cause of metatarsalgia. Operative treatment is indicated if nonoperative management has failed. The objective of the present study was to describe a technique of Morton's neuroma excision by a minimally invasive commissural approach and evaluate the long-term outcome and complications. METHODS A retrospective study of 108 patients with Morton's neuroma treated surgically with a commissural approach between September 1990 and December 2010 was performed. The surgical technique is described. Clinical outcomes and complications were evaluated. The average follow-up was 121 months. Eleven patients were men and 97 women. The average age was 49.4 years; 56.8% neuromas were at the third space and 43.2% at the second space. Six patients presented 2 neuromas in the same foot, and 9 patients had bilateral neuroma. RESULTS The visual analog scale (VAS) average pain score was 5.4 points preoperatively and 0.2 points at the final follow-up. The author found a significant difference between the VAS scores preoperatively and postoperatively (P < .01). Excellent and good satisfaction outcomes were achieved in 93.6%. The postoperative complication incidence was 3%. CONCLUSION The author believes a minimally invasive commissural approach has advantages over a dorsal or plantar incision. It is a simple and reproducible technique, with satisfactory outcomes, low complication rates, and a quick return to usual activities. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Santiago FR, Muñoz PT, Pryest P, Martínez AM, Olleta NP. Role of imaging methods in diagnosis and treatment of Morton's neuroma. World J Radiol 2018; 10:91-99. [PMID: 30310543 PMCID: PMC6177560 DOI: 10.4329/wjr.v10.i9.91] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/21/2018] [Accepted: 08/04/2018] [Indexed: 02/06/2023] Open
Abstract
Among the many causes of forefoot pain, Morton's neuroma (MN) is often suspected, particularly in women, due to its high incidence. However, there remain controversies about its relationship with symptomatology and which diagnostic and treatment choices to choose. This article mainly focuses on the role of the various imaging methods and their abilities to support an accurate diagnosis of MN, ruling out other causes of forefoot pain, and as a way of providing targeted imaging-guided therapy for patients with MN.
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Affiliation(s)
- Fernando Ruiz Santiago
- Radiology Department, Hospital of Neuro-Traumatology (Virgen de las Nieves), Granada 18014, Spain
| | - Pablo Tomás Muñoz
- Radiology Department, Hospital of Neuro-Traumatology (Virgen de las Nieves), Granada 18014, Spain
| | - Patel Pryest
- Radiology Department, North Tyneside General Hospital, North Shields NE29 8NH, United Kingdom
| | | | - Nicolás Prados Olleta
- Orthopaedic Department, Hospital of Neuro-Traumatology (Virgen de las Nieves), Granada 18014, Spain
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Di Caprio F, Meringolo R, Shehab Eddine M, Ponziani L. Morton's interdigital neuroma of the foot: A literature review. Foot Ankle Surg 2018; 24:92-98. [PMID: 29409221 DOI: 10.1016/j.fas.2017.01.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/15/2016] [Accepted: 01/27/2017] [Indexed: 02/04/2023]
Abstract
Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains little studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study may deal with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The present literature review crosses all key points, from diagnosis to surgical and nonoperative treatment, and recurrences. Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in those who want to delay or avoid surgery. Dorsal or plantar approaches were described for surgical treatment, both with strengths and weaknesses that will be scanned. Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse metatarsal ligament, too distal resection of common plantar digital nerve, an association of tarsal tunnel syndrome and incomplete removal. A deep knowledge of the causes and presentation of failures is needed to surgically face recurrences.
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Affiliation(s)
- Francesco Di Caprio
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy.
| | - Renato Meringolo
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
| | - Marwan Shehab Eddine
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
| | - Lorenzo Ponziani
- Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione 47838, Italy
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Kundert HP, Plaass C, Stukenborg-Colsman C, Waizy H. Excision of Morton's Neuroma Using a Longitudinal Plantar Approach: A Midterm Follow-up Study. Foot Ankle Spec 2016; 9:37-42. [PMID: 26253529 DOI: 10.1177/1938640015599032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Operative procedures are indicated in the treatment of Morton's neuroma (MN) when conservative therapies have been unsuccessful. A dorsal approach for neurolysis or neurectomy was strongly recommended. The aim of this case series study was to prospectively analyze the midterm clinical outcome and complications following the excision of a MN using a plantar longitudinal approach. METHODS Between September 2000 and January 2009, we included 44 patients (51 feet, 56 neuromas) in a prospective study treated by excision of a primary MN using a plantar longitudinal approach. The MN diagnosis was based on clinical symptoms, magnetic resonance imaging findings, and pain relief after infiltration of local anesthetics. Histological examinations were performed in all resected specimens. The patients returned for final follow-up at a mean of 54 (range = 12 to 99) months, comparing preoperative and postoperative perception of pain on a Visual Analogue Scale (VAS) and assessing clinical findings. RESULTS The average amount of pain, according to VAS, was 8 (range = 6-9) points preoperatively and 0.4 (range = 0-5) points at final follow-up. Complications occurred in 7.1% of interventions and scar problems in 5.2%, including delayed wound healing, hypertrophic scar formation, and inclusion cyst. CONCLUSION The present study shows a strong relief of pain after MN resection using a plantar longitudinal incision, coupled with a low rate of local complications. This surgical procedure seems to be a reliable choice for the excision of MN, even in cases with MN in adjacent webspaces, because it is technically simple and the plantar scar is not bothersome if properly located. LEVELS OF EVIDENCE Therapeutic, Level IV: Prospective, Case series.
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Affiliation(s)
- Hans-Peter Kundert
- Foot and Ankle Center, Hirslanden Clinic Zurich, Switzerland (H-PK)Department for Foot and Ankle Surgery, Orthopedic Clinic, Hannover Medical School, Hannover, Germany (CP, CSC)Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW)
| | - Christian Plaass
- Foot and Ankle Center, Hirslanden Clinic Zurich, Switzerland (H-PK)Department for Foot and Ankle Surgery, Orthopedic Clinic, Hannover Medical School, Hannover, Germany (CP, CSC)Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW)
| | - Christina Stukenborg-Colsman
- Foot and Ankle Center, Hirslanden Clinic Zurich, Switzerland (H-PK)Department for Foot and Ankle Surgery, Orthopedic Clinic, Hannover Medical School, Hannover, Germany (CP, CSC)Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW)
| | - Hazibullah Waizy
- Foot and Ankle Center, Hirslanden Clinic Zurich, Switzerland (H-PK)Department for Foot and Ankle Surgery, Orthopedic Clinic, Hannover Medical School, Hannover, Germany (CP, CSC)Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW)
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Rungprai C, Cychosz CC, Phruetthiphat O, Femino JE, Amendola A, Phisitkul P. Simple Neurectomy Versus Neurectomy With Intramuscular Implantation for Interdigital Neuroma: A Comparative Study. Foot Ankle Int 2015; 36:1412-24. [PMID: 26297693 DOI: 10.1177/1071100715596741] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Simple neurectomy is a standard treatment of interdigital nerve neuroma after failure of conservative treatment. Recently, neurectomy with intramuscular implantation of the proximal nerve stump has been proposed as a safe and effective alternative method providing significant pain improvement. However, there remains little evidence supporting one technique over the other. The purpose of this study was to compare functional outcomes and complications of simple neurectomy versus neurectomy with intramuscular implantation. METHODS Retrospective chart review along with prospectively collected data of 99 consecutive patients (105 feet with 118 neuromas) who were diagnosed with interdigital neuroma of the foot and underwent simple neurectomy (66 patients / 72 feet / 78 neuromas) and neurectomy with intramuscular implantation of proximal nerve stump into intrinsic muscle of foot (33 patients / 33 feet / 40 neuromas) between 2000 and 2013. The minimum follow-up to be included in the study was 6 months for both techniques (mean = 44.6 months, range = 6 to 150 months for simple neurectomy; and mean = 19.3 months, range = 6 to 66 months for neurectomy with intramuscular implantation of proximal nerve stump into the intrinsic muscle). The primary outcomes were Foot Function Index (FFI); pain, disability, activity limitation, and total score, Short Form-36 (SF-36: physical and mental component scores); and visual analog scale (VAS). Secondary outcomes included operative time and complications. Pre- and postoperative SF-36, and FFI, and pain (VAS) scores were obtained and compared using a paired t test. An independent t test was used to assess the functional outcomes and operative time between the 2 groups, and a chi-square test was used to compare the complications between the 2 techniques. RESULTS Both groups demonstrated significant improvement of postoperative functional outcomes (FFI, SF-36, and VAS; P < .001, all) compared to the preoperative period. Neurectomy with intramuscular implantation demonstrated significant improvement of pain compared to simple neurectomy as measured with VAS (P = .002); however, the operative time was significantly longer than the simple neurectomy technique (P = .001). The rest of the functional outcomes measured were comparable between the 2 techniques. Complications in both simple neurectomy and implantation techniques were persistent pain (11.5% vs. 2.5%, P = .07), revision rate (5.1% vs. 0.0%, P = .08), and painful scar (5.1% vs. 5.0%, P = .83), respectively, but it did not reach statistical significance (P > .05, all). CONCLUSION Both simple neurectomy and neurectomy with intramuscular implantation demonstrated significant improvement in terms of functional outcomes as measured with the FFI, SF-36, and VAS in patients with interdigital neuroma. Although requiring a longer operative time, neurectomy with intramuscular implantation technique might offer superior pain relief with comparable complications to the simple neurectomy technique.
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Affiliation(s)
- Chamnanni Rungprai
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Christopher C Cychosz
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Ongart Phruetthiphat
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - John E Femino
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Annunziato Amendola
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, IA, USA
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Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic Accuracy of Clinical Tests for Morton's Neuroma Compared With Ultrasonography. J Foot Ankle Surg 2015; 54:549-53. [PMID: 25432459 DOI: 10.1053/j.jfas.2014.09.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Indexed: 02/03/2023]
Abstract
The aim of the present study was to assess the diagnostic accuracy of 7 clinical tests for Morton's neuroma (MN) compared with ultrasonography (US). Forty patients (54 feet) were diagnosed with MN using predetermined clinical criteria. These patients were subsequently referred for US, which was performed by a single, experienced musculoskeletal radiologist. The clinical test results were compared against the US findings. MN was confirmed on US at the site of clinical diagnosis in 53 feet (98%). The operational characteristics of the clinical tests performed were as follows: thumb index finger squeeze (96% sensitivity, 96% accuracy), Mulder's click (61% sensitivity, 62% accuracy), foot squeeze (41% sensitivity, 41% accuracy), plantar percussion (37% sensitivity, 36% accuracy), dorsal percussion (33% sensitivity, 26% accuracy), and light touch and pin prick (26% sensitivity, 25% accuracy). No correlation was found between the size of MN on US and the positive clinical tests, except for Mulder's click. The size of MN was significantly larger in patients with a positive Mulder's click (10.9 versus 8.5 mm, p = .016). The clinical assessment was comparable to US in diagnosing MN. The thumb index finger squeeze test was the most sensitive screening test for the clinical diagnosis of MN.
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Abstract
Interdigital neuromas are a common cause of forefoot pain, and approximately 80% of patients require surgical excision for symptom relief. Although 50% to 85% of patients obtain relief after primary excision, symptoms may recur because of an incorrect diagnosis, inadequate resection, or adherence of pressure on a nerve stump neuroma. The symptom relief rate after reoperation is similar to that after primary excision. A plantar longitudinal incision provides optimal exposure, and transposition of the nerve stump into bone or muscle and avoids traction or pressure on the nerve ending that can result in a painful stump neuroma. Preoperative counseling is essential to align patient expectations with potential outcomes.
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Affiliation(s)
- David R Richardson
- Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| | - Erin M Dean
- Crystal Clinic Orthopaedic Center, 1310 Corporate Drive, Hudson, OH 44236, USA
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Abstract
Interdigital neuralgia affects a significant number of individuals, with an average age of presentation in the sixth decade and a 4- to 15-fold increased prevalence in women. Historical descriptions date back to the 19th century. Nonoperative treatment with shoe modifications, metatarsal pads, and injections provides relief for most, but long term, 60% to 70% of patients eventually elect to have surgery. Although excision can be performed through a dorsal or plantar approach, we prefer the dorsal incision to prevent scar formation on the plantar aspect of the foot. Satisfactory results are common but not certain with reports of excellent or good ranging from 51% to 93%.
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Affiliation(s)
- Paul G Peters
- Department of Orthopaedic Surgery, Foot and Ankle Service, Union Memorial Hospital, Baltimore, MD 21218, USA
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Abstract
Several reports demonstrated that the interdigital neuroma is a form of entrapment neuropathy. Nonoperative measures may provide satisfactory results to some patients, but surgical treatment seems to provide more predictable results and lasting pain relief. Neurectomy remains the most commonly used procedure for the treatment of interdigital neuritis through a plantar or a dorsal approach. Outcome results after neurectomy note a failure rate of 2% to 35%.
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Affiliation(s)
- Emmanouil D Stamatis
- Major, 401 General Army Hospital, Orthopaedic Department, Katehaki and Mesogeion Streets, Athens, Greece.
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Coughlin MJ, Schenck RC, Shurnas PS, Bloome DM. Concurrent interdigital neuroma and MTP joint instability: long-term results of treatment. Foot Ankle Int 2002; 23:1018-25. [PMID: 12449407 DOI: 10.1177/107110070202301109] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION An interdigital neuroma is a common source of forefoot pain, and while second metatarsophalangeal joint instability is a less common entity, it can be a concomitant source of pain. The purpose of this study was to evaluate the long-term clinical course and surgical outcomes of the treatment of these concomitant problems. METHODS 121 consecutive patients (131 feet and 136 neuromas) were evaluated and treated for a symptomatic interdigital neuroma from 1981 to 1997. Of these, 24 patients (20%) had a concurrent interdigital neuroma (IDN) and second metatarsophalangeal (MTP) capsular instability that underwent surgical treatment. At the final follow-up examination, 20 patients (21 feet) were evaluated by an independent orthopaedic surgeon with a standardized clinical and radiographic examination, patient self-assessment and outcome measures. RESULTS Overall, there were 18 females and two males (21 feet) treated with an average age of 54 years at the time of surgery that returned for examination and follow-up at an average of 80 months (48 to 108 months) following surgery. Seventeen patients (85%) rated their result as good or excellent and three as fair. Six patients had mild continued symptoms referable to the second toe and none to the neuroma. Simultaneous neuroma excision and second MTP stabilization was performed in 15 cases and in six cases a staged repair was performed. The mean visual analog pain score was 1.4 (0=no pain, 10=severe pain) and mean MHAQ score was 1.13 (1-1.625) with activity modification stemming from hip, back and knee complaints. CONCLUSION With careful patient selection and preoperative assessment, resection of an interdigital neuroma and stabilization of second metatarsophalangeal joint instability resulted in a high percentage of successful results at greater than four years following the procedure. Objective results were comparable to previous reports on the surgical treatment of isolated interdigital neuroma and crossover second toe reconstruction. Subjective patient satisfaction was high but both subjective and objective results were lower in patients with persistent symptoms of MTP instability.
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Abstract
Twenty-three patients with clinical signs of adjacent intermetatarsal nerve irritation who underwent adjacent nerve release with single-nerve excision through one incision were studied. Mean follow-up was 11 months. Of 21 patients interviewed, 19 (90%) had resolution of all or most of their pain, 20 (95%) had no or only minimal activity limitation, and 20 (95%) were completely satisfied with their outcome. Of 19 patients examined, none had pain with compression of the interspace of the excised nerve, although two (11%) had discomfort with compression of the interspace of the nerve that was only released. Protective sensation was present postoperatively in all patients except one who had preoperative neuropathy.
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Affiliation(s)
- Kurtis R Hort
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida 32224, USA
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15
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Wolfort SF, Dellon AL. Treatment of recurrent neuroma of the interdigital nerve by implantation of the proximal nerve into muscle in the arch of the foot. J Foot Ankle Surg 2001; 40:404-10. [PMID: 11777237 DOI: 10.1016/s1067-2516(01)80009-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A prospective study was done to evaluate the results of treating recurrent "Morton's" neuroma by a technique that combined resecting the interdigital neuroma through a plantar approach and implantation of the proximal end of the nerve into an intrinsic muscle in the arch of the foot. As a part of this study, quantitative sensory testing was done for the medial plantar and medial calcaneal nerves. Seventeen recurrent interdigital neuromas were resected in 13 patients. Pain was identified on physical examination as being due to neuromas located in the first (one), second (six), third, (eight) and fourth (two) web spaces. Seven of the 13 patients were found to have, by quantitative sensory testing and physical examination, an associated tarsal tunnel syndrome responsible for symptoms related to numbness in the foot in addition to the pain of the recurrent neuroma. These patients had tarsal tunnel decompression at the time of the neuroma resection. At a mean follow-up time of 33.8 months (range 24-42 months), done by direct physician interview and examination, 80% of the patients had excellent relief of symptoms, returned to their regular job, and wore usual footwear. Twenty percent of the patients had good relief of symptoms, worked at a different job, and had to change their footwear. It is concluded that recurrent pain after a dorsal interdigital neurectomy can be treated successfully through a plantar approach with implantation of the proximal end of the nerve into an intrinsic muscle. This study also identified an association of tarsal tunnel syndrome in 54% of this series of patients with recurrent Morton's neuroma.
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Affiliation(s)
- S F Wolfort
- Division of Plastic Surgery, Vanderbilt University, Nashville, TN, USA
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Biasca N, Zanetti M, Zollinger H. Outcomes after partial neurectomy of Morton's neuroma related to preoperative case histories, clinical findings, and findings on magnetic resonance imaging scans. Foot Ankle Int 1999; 20:568-75. [PMID: 10509684 DOI: 10.1177/107110079902000906] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Our purpose was to evaluate the reliability of preoperative case histories, clinical findings, and magnetic resonance imaging (MRI) scans in substantiating the diagnosis of Morton's neuroma and in predicting clinical outcomes after surgical intermetatarsal neurectomy. We studied 19 consecutive patients with histologically proved Morton's neuroma. All had preoperative MRI of the forefoot. Partial neurectomy was performed when there was forefoot pain with transmetatarsal compression and positive findings on MRI scans. Case histories, clinical findings, and findings on MRI scans were correlated with clinical outcomes. Preoperative clinical findings including localization correlated with intraoperative findings in 11 of 19 patients (58%), and MRI scans correlated in 16 of 19 patients (84%). Of the 19 patients, 74% achieved satisfactory outcomes. Neither reliable clinical findings or findings on MRI scans nor confirmation of clinical findings by MRI correlated with a superior result, but 77% of patients with neuromas measuring more than 5 mm in transverse measurement on MRI scans had good outcomes; only 17% with neuromas measuring 5 mm or less had good outcomes. Preoperative localization and diagnosis of Morton's neuroma is better achieved with MRI than through clinical findings. A more favorable clinical outcome can be expected after surgical intermetatarsal neurectomy when a Morton's neuroma has a transverse measurement larger than 5 mm on MRI scans.
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Affiliation(s)
- N Biasca
- Department of Orthopedics, University of Zurich, Switzerland
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Levine SE, Myerson MS, Shapiro PP, Shapiro SL. Ultrasonographic diagnosis of recurrence after excision of an interdigital neuroma. Foot Ankle Int 1998; 19:79-84. [PMID: 9498579 DOI: 10.1177/107110079801900205] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We retrospectively reviewed the records of 20 patients (21 feet) with previous interdigital neuroma resections and symptoms suggestive for, but not diagnostic of, recurrent neuroma. Sonography was performed when clinical findings supplemented by local anesthetic block did not conclusively confirm the presence of recurrent neuroma. Studies performed in 13 patients (14 feet) were positive for recurrent neuromas. Three studies were indeterminate. The remaining four studies were negative for recurrent neuroma. The ultrasound studies were performed at an average of 19.2 months (range, 2-82 months) after the resection. Nine patients with 11 previous interdigital neuromas underwent ultrasonographic examination of the forefoot and subsequent revision neuroma resection. At surgery, gross and histologic findings were consistent with recurrent neuroma in 10 of 11 cases; one patient was found to have metatarsal-phalangeal synovitis. Ultrasonography appears to be a useful means for confirming neuroma recurrence in patients with symptoms after interdigital neurectomy when the diagnosis is not clear on physical examination.
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Affiliation(s)
- S E Levine
- Department of Orthopaedic Surgery, The Union Memorial Hospital, Baltimore, Maryland 21218, USA
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Abstract
Morton's neuroma, known also as intermetatarsal or interdigital neuroma, is a common foot injury that often curtails athletic activity. Nerve compression involving adjacent metatarsal heads and the transverse intermetatarsal ligament appears implicated in injury onset. Diagnosis is made clinically, and the condition typically causes initial symptoms of dull cramping or burning pain and more persistent sharp pain with nerve deterioration. Depending on injury severity, treatment is either conservative or surgical.
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Affiliation(s)
- M B Mollica
- Windy Hill Podiatry Clinic, Essendon, VIC 3040, AU
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Abstract
Morton's neuroma is a frequent cause of metatarsalgia. Neuroma resection was the usual recommended surgical treatment. Failure rate of neurectomy can be as high as 14% to 21%, and treatment of recurrences is difficult. The authors have treated Morton's neuroma by neurolysis since 1985. They present their results in a group of 40 patients with 5 years follow up. Thirty-seven of 40 patients had an excellent result after neurolysis and 35 patients had normal toe sensitivity at the date of examination. Thirty-nine patients stated they would undergo the operation again if necessary.
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Benedetti RS, Baxter DE, Davis PF. Clinical results of simultaneous adjacent interdigital neurectomy in the foot. Foot Ankle Int 1996; 17:264-8. [PMID: 8734796 DOI: 10.1177/107110079601700505] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fifteen patients (19 feet) who underwent simultaneous surgical excision of two primary interdigital neuromas in adjacent web spaces of the foot were studied retrospectively. There were 11 female patients (73%). The average age of the patients was 54.4 years. Other causes of multiple web space tenderness were excluded prior to surgical resection of both neuromas. At an average follow-up of 68.6 months (range, 32-113 months), 10 feet (53%) had complete resolution of symptoms and six feet (31%) had minimal residual symptoms. Three feet in two patients (16%) continued to have significant pain after surgery. One sequela of the procedure was dense sensory loss of the plantar aspect of the third metatarsal head to the tip of the third toe. There was also proximal dorsal sensory loss to the second, third, and fourth toes which was a function of the type of incision used. The sensory loss did not cause disability in the patients, but did cause some awkwardness with nail care. Resection of adjacent interdigital neuromas, although rarely indicated, can be expected to provide significant pain relief in 84% of patients, which is similar to results reported for resection of a single neuroma.
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Affiliation(s)
- R S Benedetti
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
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Abstract
Fifty surgical patients with symptoms suggestive of Morton's neuroma underwent preoperative ultrasound examination of the forefoot using a 7.5 MHz transducer. Fifty-five neuromas were excised. Of these, one neuroma had a ganglion associated with it and five neuromas were recurrent. Four feet had adjacent neuromas. Ultrasound accurately predicted the presence, location and size of the neuromas in 98% of the cases. There were no false positives. In all cases in which a neuroma was predicted by ultrasound, it was confirmed grossly at the time of surgery and later by histological exams. We conclude that ultrasound is an accurate technique in the diagnosis of interdigital neuromas.
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