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JBJS Essential Surgical Techniques 2023Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of...
BACKGROUND
Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.
DESCRIPTION
Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.
ALTERNATIVES
Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial. The results of these techniques have varied, and none has gained clinical superiority over the other.
RATIONALE
A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to the previously discussed methods of resection. That study by Gould et al. found that 85% of patients had a substantial reduction in pain, with mean visual analog scale (VAS) pain scores reducing from 8 to 10 preoperatively to 0 to 4 postoperatively. Moreover, alternative biological conduits, such as the greater saphenous vein, have proven to be costly in time and resources, as this structure is often utilized in cardiovascular bypass surgery and its harvest conveys a risk of iatrogenic nerve injury to the patient.Numerous studies focusing on excision of recurrent Morton neuromas via a plantar approach have found variable success rates. Of the patients surveyed in those studies, 75% reported substantial pain improvement. However, <50% of these queried patients reported complete pain relief. Studies analyzing the dorsal approach for revision Morton neuroma excision found similar success rates. Approximately 78% of patients reported good or excellent postoperative outcomes, and significant improvements were observed in patient postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores for pain interference, intensity, and global physical health. One study comparing outcomes following plantar versus dorsal approaches for recurrent Morton neuroma found no significant difference in postoperative patient outcomes. That study suggested that surgeons utilize the approach with which they are most comfortable. Gould et al. reported an 85% success rate with collagen conduit, which was similar to if not slightly improved compared with the other prior studies. The utilization of a collagen conduit technique thus offers comparable patient outcomes for patients with difficult neuromas.
EXPECTED OUTCOMES
Recurrent neuroma resection with the use of a collagen conduit has proven to provide satisfactory patient outcomes regarding pain and neuritis symptoms. The goal of any neuroma resection is to greatly diminish or entirely eliminate nerve pain. Based on the available evidence, there has been no proven clinical superiority of any particular technique over the others. However, in the present example case, the location of the patient's neuroma in this video makes it 85% likely that the patient will report satisfactory outcomes and 50% likely that the patient will be entirely symptom-free. At two weeks postoperatively, the patient reported well controlled pain, absence of burning or tingling sensation, full range of movement in the foot, and intact sensation throughout all major nerve distributions, including the saphenous; superficial peroneal nerve; deep peroneal nerve; and sural, medial, and lateral plantar nerves. However, sensation is absent distal to the site of a neuroma resection.
IMPORTANT TIPS
Careful preoperative planting is of utmost importance.Ruling out other potential pathologies is necessary to ensure proper outcomes.Meticulous dissection should be carried out, with delicate handling of the proximal nerve ending.Excision of the nerve should be done sharply through the healthy portion of the nerve.Appropriate sizing of the nerve conduit (with a commercially available industry sizer) should be performed.The nerve conduit should be passed dorsally and secured to the dorsal fascia without any tension.
ACRONYMS AND ABBREVIATIONS
MRI = magnetic resonance imagingUS = ultrasoundVAS = visual analog scale.
PubMed: 38357467
DOI: 10.2106/JBJS.ST.22.00065 -
Journal of Ultrasonography Oct 2023Radiography is the appropriate initial imaging modality to assess for midfoot and forefoot pathology before turning to advanced imaging techniques. While most lesions of...
Radiography is the appropriate initial imaging modality to assess for midfoot and forefoot pathology before turning to advanced imaging techniques. While most lesions of the mid- and forefoot can be diagnosed clinically, the exact nature and severity of the pathology is often unclear. This review addresses the use of the ultrasound, as well as the added value of magnetic resonance imaging, in diagnosing conditions of the midfoot and forefoot. Ultrasound allows a dynamic assessment as well as enabling imaging-guided interventions for diagnostic and therapeutic purposes. Practical tips for optimal examination of this area with ultrasound and magnetic resonance imaging are provided. Metatarsal stress fracture, Chopart's injury, Lisfranc injury, as well as the 1 metatarsophalangeal joint injury and lesser metatarsophalangeal plantar plate injury are injuries unique to the mid- and forefoot. The imaging anatomy of the 1 and lesser metatarsophalangeal joints is reviewed, as such knowledge is key to correctly assessing injury of these joints. Characteristic imaging features of masses commonly encountered in the mid- and forefoot, such as ganglion cyst, Morton neuroma, gouty tophus, plantar fibroma, foreign body granuloma, and leiomyoma are reviewed. The use of ultrasound and magnetic resonance imaging in assessing degenerative and inflammatory joint disorders, and in particular rheumatoid arthritis, of the mid- and forefoot region is also reviewed. In summary, when necessary, most lesions of the mid-and forefoot can be adequately assessed with ultrasound, supplemented on occasion with radiographs, computed tomography, or magnetic resonance imaging.
PubMed: 38020514
DOI: 10.15557/jou.2023.0033 -
Journal of Foot and Ankle Research Sep 2023Surgical 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... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Humans; Morton Neuroma; Consensus; Lower Extremity; Orthopedics; Software
PubMed: 37674248
DOI: 10.1186/s13047-023-00660-w -
Heliyon Aug 2023Morton's neuroma (MN) is a compressive neuropathy of the common digital plantar nerve causing forefoot pain. Foot posture and altered plantar pressure distribution have...
Morton's neuroma (MN) is a compressive neuropathy of the common digital plantar nerve causing forefoot pain. Foot posture and altered plantar pressure distribution have been identified as predispoing factors, however no studies have compared individuls with different foot postures with MN. Thus, we aimed to compare the effect of MN on spatiotemporal gait parameters and foot-pressure distribution in individuals with pes planus and pes cavus. Thirty-eight patients with unilateral MN were evaluated between June and August 2021. Nineteen patients with bilateral pes planus and 19 age and gender-matched patients with pes cavus who had no prior surgery were recruited. A Zebris FDM-THM-S treadmill system (Zebris Medical GmbH, Germany) was used to evaluate step length, stride length, step width, step time, stride time, cadence, velocity, foot-pressure distribution, force and whole stance phase, loading response, mid stance, pre-swing and swing phase percentages. There were no significant differences between the groups in spatiotemporal gait parameters (p > 0.05). Patients with pes planus displayed the following results for step length (49.36 ± 8.38), step width (9.05 ± 2.12), stance phase percentage (65.92 ± 2.11), swing phase percentage (34.08 ± 2.12), gait speed (2.96 ± 0.55), and cadence (100.57 ± 8.84). In contrast, patients with pes cavus displayed the following results for step length (49.06 ± 8.37), step width (8.10 ± 2.46), stance phase percentage (64.96 ± 1.61), swing phase percentage (34.79 ± 1.60), gait speed (2.95 ± 0.65), and cadence (99.73 ± 13.81). Foot-pressure distribution values showed no differences were detected in force, forefoot, and rearfoot pressure distribution, except for midfoot force (p < 0.05). The forefoot, midfoot, and rearfoot pressure values for the pronated group were 32.14 ± 10.90, 13.80 ± 3.03, and 22.78 ± 5.10, and for the supinated group were 33.50 ± 11.49, 14.23 ± 3.11 and 24.93 ± 6.52. MN does not significantly affect spatiotemporal gait parameters or foot-pressure distribution in patients with pes cavus or pes planus.
PubMed: 37636349
DOI: 10.1016/j.heliyon.2023.e19111 -
Journal of Clinical Medicine Jul 2023Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly affecting the third inter-digital space. The conservative approach...
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.
PubMed: 37510755
DOI: 10.3390/jcm12144640 -
Radiology Case Reports Jul 2023A 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...
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. 4.
PubMed: 37214324
DOI: 10.1016/j.radcr.2023.04.001 -
Journal of Hand Surgery Global Online Jan 2023Painful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that...
PURPOSE
Painful neuromas commonly cause neuropathic pain, in up to 1 in 20 cases of traumatic or iatrogenic nerve injury. Despite the multiple surgical treatment types that reduce pain, no type has been universally accepted.
METHODS
We performed a retrospective cohort study by administering follow-up surveys to all surgical patients treated in our department for lower-extremity neuroma from September 1, 2015, to October 22, 2021, that could be contacted, excluding those with Morton neuroma. In addition to the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) questionnaire, survey questions covered the time to pain reduction, use of physical or occupational therapy, and characteristics of the pain. When available, previously collected preoperative and postoperative PROMIS PI data were used for patients who could not be contacted for the telephone survey. Paired-sample nonparametric testing was used to compare preoperative and postoperative PROMIS PI scores.
RESULTS
Initial query in the medical record by Current Procedural Terminology codes yielded 1,812 patients for chart review, of whom 33 were eligible to call. In total, 9 (27%) patients completed both preoperative and postoperative PROMIS PIs: 6 (18.2%) completed full telephone surveys and 3 (9.1%) had preoperative and postoperative PROMIS PI data in the chart review but could not be contacted for the full telephone survey. Four of the 6 telephone-survey respondents reported pain reduction within 12 months of their surgery. Wilcoxon signed-rank testing demonstrated a moderate but nonstatistically significant reduction in PROMIS PI scores, with a median difference of -4.85 ( = .1; 95% CI -12 to 1.2).
CONCLUSIONS
There were notable improvements in our cohort, but larger studies are needed to determine whether surgical treatment of lower-extremity neuroma results in a clinically important and significant difference in PROMIS PI scores, as well as to discern the advantages each treatment.
TYPE OF STUDY/LEVEL OF EVIDENCE
Therapeutic IV.
PubMed: 36704377
DOI: 10.1016/j.jhsg.2022.03.005 -
Diagnostics (Basel, Switzerland) Jan 2023Intermetatarsal bursitis (IMB) is an inflammation of the intermetatarsal bursas. The condition causes forefoot pain with symptoms similar to those of Morton's neuroma... (Review)
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 ( = 3), studies of patients with metatarsalgia ( = 10), and studies of patients with rheumatic diseases ( = 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.
PubMed: 36673020
DOI: 10.3390/diagnostics13020211