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Kaufman C, Jahangiri Y, Otto B. Comparative Effectiveness of Cryoablation with Steroid and Lidocaine Versus Steroid and Lidocaine Alone for Treatment of Morton Neuroma: Protocol for a Randomized Controlled Trial. J Vasc Interv Radiol 2024; 35:767-769. [PMID: 38272113 DOI: 10.1016/j.jvir.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/27/2024] Open
Affiliation(s)
- Claire Kaufman
- Dotter Interventional Institute, Department of Interventional Radiology, Oregon Health & Science University, Portland, Oregon.
| | - Younes Jahangiri
- Division of Interventional Radiology, Corewell Health West Michigan, Grand Rapids, Michigan
| | - Bettricia Otto
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Cooper MT. Common Painful Foot and Ankle Conditions: A Review. JAMA 2023; 330:2285-2294. [PMID: 38112812 DOI: 10.1001/jama.2023.23906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Importance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment. Observations Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used. Conclusions and Relevance Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.
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Kim DH, Kim BS, Kim JH, Cho CH. Outcomes and complications after treatment for anteromedial facet fracture of the coronoid process: A systematic review. J Orthop Sci 2023:S0949-2658(23)00315-9. [PMID: 37949770 DOI: 10.1016/j.jos.2023.11.002] [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: 08/31/2023] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Fracture of the anteromedial facet (AMF) of the coronoid process is associated with varus posteromedial rotatory instability (VPMRI). However, there is still controversy regarding the optimal treatment for AMF fracture. The purpose of this study is to report on a systematic review of the outcomes and complications after treatment for AMF fracture. METHODS This study was conducted using electronic databases, PubMed, EMBASE and Scopus. Studies reporting outcome scores and complications were included. Studies that did not utilize O'Driscoll classification for AMF fractures were excluded. Through conduct of a thorough review of included studies, definite VPMRI were identified and cases involving other injury mechanisms were excluded. RESULTS Fifteen articles reporting on 246 patients were included. According to O'Driscoll classification, 6.2% of cases were anteromedial subtype I, 73.7% were subtype II, and 20.1% were subtype III. Two-hundred sixteen patients (87.8%) were treated surgically and 30 patients (12.2%) were treated conservatively. Lateral collateral ligament (LCL) injuries were 76.2% (157/206) and medial collateral ligament injuries were 16.9% (33/195). Among 216 cases who underwent surgical treatment, depending on the fragment size, displacement, and instability, coronoid fixation was performed in 189 cases and LCL repair alone was performed in 27 cases. The mean final Mayo Elbow Performance Score was 92.1 and the Broberg & Morrey score was 89.5. The overall complication and reoperation rates were 17.7% (41/232) and 12.9% (26/202). CONCLUSIONS Both surgical and conservative treatment for AMF fractures resulted in satisfactory final clinical outcomes. However, high complication and reoperation rates were observed.
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Affiliation(s)
- Du-Han Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | - Ji-Hoon Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea.
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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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Burke CJ, Walter WR, Adler RS. Interventional Imaging Techniques as Alternative to Surgery of the Foot and Ankle. Semin Musculoskelet Radiol 2022; 26:744-754. [PMID: 36791742 DOI: 10.1055/s-0042-1760120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
A variety of foot and ankle pathologies can impair patient's daily activities, ultimately requiring surgical management. However, with improvements in image-guided intervention, the joints, soft tissues, and osseous structures may be accessible using various percutaneous techniques as a potential alternative therapeutic tool, avoiding the need for surgery with its associated risks and morbidity. This article discusses the potential range of image-guided interventional treatments. Injections, aspiration, biopsies, cryoablation, and radiofrequency ablation are described. Newer novel treatments are also covered. Finally, the common pathologies of Morton's neuroma, Achilles tendinopathy, and plantar fasciitis are addressed.
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Affiliation(s)
- Christopher J Burke
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
| | - William R Walter
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
| | - Ronald S Adler
- Department of Radiology, NYU Langone Orthopedic Center, Center for Musculoskeletal Care, New York, New York
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Long-term comparison between blind and ultrasound-guided corticoid injections in Morton neuroma. Eur Radiol 2022; 32:8414-8422. [PMID: 35726101 DOI: 10.1007/s00330-022-08932-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up. METHODS This is an evaluator-blinded randomised trial in which 33 patients with MN were injected by an experienced orthopaedic surgeon based on anatomical landmarks (blind injection, group 1) and 38 patients were injected by an experienced musculoskeletal radiologist under US guidance (group 2). Patients were assessed using the visual analogue scale and the Manchester Foot Pain and Disability index (MFPDI). Injections consisted of 1 ml of 2% mepivacaine and 40 mg triamcinolone acetonide in each web space with MN. Up to 4 injections were allowed during the first 3 months of follow-up. Follow-up was performed by phone calls and/or scheduled consultations at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1, 2 and 3 years. Statistical analysis was performed using unpaired Student's t tests. RESULTS No differences in age or clinical measures were found at presentation between group 1 (VAS, 8.5 ± 0.2; MFPDI, 40.9 ± 1.1) and group 2 (VAS, 8.4 ± 0.2; MFPDI, 39.8 ± 1.2). Improvement in VAS was superior in group 2 up to 3 years of follow-up (p < 0.05). Improvement in MFPDI was superior in group 2 from 45 days to 2 years of follow-up (p < 0.05). Satisfaction with the treatment was higher in group 2 (87%) versus group 1 (59.1%) at 3 years of follow-up. CONCLUSION Ultrasound-guided injections lead to a greater percentage of long-term improvement than blind injections in MN. KEY POINTS • Ultrasound-guided corticosteroid injections in Morton neuroma provide long-term pain relief in more than 75% of patients. • Ultrasound-guided injections in Morton neuroma led to greater long-term pain relief and less disability than blind injections up to 3 years of follow-up. • The presence of an ipsilateral neuroma is associated with worse long-term disability score.
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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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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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