Intra- and Interobserver Reliability of Size Measurement of Morton Neuromas on Sonography

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners

BACKGROUND

This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements.

METHODS

Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests.

RESULTS

Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance.

CONCLUSION

The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14-189) months. The mean age was 49 (range 15-71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

Novel Ultrasound Anatomical Measurement of the Deep Transverse Metatarsal Ligament: An Intra-Rater Reliability and Inter-Rater Concordance Study

Insufficient space below the Deep Transverse Metatarsal Ligament (DTML) could be an etiological factor for Morton’s Neuroma (MN). To date, there is a lack of studies measuring the space below the DTML. For this reason, this study assesses the intra- and inter-rater concordance and reproducibility of measurements of the space below the DTML between the third and the fourth metatarsal heads (M3 and M4) using ultrasound imaging to assess and verify the reliability and reproducibility of measurements of the space under the DTML. Forty feet from twenty patients were examined using ultrasound by three trained evaluators at two different times. The two measurements taken on each foot were: base (b)—distance between M3 and M4, and height (h)—distance between the DTML and the plantar skin surface. This was a quantitative, observational, analytical study. The concordance rate between observers for measurements of height and base were 98.5% and 99.5%, respectively. The mean area obtained of the space was 54.6 mm2 and 57.2 mm2 for both the left and right foot (p > 0.05). Reproducibility over time calculated in pre- and post-measurements showed an intraclass correlation coefficient of 1.00 (95%CI: 0.99−1.00), which leads us to conclude that the measurements are perfectly reproducible. Both measurements (height and base) of the space under the DTML, performed by ultrasound, are reliable and reproducible.

Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery

BACKGROUND

Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.

MATERIALS AND METHODS

A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.

CONCLUSIONS

There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.

LEVEL OF EVIDENCE

Level V, meta-synthesis.