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Lee W, McDonald J, Azam M, Lachance AD. The comparison of postoperative outcomes in Morton's neuroma excision between plantar versus dorsal approach: A systematic review and meta-analysis. Foot Ankle Surg 2024:S1268-7731(24)00122-X. [PMID: 38880729 DOI: 10.1016/j.fas.2024.05.018] [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: 02/15/2024] [Revised: 04/27/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Current literature lacks comprehensive information comparing the clinical outcomes of plantar and dorsal approaches for Civinini-Morton syndrome, also known as Morton's neuroma. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of neurectomy for Morton's neuroma, focusing on the differences between the plantar and dorsal approach. METHODS Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included postoperative sensory loss, scar tenderness, reoperation, histopathology, complications, pain score, patient satisfaction, functional scores, and time to weight bearing. RESULTS Total eight studies were included in this study. In aggregate, 237 neuromas underwent excision using the plantar approach, while 312 neuromas were treated via the dorsal approach. A significantly higher rate of postoperative reduced sensory was found in the dorsal group: 48.5 % (64/132) Vs. 62.0 % (80/129) with the relative ratio (RR) of 0.79 (95 % CI, 0.64-0.97). A significantly higher rate of postoperative scar tenderness was noted in the plantar group: 16.7 % (32/192) Vs. 6.2 % (14/225) with the RR of 2.27 (95 % CI, 1.28-4.04). Regarding the histopathology, 99.3 % (143/144) and 97.1 % (134/138) accuracy rate was confirmed in the plantar approach and dorsal approach, respectively, with the RR of 1.02 (95 % CI, 0.98-1.07). Overall reoperations and complications were not different between groups at 5.3 % (10/189) and 8.8 % (19/216) in the plantar group versus 6.1 % and 12.0 % (35/291) in dorsal group. CONCLUSIONS We recommend detailed discussions with patients prior to surgery to weigh the advantages and disadvantages of each approach.
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Affiliation(s)
- Wonyong Lee
- Department of Orthopaedic Surgery, Guthrie Clinic, 1 Guthrie Sq, Sayre 18840, PA, USA.
| | - John McDonald
- Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton 18510, PA, USA.
| | - Mohammad Azam
- Department of Orthopaedic Surgery, Guthrie Clinic, 1 Guthrie Sq, Sayre 18840, PA, USA.
| | - Andrew D Lachance
- Department of Orthopaedic Surgery, Guthrie Clinic, 1 Guthrie Sq, Sayre 18840, PA, USA.
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Matthews BG, Thomson CE, Harding MP, McKinley JC, Ware RS. Treatments for Morton's neuroma. Cochrane Database Syst Rev 2024; 2:CD014687. [PMID: 38334217 PMCID: PMC10853972 DOI: 10.1002/14651858.cd014687.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Morton's neuroma (MN) is a painful neuropathy resulting from a benign enlargement of the common plantar digital nerve that occurs commonly in the third webspace and, less often, in the second webspace of the foot. Symptoms include burning or shooting pain in the webspace that extends to the toes, or the sensation of walking on a pebble. These impact on weight-bearing activities and quality of life. OBJECTIVES To assess the benefits and harms of interventions for MN. SEARCH METHODS On 11 July 2022, we searched CENTRAL, CINAHL Plus EBSCOhost, ClinicalTrials.gov, Cochrane Neuromuscular Specialised Register, Embase Ovid, MEDLINE Ovid, and WHO ICTRP. We checked the bibliographies of identified randomised trials and systematic reviews and contacted trial authors as needed. SELECTION CRITERIA We included all randomised, parallel-group trials (RCTs) of any intervention compared with placebo, control, or another intervention for MN. We included trials where allocation occurred at the level of the individual or the foot (clustered data). We included trials that confirmed MN through symptoms, a clinical test, and an ultrasound scan (USS) or magnetic resonance imaging (MRI). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We assessed bias using Cochrane's risk of bias 2 tool (RoB 2) and assessed the certainty of the evidence using the GRADE framework. MAIN RESULTS We included six RCTs involving 373 participants with MN. We judged risk of bias as having 'some concerns' across most outcomes. No studies had a low risk of bias across all domains. Post-intervention time points reported were: three months to less than 12 months from baseline (nonsurgical outcomes), and 12 months or longer from baseline (surgical outcomes). The primary outcome was pain, and secondary outcomes were function, satisfaction or health-related quality of life (HRQoL), and adverse events (AE). Nonsurgical treatments Corticosteroid and local anaesthetic injection (CS+LA) versus local anaesthetic injection (LA) Two RCTs compared CS+LA versus LA. At three to six months: • CS+LA may result in little to no difference in pain (mean difference (MD) -6.31 mm, 95% confidence interval (CI) -14.23 to 1.61; P = 0.12, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Assessed via a pain visual analogue scale (VAS; 0 to 100 mm); a lower score indicated less pain.) • CS+LA may result in little to no difference in function when compared with LA (standardised mean difference (SMD) -0.30, 95% CI -0.61 to 0.02; P = 0.06, I2 = 0%; 2 studies, 157 participants; low-certainty evidence). (Function was measured using: the American Orthopaedic Foot and Ankle Society Lesser Toe Metatarsophalangeal-lnterphalangeal Scale (AOFAS; 0 to 100 points) - we transformed the scale so that a lower score indicated improved function - and the Manchester Foot Pain and Disability Schedule (MFPDS; 0 to 100 points), where a lower score indicated improved function.) • CS+LA probably results in little to no difference in HRQoL when compared to LA (MD 0.07, 95% CI -0.03 to 0.17; P = 0.19; 1 study, 122 participants; moderate-certainty evidence), and CS+LA may not increase satisfaction (risk ratio (RR) 1.08, 95% CI 0.63 to 1.85; P = 0.78; 1 study, 35 participants; low-certainty evidence). (Assessed using the EuroQol five dimension instrument (EQ-5D; 0-1 point); a higher score indicated improved HRQoL.) • The evidence is very uncertain about the effects of CS+LA on AE when compared with LA (RR 9.84, 95% CI 1.28 to 75.56; P = 0.03, I2 = 0%; 2 studies, 157 participants; very low-certainty evidence). Adverse events for CS+LA included mild skin atrophy (3.9%), hypopigmentation of the skin (3.9%) and plantar fat pad atrophy (2.6%); no adverse events were observed with LA. Ultrasound-guided (UG) CS+LA versus non-ultrasound-guided (NUG) CS+LA Two RCTs compared UG CS+LA versus NUG CS+LA. At six months: • UG CS+LA probably reduces pain when compared with NUG CS+LA (MD -15.01 mm, 95% CI -27.88 to -2.14; P = 0.02, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). (Assessed with a pain VAS.) • UG CS+LA probably increases function when compared with NUG CS+LA (SMD -0.47, 95% CI -0.84 to -0.10; P = 0.01, I2 = 0%; 2 studies, 116 feet; moderate-certainty evidence). We do not know of any established minimum clinical important difference (MCID) for the scales that assessed function, specifically, the MFPDS and the Manchester-Oxford Foot Questionnaire (MOXFQ; 0 to 100 points; a lower score indicated improved function.) • UG CS+LA may increase satisfaction compared with NUG CS+LA (risk ratio (RR) 1.71, 95% CI 1.19 to 2.44; P = 0.003, I2 = 15%; 2 studies, 114 feet; low-certainty evidence). • HRQoL was not measured. • UG CS+LA may result in little to no difference in AE when compared with NUG CS+LA (RR 0.42, 95% CI 0.12 to 1.39; P = 0.15, I2 = 0%; 2 studies, 116 feet; low-certainty evidence). AE included depigmentation or fat atrophy for UG CS+LA (4.9%) and NUG CS+LA (12.7%). Surgical treatments Plantar incision neurectomy (PN) versus dorsal incision neurectomy (DN) One study compared PN versus DN. At 34 months (mean; range 28 to 42 months), PN may result in little to no difference for satisfaction (RR 1.06, 95% CI 0.87 to 1.28; P = 0.58; 1 study, 73 participants; low-certainty evidence), or for AE (RR 0.95, 95% CI 0.32 to 2.85; P = 0.93; 1 study, 75 participants; low-certainty evidence) compared with DN. AE for PN included hypertrophic scaring (11.4%), foreign body reaction (2.9%); AE for DN included missed nerve (2.5%), artery resected (2.5%), wound infection (2.5%), postoperative dehiscence (2.5%), deep vein thrombosis (2.5%) and reoperation with plantar incision due to intolerable pain (5%). The data reported for pain and function were not suitable for analysis. HRQoL was not measured. AUTHORS' CONCLUSIONS Although there are many interventions for MN, few have been assessed in RCTs. There is low-certainty evidence that CS+LA may result in little to no difference in pain or function, and moderate-certainty evidence that UG CS+LA probably reduces pain and increases function for people with MN. Future trials should improve methodology to increase certainty of the evidence, and use optimal sample sizes to decrease imprecision.
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Affiliation(s)
- Barry G Matthews
- Faculty of Health, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, Australia
| | - Colin E Thomson
- Department of Trauma & Orthopaedics, The Royal Infirmary of Edinburgh and St John's Hospital Livingston, Edinburgh, UK
| | | | - John C McKinley
- Royal Infirmary of Edinburgh and Royal Hospital for Sick Children, Edinburgh, UK
| | - Robert S Ware
- School of Medicine and Dentistry, Griffith University, Brisbane, Australia
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Zhang J, Li J, Cai W, Zheng K, Huang X, Rong X, Li Q. Effect of surgical approach on the treatment of Morton's neuroma: a systematic review and meta-analysis. J Foot Ankle Res 2023; 16:57. [PMID: 37674248 PMCID: PMC10483740 DOI: 10.1186/s13047-023-00660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Surgical resection of Morton's neuroma includes dorsal and plantar approaches. However, there is no consensus on the choice of approach in clinic. The purpose of this study was to conduct a systematic review and meta-analysis to compare the surgical results of dorsal and plantar approaches. METHODS The literatures of PubMed, Cochrane library, Embase and Web of Science were searched on April 26th, 2023. A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The data were extracted after screening the literature and evaluating the quality of the methodology included in the study. The RevMan5.4 software was used to analyze and calculate the OR value and 95% confidence interval. RESULTS A total of 7 randomized controlled trials and comparative studies were published, of which only 5 were included. There were 158 feet via plantar approach (plantar group, PG) and 189 via dorsal approach (dorsal group, DG). There was no significant difference between PG and DG in overall adverse events, sensory problems, incision infection and deep vein thrombosis (p > 0.05). In terms of scar problems, PG showed more than DG (OR, 2.90[95%CI, 1.40 to 5.98]; p = 0.004). Other outcome indicators such as visual analogue scale (VAS) scores and American Orthopedic Foot and Ankle Society (AOFAS) scores were difficult to be included in the comparison. CONCLUSIONS Based on the relatively low quality and small amount of available evidence, the meta-analysis conducted produces a hypothesis that the frequency of adverse events in surgical treatment of Morton's neuroma, dorsal approach and plantar approach may be the same, but the types are different. More high-level evidence is needed to further verify this hypothesis.
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Affiliation(s)
- Jiayao Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wufeng Cai
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Kaiwen Zheng
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xihao Huang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Rong
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qi Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Giarda F, Agostini A, Colonna S, Sciumè L, Meroni A, Beretta G, Dalla Costa D. Infiltrative Type I Collagen in the Treatment of Morton's Neuroma: A Mini-Series. J Clin Med 2023; 12:4640. [PMID: 37510755 PMCID: PMC10380245 DOI: 10.3390/jcm12144640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly affecting the third inter-digital space. The conservative approach is the first recommended treatment option. However, other different approaches have been proposed, offering several options of treatments, where, several degrees of efficacy and safety have been reported. We treated five consecutive patients affected by MN through three indirect ultrasound-guided injections of type I porcine collagen at weekly intervals. All patients were assessed before the treatment, after the treatment and up to 6 months after the last injection via AOFAS and VNS scores for pain, in which the function and pain were evaluated, respectively. In all patients, both analyzed variables progressively ameliorated, with benefits lasting until the last follow-up. The trend of the scores during the follow-up showed significant statistical differences. No side effects occurred. To our knowledge, this is the first study on injections of type I porcine collagen for the treatment of Morton's neuroma. Future research is needed to confirm the positive trend achieved in this MN mini-series.
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Affiliation(s)
- Federico Giarda
- Unit of Rehabilitation Medicine and Neurorehabilitation, Department of Neuroscience, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Adele Agostini
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Stefano Colonna
- Unit of Rehabilitation Medicine and Neurorehabilitation, Department of Neuroscience, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Luciana Sciumè
- Unit of Rehabilitation Medicine and Neurorehabilitation, Department of Neuroscience, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Alberto Meroni
- Department of Orthopedic Surgery and Traumatology, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Giovanna Beretta
- Unit of Rehabilitation Medicine and Neurorehabilitation, Department of Neuroscience, ASST Niguarda Hospital, 20162 Milan, Italy
| | - Davide Dalla Costa
- Unit of Rehabilitation Medicine and Neurorehabilitation, Department of Neuroscience, ASST Niguarda Hospital, 20162 Milan, Italy
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5
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Thomajan CH. A Method for Entubulating Exposed Nerve Ends Following Neurectomy Using a Porcine Extracellular Matrix Nerve Cap. Foot Ankle Spec 2022; 15:579-585. [PMID: 35778874 PMCID: PMC9643824 DOI: 10.1177/19386400221106642] [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] [Indexed: 12/04/2022]
Abstract
Compression and irritation at the plantar aspect of the transverse intermetatarsal ligament may lead to a compressive neuropathy called Morton's neuroma. There are many treatment options for Morton's neuroma, with the most common surgical option being traction neurectomy. While there has been success in many surgical procedures, up to 35% of patients treated with traction neurectomy have recurrent pain and up to one-third of these patients have a recurrent stump neuroma. These neuromas are caused by abnormal axonal growth during regeneration, leading to an unorganized mass of fibrotic collagenous tissues, Schwann cells, and axons. More recent surgical treatments of neuromas have included nerve capping, which has been proposed to prevent painful neuroma formation by isolating the nerve end from external chemosignaling and reducing disorganized axonal outgrowth. An off-the-shelf, biocompatible porcine small intestine submucosa (pSIS) derived nerve cap with internal chambering has been investigated in a rodent study, which showed less pain sensitivity and less axonal swirling indicative of reduced likelihood of neuroma formation. Furthermore, a recent clinical study indicated that patients experienced a significant reduction in pain 3 months after Morton's neuroma excision followed by repair using a nerve cap. This article describes the surgical technique of the aforementioned clinical study to mitigate neuroma formation, where a Morton's neuroma is excised, and the remaining proximal nerve stump is inserted within a nerve cap and buried in the surrounding muscle.Level of Evidence: Level V: Expert opinion.
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Affiliation(s)
- Craig H. Thomajan
- Craig H. Thomajan, DPM, Austin Foot and
Ankle Specialists, 5000 Bee Caves Road, Suite 202, Austin, TX 78746; e-mail:
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Sato G, Ferreira GF, Sevilla D, Oliveira CN, Lewis TL, Dinato MCME, Pereira Filho MV. Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML): a case series with minimum two-year follow-up. INTERNATIONAL ORTHOPAEDICS 2022; 46:2829-2835. [PMID: 36031662 DOI: 10.1007/s00264-022-05557-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal treatment of symptomatic Morton's neuroma remains unclear; conservative methods are sometimes ineffective and neurectomy has significant rates of patient dissatisfaction. The aim of this study was to evaluate the outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML) in patients with Morton's neuroma. METHODS Between January 2018 and November 2019, 27 patients (29 feet) diagnosed with Morton's neuroma after clinical and radiological evaluation underwent DMMO and percutaneous DTML release. The primary clinical outcomes were pain (VAS) and function (AOFAS score). Secondary outcomes included patient satisfaction, complications, and radiographic outcomes. Patients were followed up for a minimum of two years. RESULTS The median age of the participants was 66 years (range 48-79) and the follow-up time was 28 months (24-47). There was a decrease of 5.7 points in the VAS for pain (p < .001) and an increase of 19.9 in AOFAS (p < .001) after the surgical procedure. There was one case of superficial infection and one patient required resection of the neuroma (neurectomy). The majority of patients (89.7%) were satisfied and considered the procedure outcome as excellent or good. CONCLUSION Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy and percutaneous release of the deep transverse metatarsal ligament showed significant improvement in pain and function with a low incidence of complications and a high rate of personal satisfaction.
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Affiliation(s)
- Gustavo Sato
- Department of Orthopaedics, Rheumatology and Traumatology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.,Instituto Vita, São Paulo, Brazil
| | - Gabriel Ferraz Ferreira
- Instituto Vita, São Paulo, Brazil.,Foot and Ankle Surgery Group, Orthopaedics and Traumatology Unit, Prevent Senior, São Paulo, Brazil.,Minimally Invasive Foot Ankle Society (MIFAS By GRECMIP), Merignac, France
| | - Davy Sevilla
- Department of Orthopaedics and Traumatology, Prevent Senior, São Paulo, Brazil
| | | | | | - Mauro Cesar Mattos E Dinato
- Department of Orthopaedics, Rheumatology and Traumatology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.,Instituto Vita, São Paulo, Brazil
| | - Miguel Viana Pereira Filho
- Instituto Vita, São Paulo, Brazil. .,Foot and Ankle Surgery Group, Orthopaedics and Traumatology Unit, Prevent Senior, São Paulo, Brazil.
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Muramatsu K, Tani Y, Seto T, Arcinue J, Iwanaga R, Sakai T. Microsurgical Neurectomy for Morton’s Neuroma. J Hand Microsurg 2022; 14:200-204. [DOI: 10.1055/s-0040-1713081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Abstract
Introduction “Morton’s neuroma” is one of the common causes of forefoot pain. If conservative therapy fails, surgical treatment should be performed. Microscopy is often used to operate on the digital nerve in the hand. However, to our knowledge, there has only been one report on the use of microsurgical technique. In this study, we describe a new microsurgical technique for Morton’s neuroma and discuss the advantages of this procedure.
Materials and Methods Ten patients with Morton’s neuroma underwent surgical neurolysis or neurectomy using microsurgical technique. All patients were females with a mean age of 53 years (range = 35–65). The average follow-up time after surgery was 18 months (range = 6–24 months).
Results Four cases initially underwent microsurgical neurolysis, but the patient’s symptoms did not improve. Two of these cases were then referred for revision surgery by microsurgical neurectomy. Following neurectomy, the mean preoperative pain and functional score improved significantly. In five cases, histopathology showed the neuroma was surrounded by metatarsal bursitis. In three cases, the nerve was sutured because each stump was easily reached.
Conclusion Microsurgical technique allows careful visualization of the plantar digital nerve even through a dorsal approach. Separation of the digital nerve from the adhesive fibrous tissue can be performed quite readily under the microscope and Morton’s neuroma can then be completely removed en block. In some cases, microsurgical nerve repair may also be possible. A microsurgical approach is a reliable and useful tool for neurectomy of Morton’s neuroma.
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Affiliation(s)
- Keiichi Muramatsu
- Department of Orthopedic Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
- Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Yasuhiro Tani
- Department of Orthopedic Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Tetsuya Seto
- Department of Orthopedic Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Jasson Arcinue
- Department of Orthopedic Surgery, Nagato General Hospital, Nagato, Yamaguchi, Japan
| | - Ryuta Iwanaga
- Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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Choi JY, Hong WH, Kim MJ, Chae SW, Suh JS. Operative treatment options for Morton's neuroma other than neurectomy - a systematic review. Foot Ankle Surg 2022; 28:450-459. [PMID: 34736848 DOI: 10.1016/j.fas.2021.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/24/2021] [Accepted: 10/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effectiveness of operative treatments other than neurectomy for Morton's neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton's neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies. METHODS Several electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton's neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type. RESULTS After reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. CONCLUSION Whether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable. LEVEL OF EVIDENCE Level III, systematic review.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Woi Hyun Hong
- College of Medicine, Medical Research Information Center, Chungbuk National University, 1 Chungdae-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do, South Korea.
| | - Min Jin Kim
- Health Care Center, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Bucheon-si, Gyeonggi-do, South Korea.
| | - Su Whi Chae
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Kuruvilla SI, Schaeffer CV, Cooper MT, DeGeorge BR. "The Feasibility of Targeted Muscle Reinnervation for the Management of Morton's Neuroma". Foot Ankle Spec 2022; 15:76-81. [PMID: 34854338 DOI: 10.1177/19386400211002702] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be explored as an option for the prevention of recurrence of Morton's neuroma. The purpose of the present investigation was to determine the consistency of the relevant foot neurovascular and muscle anatomy and to demonstrate the feasibility of TMR as an option for Morton's neuroma. METHODS The anatomy of 5 fresh-tissue donor cadaver feet was studied, including the course and location of the medial and lateral plantar nerves (MPNs and LPNs), motor branches to abductor hallucis (AH) and flexor digitorum brevis (FDB), as well as the course of sensory plantar digital nerves. Measurements for the locations of the muscular and sensory branches were taken relative to landmarks including the navicular tuberosity (NT), AH, FDB, and the third metatarsophalangeal joint (third MTPJ). RESULTS The mean number of nerve branches to FDB identified was 2. These branch points occurred at an average of 8.6 cm down the MPN or LPN, 9.0 cm from the third MTPJ, 3.0 cm distal to AH distal edge, and 4.8 cm from the NT. The mean number of nerves to AH was 2.2. These branch points occurred at an average of 6.3 cm down the MPN, 11.9 cm from the third MTPJ, 0.8 cm from the AH distal edge, and 3.8 cm from the NT. CONCLUSIONS Recurrent interdigital neuroma, painful scar, and neuropathic pain are common complications of operative management for Morton's neuroma. Targeted muscle reinnervation is a technique that has demonstrated efficacy for the prevention and treatment of neuroma, neuropathic pain, and phantom limb pain in amputees. Herein, we have described the neuromuscular anatomy for the application of TMR for the management of Morton's neuroma. Target muscles, including the AH and FDB, have consistent innervation patterns in the foot, and consequently, TMR represents a viable option to consider for the management of recalcitrant Morton's neuroma. LEVELS OF EVIDENCE V.
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Affiliation(s)
- Shannon I Kuruvilla
- Department of Plastic Surgery, The University of Virginia, Charlottesville, Virginia (SIK, CVS, BRD).,Department of Orthopaedic Surgery, The University of Virginia, Charlottesville, Virginia (MTC, BRD)
| | - Christine V Schaeffer
- Department of Plastic Surgery, The University of Virginia, Charlottesville, Virginia (SIK, CVS, BRD).,Department of Orthopaedic Surgery, The University of Virginia, Charlottesville, Virginia (MTC, BRD)
| | - Minton T Cooper
- Department of Plastic Surgery, The University of Virginia, Charlottesville, Virginia (SIK, CVS, BRD).,Department of Orthopaedic Surgery, The University of Virginia, Charlottesville, Virginia (MTC, BRD)
| | - Brent R DeGeorge
- Department of Plastic Surgery, The University of Virginia, Charlottesville, Virginia (SIK, CVS, BRD).,Department of Orthopaedic Surgery, The University of Virginia, Charlottesville, Virginia (MTC, BRD)
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10
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Bilateral Finger Morton Neuroma after Primary Fingertip Amputation. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4035. [PMID: 35186616 PMCID: PMC8849316 DOI: 10.1097/gox.0000000000004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
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11
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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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12
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Ito E, Shima H, Togei K, Hirai Y, Tsujinaka S, Yasuda T, Neo M. Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report. SAGE Open Med Case Rep 2021; 9:2050313X211046744. [PMID: 34552753 PMCID: PMC8450979 DOI: 10.1177/2050313x211046744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/30/2021] [Indexed: 11/17/2022] Open
Abstract
Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.
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Affiliation(s)
- Eichi Ito
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Hiroaki Shima
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Kosho Togei
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yoshihiro Hirai
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Seiya Tsujinaka
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Toshito Yasuda
- Department of Nursing, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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13
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Ultrasound-guided Injection Treatments versus Surgical Neurectomy for Morton Neuroma: A Cost-effectiveness Analysis. AJR Am J Roentgenol 2021; 218:234-240. [PMID: 34523955 DOI: 10.2214/ajr.21.26419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. Objective: The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas that have failed conservative management. Methods: An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three injection selective strategies in which one or more ultrasound-guided injection therapies was tried first prior to surgery for non-responders. The three injection selective strategies included: (1) steroid selective (2) alcohol selective, and (3) steroid/alcohol selective in which both steroid injections and alcohol sclerosing injections were trialed successively prior to surgical neurectomy. The direct to surgery approach was compared with the three different injection selective strategies, and with a no-treatment strategy, in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuromas that had failed conservative management. Model parameters including treatment costs, effectiveness, complication rates, and health utility states were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality adjusted life year (QALY) with a time horizon of three years. A societal cost perspective was adopted with a willingness to pay threshold of $100,000 per QALY. Sensitivity analyses for key model parameters were performed. Results: For the base input values, the steroid/alcohol selective strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401/QALY compared to no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective strategy became most cost-effective. Conclusion: A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared to proceeding directly to surgical neurectomy. Clinical Impact: Ultrasound-guided injection therapies are indicated as a first line treatment for patients with symptomatic Morton neuromas that have failed conservative management.
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14
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Cooke R, Manning C, Palihawadana D, Zubairy AI, Khan SH. Metatarsalgia: anatomy, pathology and management. Br J Hosp Med (Lond) 2021; 82:1-8. [PMID: 34601927 DOI: 10.12968/hmed.2021.0348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metatarsalgia is a common presentation, particularly in middle-aged women. This review discusses the anatomical basis and classifies the different pathologies into primary, secondary and iatrogenic. The key elements to differentiate the pathologies within each classification which could cause a patient to suffer with metatarsalgia are outlined. Further investigations are briefly covered, but a linked article discusses the investigations of metatarsalgia in more detail. The article gives an overview of metatarsalgia to help clinicians to investigate and manage these symptoms.
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Affiliation(s)
- Robert Cooke
- Department of Trauma and Orthopaedics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Christopher Manning
- Department of Trauma and Orthopaedics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Dhanushka Palihawadana
- Department of Trauma and Orthopaedics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Aamir I Zubairy
- Department of Trauma and Orthopaedics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Shah Hm Khan
- Department of Radiology, East Lancashire Hospitals NHS Trust, Blackburn, UK
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15
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Biz C, Stecco C, Fantoni I, Aprile G, Giacomini S, Pirri C, Ruggieri P. Fascial Manipulation Technique in the Conservative Management of Morton's Syndrome: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157952. [PMID: 34360245 PMCID: PMC8345745 DOI: 10.3390/ijerph18157952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
Background and Objective: Morton’s syndrome (MS) is a common cause of neuropathic chronic forefoot pain, characterised by the development of a swelling of the common digital plantar nerve, whose aetiology is not fully known. There is currently no gold standard of treatment; nonoperative management commonly involves manual therapies, orthoses therapy and infiltrative techniques, while surgery is indicated after failure of conservative measures. The present preliminary study prospectively evaluates patients affected by MS treated by Fascial Manipulation technique (FM), a noninvasive manual therapy, focused on the release of the deep fascia, reducing its stiffness. Materials and Methods: Patients with clinical and sonographic diagnosis of MS with at least a 4-month history of neuropathic symptoms underwent a cycle of three weekly FM sessions. Clinical follow-up, including VAS and AOFAS scores, was performed 21 days (T1) and 3 months (T2) after treatment. Results: Nine patients, among 28 recruited initially, completed the manual therapy sessions and relative follow-up points. This noninvasive pain treatment led to significant improvement of VAS (p = 0.0034) and AOFAS scores (p = 0.0240) at the first follow-up (T1). At 3-month follow-up (T2), both scores decreased slightly, remaining however superior to the pre-treatment values. Only VAS was still significant (p = 0.0184). Conclusions: Despite the small size of the case series, this pilot study is unique in supporting Fascial Manipulation in the nonoperative treatment of MS. Further studies are needed with a large cohort of gender balanced patients to confirm the encouraging results obtained.
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Affiliation(s)
- Carlo Biz
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopaedic Clinic, University of Padova, 35128 Padova, Italy; (I.F.); (G.A.); (P.R.)
- Correspondence: ; Tel.: +39-049-821-3239
| | - Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (S.G.); (C.P.)
| | - Ilaria Fantoni
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopaedic Clinic, University of Padova, 35128 Padova, Italy; (I.F.); (G.A.); (P.R.)
| | - Gianluca Aprile
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopaedic Clinic, University of Padova, 35128 Padova, Italy; (I.F.); (G.A.); (P.R.)
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (S.G.); (C.P.)
| | - Stefano Giacomini
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (S.G.); (C.P.)
| | - Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (S.G.); (C.P.)
| | - Pietro Ruggieri
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopaedic Clinic, University of Padova, 35128 Padova, Italy; (I.F.); (G.A.); (P.R.)
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16
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Archuleta AF, Darbinian J, West T, Weintraub MLR, Pollard JD. Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases. J Foot Ankle Surg 2021; 59:1186-1191. [PMID: 32830016 DOI: 10.1053/j.jfas.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/07/2020] [Accepted: 05/17/2020] [Indexed: 02/03/2023]
Abstract
Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.
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Affiliation(s)
- Andy F Archuleta
- Podiatric Medical Student, California School of Podiatric Medicine, Oakland, CA
| | - Jeanne Darbinian
- Senior Data Consultant, Biostatistical Consulting Unit, Kaiser Permanente Division of Research, Oakland, CA
| | - Tenaya West
- Podiatric Surgical Fellow, Palo Alto Medical Foundation, Mountain View, CA
| | - Miranda L Ritterman Weintraub
- Senior Research Project Manager, Department of Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Jason D Pollard
- Research Director and Surgeon, Department of Podiatric Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA.
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17
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Klontzas ME, Koltsakis E, Kakkos GA, Karantanas AH. Ultrasound-guided treatment of Morton's neuroma. J Ultrason 2021; 21:e134-e138. [PMID: 34258038 PMCID: PMC8264811 DOI: 10.15557/jou.2021.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
Morton’s neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular degeneration, and deregulation of sympathetic innervation. Patients usually present with burning or sharp metatarsalgia at the dorsal or plantar aspect of the foot. The management of Morton’s neuroma starts with conservative measures, usually with limited efficacy, including orthotics and anti-inflammatory medication. When conservative treatment fails, a series of minimally invasive ultrasound-guided procedures can be employed as second-line treatments prior to surgery. Such procedures include infiltration of the area with a corticosteroid and local anesthetic, chemical neurolysis with alcohol or radiofrequency thermal neurolysis. Ultrasound aids in the accurate diagnosis of Morton’s neuroma and guides the aforementioned treatment, so that significant and potentially long-lasting pain reduction can be achieved. In cases of initial treatment failure, the procedure can be repeated, usually leading to the complete remission of symptoms. Current data shows that minimally invasive treatments can significantly reduce the need for subsequent surgery in patients with persistent Morton’s neuroma unresponsive to conservative measures. The purpose of this review is to present current data on the application of ultrasound for the diagnosis and treatment of Morton’s neuroma, with emphasis on the outcomes of ultrasound-guided treatments.
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Affiliation(s)
- Michail E Klontzas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
| | - Emmanouil Koltsakis
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - George A Kakkos
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece
| | - Apostolos H Karantanas
- Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece.,Advanced Hybrid Imaging Systems, Institute of Computer Science, FORTH, Crete, Greece.,Department of Radiology, School of Medicine, University of Crete, Greece
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18
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Samaila E, Colò G, Rava A, Negri S, Valentini R, Felli L, Magnan B. Effectiveness of corticosteroid injections in Civinini-Morton's Syndrome: A systematic review. Foot Ankle Surg 2021; 27:357-365. [PMID: 32600970 DOI: 10.1016/j.fas.2020.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/07/2020] [Accepted: 05/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this paper is to analyze the effectiveness of corticosteroid injections (CI), in combination with or without a local anaesthetic, for Civinini-Morton's Syndrome to determine which protocol could be the most appropriate among conservative treatments. METHODS All selected articles were screened using a thorough database search of PubMed, EMBASE and SCOPUS to assess their suitability to the research focus. RESULTS Selection produced 10 articles as full-text, for a total of 590 patients, with a mean follow-up of 14 ± 14.2 (range 3-48) months. Johnson satisfaction scale, resulting from 6 studies, scored 25.6% (range 5-38) and 39.4% (range 15-51.8), respectively completely satisfied and satisfied with minor reservations. Mean VAS, declared in 5 studies, decreased from 70.7 ± 16.5 (range 67-89) to 33.4 ± 7.6 (26-42.5) points (p < 0.01). Most common complication was skin depigmentation in 7 (2.6%) cases. CONCLUSIONS CI appear to be a safe treatment allowing good results with a very low complications rate. A neuroma of 6.3 mm seems to be the cut-off size; below which CI could have best indications and be considered as an intermediate treatment between shoe modifications and more invasive procedures such as percutaneous alcoholization or surgery. LEVEL OF EVIDENCE Level II, systematic review.
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Affiliation(s)
- Elena Samaila
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | | | - Alessandro Rava
- Department of Orthopaedic and Traumatology, University of Turin, Italy
| | - Stefano Negri
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | - Roberto Valentini
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy
| | | | - Bruno Magnan
- Department of Orthopedics and Trauma Surgery, University of Verona, Italy.
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19
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Khan S, Qamar N, Ullah I. Health economic evaluation of different treatment strategies for peripheral entrapment mononeuropathies: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2021; 21:943-952. [PMID: 33896326 DOI: 10.1080/14737167.2021.1919088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: In this era of cost-conscious health systems, it is of utmost importance to identify and establish the most cost-effective treatment option. However, in the case of peripheral entrapment mononeuropathies there is alack of data regarding economically effective treatment strategies. Therefore, the objective was to conduct an economic evaluation including both costs and benefits of various treatment strategies applied to peripheral entrapment mononeuropathies to estimate the relative cost-effective treatment regimens.Areas covered: Over the 19 years, seven excellent-high quality economic evaluations of three types of peripheral entrapment mononeuropathies were identified in four countries. Our findings showed that surgery was the most cost-effective therapy followed by same cost efficacy of infiltrative therapy and conservative therapy for peripheral entrapment mononeuropathies. However, the fact that surgery was the most common comparator (n = 6) in our selected studies cannot be neglected.Expert opinion: Due to huge methodological variability, the finding of surgery as the cost-effective treatment strategy remains tentative and the decision about the most suitable clinical and cost-effective therapy should be individualized from case to case. Moreover, the economic evaluation of all possible treatment strategies for peripheral entrapment mononeuropathies over alonger period of analysis is required in future studies.
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Affiliation(s)
- Safeer Khan
- Department of Pharmacy Services, Al-Taaluf National Group of Polyclinics, Makkah, Kingdom of Saudi Arabia
| | - Nauman Qamar
- Department of Production, Frontier Dextrose Limited, Industrial Estate, Haripur, Khyber Pakthunkhwa, Pakistan
| | - Ihsan Ullah
- College of Pharmaceutical Sciences, Soochow University, Suzhou, China
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20
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Choi JY, Lee HI, Hong WH, Suh JS, Hur JW. Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review. Clin Orthop Surg 2021; 13:266-277. [PMID: 34094019 PMCID: PMC8173242 DOI: 10.4055/cios20256] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Backgroud This review aimed to evaluate the effects of corticosteroid injections on Morton's neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework. Methods Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton's neuroma. Data search, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). guidelines, and clinical outcomes were evaluated using various outcome measures. Results With 3–12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfaction scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain. Conclusions Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton's interdigital neuroma although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyun Il Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Woi Hyun Hong
- Medical Research Information Center, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jae Won Hur
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
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21
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Faulkner A, Mayne A, Davies P, Ridley D, Harrold F. Patient-Related Outcome Measures (PROMs) With Nonoperative and Operative Management of Morton's Neuroma. Foot Ankle Int 2021; 42:151-156. [PMID: 33019802 DOI: 10.1177/1071100720961069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Morton's neuroma is associated with chronic pain and disability. There is a paucity of literature regarding patient-related outcome measures (PROMs) in patients managed nonoperatively. We sought to investigate nonoperative and operative management of Morton's neuroma using PROMs in patients with follow-up to 1 year. METHODS We conducted a prospective observational study and collected data on all patients with a new diagnosis of Morton's neuroma treated from February 2016 until April 2018. Primary outcome measures were the Manchester-Oxford Foot Questionnaire (MOXFQ) for pain, EuroQoL (EQ) time trade-off (TTO), and EQ visual analog scale (VAS) taken preoperatively and at 52 weeks postoperatively. Forty-four patients were treated nonoperatively and 94 patients were treated operatively. RESULTS Pretreatment and 52-week scores were 55.7 and 43.10 (nonoperative) and 63.7 and 40.1 (operative) for MOXFQ (pain), 0.72 and 0.82 (nonoperative) and 0.68 and 0.82 (operative) for EQ-TTO, and 71.5 and 76.2 (nonoperative) and 73.1 and 68.7 (operative) for EQ-VAS. There was a statistically significant improvement in MOXFQ (pain) in nonoperative (P = .02) and operative groups (P < .001). There was a statistically significant improvement in EQ-TTO in the operative group only (P = .01). CONCLUSION This is the largest study investigating outcomes to 12 months of both nonoperative and operatively managed patients with Morton's neuroma. Both nonoperative and operative management lead to symptom improvement at 12 months. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Alastair Faulkner
- Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, Scotland, UK
| | - Alistair Mayne
- Department of Trauma and Orthopaedics, Ulster Hospital, Belfast, Northern Ireland
| | - Peter Davies
- Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, Scotland, UK
| | - David Ridley
- Tayside Orthopaedic Rehabilitation and Technology Services, Ninewells Hospital, Dundee, Scotland, UK
| | - Fraser Harrold
- Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, Scotland, UK
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22
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Ray J, Andrews NA, Dib A, Harrelson WM, Khurana A, Singh MS, Shah A. Management of acute lesser toe pain. Postgrad Med 2021; 133:320-329. [PMID: 33406375 DOI: 10.1080/00325481.2021.1873581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders.
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Affiliation(s)
- Jessyca Ray
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicholas A Andrews
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Aseel Dib
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Whitt M Harrelson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ankit Khurana
- Department of Orthopaedic Surgery, Dr. BSA Medical College, Delhi, India
| | - Maninder Shah Singh
- Department of Orthopaedic Surgery, Indian Spinal Injuries Centre, Delhi, India
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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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: 0.3] [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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Gardill K. Ginkgoblatt oder Pfifferling – Sonomorphologie von
Morton-Neuromen. KLIN NEUROPHYSIOL 2020. [DOI: 10.1055/a-1196-2864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
HintergrundBei der Morton-Metatarsalgie handelt es sich um ein chronisches Kompressionssyndrom
der distalen Nn. digitales plantares des N. tibialis zwischen den Köpfchen
der Mittelfuβknochen. Betroffen sind am häufigsten die
Nervenäste zwischen den Ossa metatarsalia III und IV, weniger häufig
II und III, noch seltener in den übrigen Zwischenräumen. Das
pathologische Korrelat dieser Störung sind die sog. Morton-Neurome als
gutartige Verdickungen der kleinen Nerven in diesem Bereich. Sinnvolle
elektrophysiologische Untersuchungen zur Diagnostik der daraus resultierenden
Morton-Metatarsalgie existieren nicht, sodass den bildgebenden Verfahren eine
besondere Bedeutung zukommt, neben der Kernspintomografie besonders die
Nervensonografie, die mit relativ geringem Aufwand kostengünstig auch in
einer neurologischen Praxis oder einer Funktionsabteilung durchgeführt
werden kann. Die Sensitivität von Nervensonografie und Kernspintomografie
scheint etwa gleich hoch zu sein, möglicherweise ist die Nervensonografie
sogar in der Spezifität überlegen 1
5.
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25
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Nieves GC, Fernández-Gibello A, Moroni S, Montes R, Márquez J, Ortiz MS, Vázquez T, Duparc F, Moriggl B, Konschake M. Anatomic basis for a new ultrasound-guided, mini-invasive technique for release of the deep transverse metatarsal ligament. Clin Anat 2020; 34:678-684. [PMID: 33012024 PMCID: PMC8246909 DOI: 10.1002/ca.23692] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022]
Abstract
Introduction Morton's neuroma is an entrapment neuropathy of the third common plantar digital nerve, caused by the deep transverse metatarsal ligament (DTML). Minimally invasive or percutaneous surgery is a very common procedure, but surgical effectivity of this technique remains controversial. The goal of our study was to prove the effectiveness and safety of a new ultrasound‐guided technique for DTML‐release in a cadaver model. Materials, Methods, and Results The DTML was visualized in 10 fresh frozen donated body to science‐feet (eight male and two females, five left and five right) using an US device (GE Logic R7; 13 MHz linear probe, Madrid, Spain). Consecutively, minimally invasive ultrasound‐guided surgery was performed. Exclusion criteria of the donated bodies to science were previous history of forefoot surgery and space occupying mass lesions. The complete release of the ligament was achieved in all specimens without damage of any important anatomical structures as proven by anatomical dissection. Conclusions The results of this study indicate that our novel approach of an ultrasound‐guided release of the DTML is safer and more effective compared to blind techniques. The DTML could reliably be visualized and securely cut through a dorsal, minimally invasive surgical incision of only 2 mm.
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Affiliation(s)
- Gabriel Camunas Nieves
- Clínica Vitruvio, Madrid, Spain.,Faculty of Health Sciences, Department of Podiatry, University of La Salle, Madrid, Spain
| | - Alejandro Fernández-Gibello
- Clínica Vitruvio, Madrid, Spain.,Faculty of Health Sciences, Department of Podiatry, University of La Salle, Madrid, Spain
| | - Simone Moroni
- Clínica Vitruvio, Madrid, Spain.,Faculty of Health Sciences at Manresa, Department of Podiatry, Universidad de Vic - Universidad Central de Catalunya (UVic-Ucc), Barcelona, Spain
| | | | | | - Mario Suárez Ortiz
- Faculty of Health Sciences, Department of Podiatry, Universidad Católica de Valencia, Valencia, Spain.,Clínica Podosalud, Madrid, Spain
| | - Teresa Vázquez
- Anatomy and Embryology Department, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Fabrice Duparc
- Laboratory of Anatomy, Faculty of Medicine, Rouen-Normandy University, Rouen, France
| | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Marko Konschake
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
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26
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The effects of a combined physical therapy approach on Morton's Neuroma. An N-of-1 Case Report. Foot (Edinb) 2020; 44:101684. [PMID: 32713798 DOI: 10.1016/j.foot.2020.101684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is a lack of supporting evidence for conservative treatments involving Morton's Neuroma, which has often a clinical presentation with many associated complications such as functional impairment and chronic pain. This case study assessed the effects of a combined physical therapy treatment for Morton's Neuroma, an injury often referred for surgery. METHODS The patient suffered a long-standing Morton's Neuroma and received 6 combined physical therapy sessions that included soft-tissue massage, joint mobilization, strengthening therapeutic exercises and pain education. Values for pain with deep pressure, pain maladaptive beliefs and functionality were taken using clinical testing and questionnaires. RESULTS After the intervention was successfully completed, pain when applying deep pressure resolved. Functionality involving the toe-to-wall test showed an improvement in ankle dorsiflexion and better results were found in both the LEFS and FAAM questionnaires. Pain maladaptive beliefs, assessed with the Pain Catastrophizing Scale and the Pain Awareness Questionnaire also reflected an improvement. CONCLUSION A combined physical therapy approach shows encouraging results in the treatment of Morton's Neuroma.
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Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:60-68. [PMID: 32555077 PMCID: PMC7944831 DOI: 10.23750/abm.v91i4-s.9713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 01/01/2023]
Abstract
Civinini Morton’s Syndrome (CMS), better known as Morton’s Neuroma, is a benign enlargement that typically affects the third common digital branch of the plantar nerve. It is a common cause of metatarsalgia leading to debilitating pain. It prefers the female gender, with a female to male ratio of 5:1 and an average age of 50 years at time of surgery. Precise aetiology remains under debate, with four etiopathogenetic theories often cited in the literature. Clinical symptoms, physical exam and instrumental evidence are important in assessing and grading the disease. Biomechanics seem to play an important role, especially regarding the usefulness of correct footwear. The first approach in the early stages of this condition usually begins with shoe modifications and orthotics, designed to limit the nerve compression. In order to prevent or delay the development of CMS, shoes should be sufficiently long, comfortable, broad toe-boxed, should bear a flat heel and a sufficiently thick external sole which should not be excessively flexible. Most authors suggested that an insole with medial arch support and a retrocapital bar or pad, just proximal to the metatarsal heads, displaces the pressure sites and can be beneficial to relieve the pain from the pinched nerve. A threshold period of 4.5 months appears to emerge from the results of the analysed studies, indicating that, beyond this period and in neuromas larger than 5-6 mm, orthotics and/or shoes modifications do not seem to give convincing results, proving to be more a palliation for the clinical condition to allow an acceptable life with pain rather than a real treatment. (www.actabiomedica.it)
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Affiliation(s)
- Gabriele Colò
- Department of Orthopaedics and Traumatology, Regional Center for Joint Arthroplasty, ASO Alessandria, Via Venezia 16, 16121, Alessandria, Italy..
| | - Alessandro Rava
- Department of Orthopaedics and Traumatology, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, via Zuretti 29, 10121, Turin, Italy.
| | - Elena Manuela Samaila
- Department of Orthopedics and Trauma Surgery, University of Verona, Surgical Center "P. Confortini", P.le A. Stefani 1, 37126, Verona (VR), Italy.
| | - Anna Palazzolo
- Department of Orthopaedics and Traumatology, Orthopaedic and Trauma Centre, Città della Salute e della Scienza di Torino, University of Turin, via Zuretti 29, 10121, Turin, Italy.
| | - Giuseppe Talesa
- Orthopaedic and Traumatologic Clinic, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Giorgio Menghini 1, 06129, Perugia, Italy.
| | - Marco Schiraldi
- Department of Orthopaedics and Traumatology, Regional Center for Joint Arthroplasty, ASO Alessandria, Via Venezia 16, 16121, Alessandria, Italy.
| | - Bruno Magnan
- Department of Orthopaedic and Truama Surgery, University of Verona, Italy.
| | - Riccardo Ferracini
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), University of Genoa, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy.
| | - Lamberto Felli
- Orthopaedic Clinic, Department of Surgical Sciences (DISC), University of Genoa, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
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Dang DY, Coughlin MJ. Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery. Indian J Orthop 2020; 54:3-13. [PMID: 32211125 PMCID: PMC7065734 DOI: 10.1007/s43465-019-00015-3] [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: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Debbie Y. Dang
- Saint Alphonsus Medical Group, Department of Orthopaedic Surgery, Coughlin Foot and Ankle Clinic, 1075 North Curtis Road, Suite 300, Boise, ID 83706 USA
| | - Michael J. Coughlin
- Saint Alphonsus Medical Group, Department of Orthopaedic Surgery, Coughlin Foot and Ankle Clinic, 1075 North Curtis Road, Suite 300, Boise, ID 83706 USA
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29
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de Oliveira HAV, Natour J, Vassalli M, Rosenfeld A, Jennings F, Jones A. Effectiveness of customized insoles in patients with Morton's neuroma: a randomized, controlled, double-blind clinical trial. Clin Rehabil 2019; 33:1898-1907. [PMID: 31505943 DOI: 10.1177/0269215519873949] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effectiveness of customized insole in patients with Morton's neuroma. DESIGN Double-blind randomized controlled trial with intent-to-treat analysis. SETTING Outpatients, University Hospital. SUBJECTS A total of 72 patients with Morton's neuroma met the inclusion criteria and were randomly allocated to either the study group (n = 36) or the control group (n = 36). INTERVENTIONS The study group was assigned to use a customized insole with metatarsal and arch support made of ethyl vinyl acetate and the control group received a flat insole of the same material, color, and density. MAIN MEASURES The primary outcome measure was walking pain intensity measured by the visual analogue scale. The secondary outcomes were as follows: pain at rest, palpation, and paresthesia (visual analogue scale); functional disability (6-minute walk test, Foot Function Index, and Foot Health Status Questionnaire); quality of life (Health Survey Short Form-36 (SF-36)); and foot pressure (AM Cube FootWalk Pro program). RESULTS In the comparison between the groups over time, a statistically significant difference, with improvement in favor of the experimental group, was found for pain during walking (P = 0.048); in the general health domains (P < 0.001) and physical activity (P = 0.025) of the Foot Health Status Questionnaire; in the general Foot Function Index score (P = 0.012); and in the functional capacity domain of the SF-36 questionnaire (P = 0.046). For the other parameters, no difference was found between groups. CONCLUSION The study demonstrated that customized insole with metatarsal and arch support relieved walking pain and improved patient-reported measures of function in patients with Morton's neuroma.
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Affiliation(s)
| | - Jamil Natour
- Rheumatology Division, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Mariana Vassalli
- Rheumatology Division, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Andre Rosenfeld
- Rheumatology Division, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Fabio Jennings
- Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
| | - Anamaria Jones
- Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, Brazil
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30
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Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. J Foot Ankle Res 2019; 12:12. [PMID: 30809275 PMCID: PMC6375221 DOI: 10.1186/s13047-019-0320-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/29/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits footwear choices and weight bearing activities. This paper aims to review non-surgical interventions for MN, to evaluate the evidence base for the clinical management of MN. METHODS Electronic biomedical databases (CINAHL, EMBASE, MEDLINE and Cochrane) were searched to January 2018 for studies evaluating the effectiveness of non-surgical interventions for Morton's neuroma. Outcome measures of interest were treatment success rate (SR) (binary) and pain as measured using 100-point visual analogue scale (VAS) (continuous). Studies with and without control groups were included and were evaluated for methodological quality using the Downs and Black Quality Index. Results from randomised controlled trials (RCT) were compared between-groups, and case series were compared pre- versus post-treatment. Effect estimates are presented as odds ratios (OR) for binary data or mean differences (MD) for continuous data. Random effects models were used to pool effect estimates across studies where similar treatments were used. Heterogeneity was assessed using the I 2 statistic. RESULTS A total of 25 studies met the inclusion criteria, seven RCTs and 18 pre/post case series. Eight different interventions were identified, with corticosteroid or sclerosing injections being the most often reported (seven studies each). Results from a meta-analysis of two RCTs found corticosteroid injection decreased pain more than control on VAS (WMD: -5.3, 95%CI: -7.5 to - 3.2). Other RCTs reported efficacy of: manipulation/mobilisation versus control (MD: -15.3, 95%CI: -29.6 to - 1.0); extracorporeal shockwave therapy versus control (MD: -5.9, 95%CI: -21.9 to 10.1). Treatment success was assessed for extracorporeal shockwave therapy versus control (OR: 0.3, 95%CI: 0.0 to 7.1); and corticosteroid injection vs footwear/padding (OR: 6.0, 95%CI: 1.9 to 19.2). Sclerosing and Botox injections, radiofrequency ablation and cryoneurolysis have been investigated by case series studies, however these were of limited methodological quality. CONCLUSIONS Corticosteroid injections and manipulation/mobilisation are the two interventions with the strongest evidence for pain reduction, however high-quality evidence for a gold standard intervention was not found. Although the evidence base is expanding, further high quality RCTs are needed.
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Affiliation(s)
- Barry G. Matthews
- School of Clinical Sciences, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Sheree E. Hurn
- School of Clinical Sciences, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059 Australia
| | - Michael P. Harding
- School of Health Sciences, University of South Australia, Adelaide, SA 5000 Australia
| | - Rachel A. Henry
- Rachel Henry Podiatry, Clayfield, Brisbane, QLD 4011 Australia
| | - Robert S. Ware
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111 Australia
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31
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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: 1.5] [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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