Morton's Neuroma Excision: What Are We Really Doing? Which Retractor Is Superior?

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.

Study of the Anatomical Association between Morton’s Neuroma and the Space Inferior to the Deep Transverse Metatarsal Ligament Using Ultrasound

Morton’s neuroma (MN) is a common condition in clinical practice. The compressive etiology is the most accepted, in which compression occurs in the tunnel formed by the adjacent metatarsals, the deep transverse metatarsal ligament (DTML) and the plantar skin. Ultrasound (US) is a reliable method of study. The presence of insufficient space under the DTML may be related to the appearance of MN. Objectives: To verify the relationship between MN and the space under the DTML between the metatarsal heads of the third (M3) and the fourth (M4) metatarsals using US. Methods: This is a cross-sectional epidemiological study. The research study using the ultrasound (US) technique was carried out on 200 feet belonging to 100 patients aged 18 to 65 of both sexes, with a control group formed by 62 patients and a study group formed by 38 patients diagnosed with MN. Results: The presence of MN and the factors associated with it were studied in 100 patients using ultrasound (US). The assessment and comparison with US of the space inferior to the DTML between M3 and M4 in control groups and patients with MN show that patients with MN have a smaller size in the variable “h” (height or distance DTML-plantar skin), in the variable “b” (base or intermetatarsal distance M3 and M4) and in the variable “s” (surface of the parallelogram “h” × “b”). The predictors of MN are a decrease in dimension “b” and an increase in weight. Sitting in an office chair and the use of a bicycle, due to equinus, have an influence on the space below the DTML, reducing it and promoting the appearance of MN. Conclusions: The two US measurements (“h” and “b”) in the space below the DTML are smaller in patients with MN than in the asymptomatic group. A shorter distance between M3 and M4, and an increase in BMI are predictors of MN.