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Plastic and Reconstructive Surgery.... Jan 2022Morton's neuroma (MN) is a painful, proliferative fibrosis of perineural tissue caused by pressure or recurrent irritation that was previously thought to affect only the...
Morton's neuroma (MN) is a painful, proliferative fibrosis of perineural tissue caused by pressure or recurrent irritation that was previously thought to affect only the common interdigital nerve of the foot. We present a case of a bilateral MN of both the ulnar and radial proper digital nerves of the fifth finger in a 30-year-old patient, following multiple surgeries on the aforementioned finger. The patient was referred to our center by a peripheral hospital after traumatic fingertip amputation distal the DIP joint, where the fingertip was initially simply sutured. Because of progressive neuropathic pain, he underwent two revision surgeries, in which the distal phalanx was removed, two neuromas were excised, and the nerve stumps were shortened, but both were unsuccessful. A final, more extensive revision surgery was then carried out, in which two club-like enlargements were excised and the nerve stumps coadapted to form a loop. Histopathological examination of the excised specimen revealed perineural fibrosis in the context of a Morton's neuroma. This is, to our knowledge, the first documented case of a bilateral MN of the hand, which may have resulted from an inadequate primary finger and nerve shortening, resulting in high pressure from the surrounding soft tissue. Finally, this report emphasizes the significance of optimal treatment for finger amputation injuries, as well as the fact that for neuromas, simple nerve resection should be avoided whenever possible, because of the high recurrence rates.
PubMed: 35186616
DOI: 10.1097/GOX.0000000000004035 -
Radiologia May 2016We aim to describe imaging-guided (ultrasound and CT) interventional techniques in the musculoskeletal system that can be performed by general radiologists, whether in...
We aim to describe imaging-guided (ultrasound and CT) interventional techniques in the musculoskeletal system that can be performed by general radiologists, whether in hospitals, primary care clinics, private offices, or other settings. The first requirement for doing these procedures is adequate knowledge of the anatomy of the musculoskeletal system. The second requirement is to inform the patient thoroughly about the technique, the risks involved, and the alternatives available in order to obtain written informed consent. The third requirement is to ensure that the procedure is performed in accordance with the principles of asepsis in relation to the puncture zone and to all the material employed throughout the procedure. The main procedures that can be done under ultrasound guidance are the following: fine needle aspiration cytology (FNAC), core needle biopsy (CNB), diagnostic and/or therapeutic arthrocentesis, drainage of juxta-articular fluid collections, drainage of abscesses, drainage of hematomas, treatment of Baker's cyst, treatment of ganglia, treatment of bursitis, infiltrations and treatment of plantar fasciitis, plantar fibrosis, epicondylitis, Achilles tendinopathy, and Morton's neuroma, puncture and lavage of calcifications in calcifying tendinopathy. We also review the following CT-guided procedures: diagnosis of spondylodiscitis, FNAC of metastases, arthrography, drainages. Finally, we also mention more complex procedures that can only be done in appropriate settings: bone biopsies, treatment of facet joint pain, radiofrequency treatment.
Topics: Biopsy, Needle; Humans; Image-Guided Biopsy; Musculoskeletal Diseases; Radiology, Interventional; Surgery, Computer-Assisted; Tomography, X-Ray Computed; Ultrasonography, Interventional
PubMed: 27134018
DOI: 10.1016/j.rx.2016.03.005 -
Acta Bio-medica : Atenei Parmensis May 2020Civinini 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.... (Review)
Review
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.
Topics: Conservative Treatment; Equipment Design; Humans; Morton Neuroma; Orthotic Devices; Shoes; Syndrome; Treatment Outcome
PubMed: 32555077
DOI: 10.23750/abm.v91i4-S.9713 -
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 Anatomy Nov 2015This study evaluates the pathogenetic role of the perineural connective tissue and foot fasciae in Civinini-Morton's neuroma. Eleven feet (seven male, four female; mean...
This study evaluates the pathogenetic role of the perineural connective tissue and foot fasciae in Civinini-Morton's neuroma. Eleven feet (seven male, four female; mean age: 70.9 years) were dissected to analyse the anatomy of inter-metatarsal space, particularly the dorsal and plantar fasciae and metatarsal transverse ligament (DMTL). The macrosections were prepared for microscopic analysis. Ten Civinini-Morton neuromas obtained from surgery were also analysed. Magnetic resonance images (MRIs) from 40 patients and 29 controls were compared. Dissections showed that the width of the inter-metatarsal space is established by two fibrous structures: the dorsal foot fascia and the DMTL, which, together, connect the metatarsal bones and resist their splaying. Interosseous muscles spread out into the dorsal fascia of the foot, defining its basal tension. The common digital plantar nerve (CDPN) is encased in concentric layers of fibrous and loose connective tissue, continuous with the vascular sheath and deep foot fascia. Outside this sheath, fibroelastic septa, from DMTL to plantar fascia, and little fat lobules are present, further protecting the nerve against compressive stress. The MRI study revealed high inter-individual variability in the forefoot structures, although only the thickness of the dorsal fascia represented a statistically significant difference between cases and controls. It was hypothesized that alterations in foot support and altered biomechanics act on the interosseous muscles, increasing the stiffness of the dorsal fascia, particularly at the points where these muscles are inserted. Chronic rigidity of this fascia increases the stiffness of the inter-metatarsal space, leading to entrapment of the CDPN.
Topics: Adult; Aged; Case-Control Studies; Collagen; Fascia; Female; Foot Diseases; Humans; Immunohistochemistry; Magnetic Resonance Imaging; Male; Metatarsus; Middle Aged; Neuroma; Radiography
PubMed: 26467241
DOI: 10.1111/joa.12371 -
Ochsner Journal 2016Morton neuroma is a compressive neuropathy of the plantar digital nerve. Several surgical approaches have been used to treat painful Morton neuroma, with each approach...
BACKGROUND
Morton neuroma is a compressive neuropathy of the plantar digital nerve. Several surgical approaches have been used to treat painful Morton neuroma, with each approach having distinct advantages and disadvantages. For this study, we used validated outcome assessment tools to retrospectively compare patient satisfaction with 2 approaches.
METHODS
The medical records and survey responses of 37 patients with 42 neuromas were evaluated with respect to outcomes and patient satisfaction after neurectomies performed through either a plantar or dorsal surgical approach by one Ochsner Clinic Foundation attending physician. Outcomes were evaluated using the 36-Item Short Form Health Survey (SF-36) and the Foot Function Index (FFI) self-assessments.
RESULTS
Twenty patients underwent neurectomy through a dorsal approach, and 17 patients underwent neurectomy through a plantar approach. We found no statistically significant differences between the dorsal and plantar approach groups with respect to outcomes and patient satisfaction as measured by the SF-36 or the FFI.
CONCLUSION
This study supports the use of either the plantar or dorsal approach for the resection of Morton neuroma and suggests that a plantar approach for neurectomy can produce satisfactory results.
PubMed: 27999504
DOI: No ID Found -
Journal of Orthopaedics and... Sep 2013Among 101 feet that presented with symptoms and signs similar to Morton's neuroma, intermetatarsal rheumatoid nodules were found in five feet (three patients). Two...
Among 101 feet that presented with symptoms and signs similar to Morton's neuroma, intermetatarsal rheumatoid nodules were found in five feet (three patients). Two patients had bilateral involvement. Histology of the excised tissue showed the presence of a rheumatoid nodule and Morton's neuroma in four feet and a rheumatoid nodule with unremarkable nerve bundles in one. A rheumatoid nodule can coexist with Morton's neuroma, as seen in our patients, and the presentation is often similar to that of a Morton's neuroma. Our patients were rendered asymptomatic with surgical treatment and went on to have appropriate management of rheumatoid arthritis. Rheumatoid nodule should be considered in the differential diagnosis of Morton's neuroma in not only rheumatoid arthritis patients but also asymptomatic patients who have never been tested for rheumatoid antibodies.
Topics: Acute Pain; Adult; Biopsy; Diagnosis, Differential; Female; Humans; Neuroma; Peripheral Nervous System Neoplasms; Rheumatoid Nodule
PubMed: 23135058
DOI: 10.1007/s10195-012-0215-x -
Advances in Clinical and Experimental... 2016Morton's neuroma, a painful enlargement of the plantar digital nerve between the metatarsal heads, is a common cause of metatarsalgia. The etiology and treatment are...
BACKGROUND
Morton's neuroma, a painful enlargement of the plantar digital nerve between the metatarsal heads, is a common cause of metatarsalgia. The etiology and treatment are still a controversial matter.
OBJECTIVES
The objective of this study was to evaluate the long-term follow-up results of neurectomy through a dorsal approach and to identify prognostic factors that can affect the final outcome.
MATERIAL AND METHODS
The study included 41 patients who were treated for Morton's neuroma. Their average age was 44 years (range: 25-69 years). The average follow-up time was 7.4 years (range: 5-12 years). Surgery was performed through a dorsal approach. The clinical evaluations, visual analog scale (VAS) scores and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed.
RESULTS
The mean preoperative AOFAS score was 39.4 ± 7.84 and the mean postoperative AOFAS score was 83.4 ± 12.1. The mean preoperative VAS scale was 7.04 ± 1.4 and the mean postoperative VAS scale was 1.4 ± 0.8. There were 31 patients (76%) with very good results in the subjective and objective patient assessments; six (15%) had good results; one (2%) had satisfactory results and three (7%) had poor results. Statistically significant differences in the results between single and multiple neuromas were found, depending on the size of the neuromas and the duration of the symptoms. There were no statistically significant differences depending on the time between surgery and assessment, on steroid injections before operation or on the duration of preoperative conservative treatment.
CONCLUSIONS
Despite the development of less invasive techniques and very good outcomes in a short period of time, long-term results have shown that neurectomy is still useful in the treatment of Morton's neuroma. The results of the study show that the outcome does not change during the postoperative follow-up period. The best results were achieved in the case of single neuromas larger than 3 mm that were resected within 12 months of the onset of symptoms.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Morton Neuroma; Neurologic Examination; Neurosurgical Procedures; Pain Measurement; Recovery of Function; Tibial Nerve; Time Factors; Treatment Outcome
PubMed: 27627563
DOI: 10.17219/acem/60249 -
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 -
Zeitschrift Fur Rheumatologie Apr 2022The goal was to assess public interest in a wide range of musculoskeletal symptoms and disorders during the coronavirus disease 2019 (COVID-19) pandemic.
OBJECTIVE
The goal was to assess public interest in a wide range of musculoskeletal symptoms and disorders during the coronavirus disease 2019 (COVID-19) pandemic.
METHODS
We searched Google Trends for 118 search queries within the United States. We compared two timeframes of 2020 (March 15-July 4 and July 5-October 31) to similar timeframes over the four prior years (2016-2019).
RESULTS
In the early pandemic, March 15-July 4, a statistically significant decrease in relative search volume of the majority of queries (60%) was detected, with a significant increase in only 2 queries (i.e. myalgia and toe swelling). In the phase July through October, a statistically significant decrease was detected in only 22% of search queries; there was no difference for 60% of search queries between 2020 and 2016-2019 suggesting a return to their prior levels for most of search queries. Interestingly, the search volume of 18% of search queries (i.e. fatigue, joint pain, muscle pain, myalgia, spondylosis, radiculopathy, myelopathy, neck pain, neck strain, lower back strain, sciatica, shoulder pain, frozen shoulder, elbow pain, lateral epicondylitis, wrist pain, carpal tunnel, hand pain, finger pain, trigger finger, and Morton's neuroma) was significantly increased compared with the four prior years.
CONCLUSION
Public interest focused on COVID-19 and sought online information for COVID-19 symptoms in the early pandemic. In the period July through October, there was an upward trend in musculoskeletal symptoms and some colloquial terms/well-known musculoskeletal conditions coupled with a downward trend in general musculoskeletal disorder terms and certain specific diagnoses. This information may help rheumatologists understand public interest in musculoskeletal symptoms and disorders and address the needs of patients to mitigate the negative impact of the pandemic on outcomes.
Topics: COVID-19; Humans; Infodemiology; Musculoskeletal Diseases; Pandemics; Search Engine; United States
PubMed: 33779835
DOI: 10.1007/s00393-021-00989-2