Is Histopathological Analysis of Interdigital Morton's Neuroma Necessary?

Effect of surgical approach on the treatment of Morton's neuroma: a systematic review and meta-analysis

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.

Rheumatoid nodule presenting as a Morton's neuroma in the foot: An important differential diagnosis to consider

A 51-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with pain and a typical history of Morton's neuroma. Examination revealed a palpable swelling over the right foot in the third intermetatarsal space. Following failed conservative management, the patient underwent excision of the neuroma. Histology revealed of necrotizing granulomas with peripheral palisading and no evidence of features specific to a neuroma. This has rarely been described previously and supports the concept of rheumatoid synovitis and nodules producing symptoms mimicking Morton's neuroma/metatarsalgia. Level of clinical evidence: 4.

Diagnostic Considerations of Intermetatarsal Bursitis: A Systematic Review

Intermetatarsal bursitis (IMB) is an inflammation of the intermetatarsal bursas. The condition causes forefoot pain with symptoms similar to those of Morton's neuroma (MN). Some studies suggest that IMB is a contributing factor to the development of MN, while others describe the condition as a differential diagnosis. Among patients with rheumatic diseases, IMB is frequent, but the scope is yet to be understood. The aim of this paper was to investigate the diagnostic considerations of IMB and its role in metatarsalgia by a systematic review approach. We identified studies about IMB by searching the electronic databases Pubmed, Embase, Cochrane Library, and Web of Science in September 2022. Of 1362 titles, 28 met the inclusion criteria. They were subdivided according to topic: anatomical studies (n = 3), studies of patients with metatarsalgia (n = 10), and studies of patients with rheumatic diseases (n = 15). We conclude that IMB should be considered a cause of pain in patients with metatarsalgia and patients with rheumatic diseases. For patients presenting with spreading toes/V-sign, IMB should be a diagnostic consideration. Future diagnostic studies about MN should take care to apply a protocol that is able to differ IMB from MN, to achieve a better understanding of their respective role in forefoot pain.

Relationship Between Sensory Symptoms, Mulder's Sign, and Dynamic Ultrasonographic Findings in Morton's Neuroma

BACKGROUND

Morton's neuroma (MN) is often a diagnostic dilemma lacking a gold standard set of diagnostic criteria. Advanced imaging of MN is evolving including ultrasonography. The current study aimed to analyze the relationship between ultrasonographic findings and symptoms, clinical data, and operative findings in a subgroup of patients.

METHODS

We evaluated physical examination, ultrasonographic findings, symptoms, and in a subgroup, the operative findings for Morton's neuroma. We analyzed the symptoms, the findings on physical examination, and ultrasonography data and performed a statistical correlation between them. A total of 175 patients were seen for suspected Morton's neuroma during the last 7 years.

RESULTS

Neuropathic pain of the toes was reported in 63% of patients. Presence of ultrasonographic findings suggesting Morton's neuroma was observed in 77% of cases. A mild significant relationship between neuropathic pain and positive ultrasonographic findings was observed. We found a strong correlation between ultrasonographic and clinical evaluation, but more than half with clinical negative Morton's neuroma had positive findings at ultrasonography. In the subgroup of operatively treated patients (n = 44) surgery confirmed Morton's neuroma in all patients who had positive ultrasonography findings.

CONCLUSIONS

The current study suggests that the association of ultrasonographic evaluation and clinical evaluation can be very useful for the management of Morton's neuroma. Our study could help with the development of a multiperspective approach in the diagnosis of Morton's neuroma.

LEVEL OF EVIDENCE

Level II, prospective cohort survey study.

Value of Preoperative Imaging and Intraoperative Histopathology in Morton's Neuroma

BACKGROUND

Recent studies have demonstrated that clinical diagnosis of Morton's neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have questioned the cost-effectiveness of intraoperative histopathology of excised specimens. The purpose of this study was to determine the utility of both preoperative imaging and intraoperative histology in the treatment of Morton's neuroma in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes.

METHODS

A retrospective review was performed on all patients who underwent operative resection suspected Morton's neuroma with 4 fellowship-trained foot and ankle surgeons between 2007 and 2017. Procedures were excluded from the study if the pathology report was not available for review. Diagnoses were made either by clinical examination and/or by the results of preoperative imaging. All pathology reports were reviewed to determine the final diagnosis, considered the "gold standard." Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton's neuroma. Two hundred eighty-seven procedures in 269 patients with 313 clinically suspected neuromas met inclusion criteria.

RESULTS

Of the 313 suspected neuromas, 309 (98.7%) were confirmed Morton's neuromas on histopathologic examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179 (57.2%) suspected neuromas, with magnetic resonance imaging (MRI) and ultrasonography used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 using both. The total estimated cost of histopathologic analysis for the cohort was $143 667, and the estimated combined cost of preoperative imaging and intraoperative histopathology in our cohort totaled $278 567.

CONCLUSION

Our study found that the diagnosis of Morton's neuroma could be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis.

LEVEL OF EVIDENCE

Level IV, retrospective case series.