SLR - January 2024 - Dieu
Title: Effect of surgical approach on the treatment of Morton’s neuroma: a systematic review and meta-analysisReference: Zhang, J., Li, J., Cai, W. et al. Effect of surgical approach on the treatment of Morton’s neuroma: a systematic review and meta-analysis. J Foot Ankle Res 16, 57 (2023).
Level of Evidence: 2
Scientific Literature Review
Reviewed By: Viet Dieu, DPM
Residency Program: MetroWest Medical Center
Podiatric Relevance: The surgical approaches for a Morton’s neuroma removal has been still a remaining controversy. Each approach has its advantages and disadvantages but there is no compromise on the choice of approach. This study compared these approaches in terms of surgical results, including clinical outcomes and complications.
Methods: A systematic review, using PRSIMA, was performed while using the literatures of PubMed, Cochrane Library, Embase and Web of Science. Inclusion criteria: surgical excision of Morton’s neuromas; The objective was to compare the two approaches, including randomized controlled trials (RCTs) and other types of clinical comparative studies; The patients > 18 years old; Limited to English publications. Exclusion criteria: Abstracts, reports, comments, expert opinions or incomplete published articles; Republishing; The data could not be compared or extracted. The number of patients or the publication year were both unrestricted. Postoperative functional scores such as visual analogue scale (VAS) scores and American Orthopedic Foot and Ankle Society (AOFAS) scores and number of complications were collected. The Cochrane Collaboration tool was used in the assessment of RCTs. The Methodological Index for Non-Randomized Studies with adequate agreement (87.2%) was employed to evaluate the quality and risk of bias. Those comparative studies were rated according to 8 categories. Each category was scored on a scale of 0 to 2 with a possible total score of 16. RevMan 5.4 software was utilized to analyze and calculate the 95% confidence interval and odds ratio. Heterogeneity was tested with I2 and the chi-squared metric.
Results: Only 7 articles conducted a comparative study of approaches, 2 of which were not included. There was a total of 347 feet with the diagnosis of Morton’s neuroma, of which 158 feet underwent the plantar approach and 189 underwent the dorsal approach. In this study, there were no significant differences between the dorsal and plantar approaches, in terms of neurological issues, incision site infections, and deep vein thrombosis. However, the plantar approach had a higher incidence of scarring than the dorsal approach (OR, 2.90 [95%CI, 1.40 to 5.98]; p=0.004). The VAS scores and AOFAS scores were difficult to measure in comparison for this systematic review.
Conclusions: The authors displayed that both approaches displayed similar results, in terms of the complications and clinical outcomes. Limitations of this study included the smaller sample size for meta-analysis and difficulties with the postoperative scores. The dorsal approach allows earlier weight bearing and greater visualization, but there is inadequate resection of the neuroma and damage to the webspace’s cutaneous nerves and deep transverse intermetatarsal ligament to attain better access. The plantar approach allows better access to the neuroma without ligament incision, but the risk of wound dehiscence and plantar scarring is possible. The decision on which different approach is appropriate for Morton’s neuroma surgery is still under investigation due to the similar results that it presents. Unless proven otherwise, the approach for Morton’s neuroma surgery is based on surgeon preference and patient parameters.