SLR - June 2012 - Eric J. Lew
Reference: Nery C, Raduan F, Buono A, Asaumi I, Maffulli N, Plantar Approach for Excision of a Morton Neuroma: A long-Term Follow-up Study. The Journal of Bone and Joint Surgery. 2012; 94:654-658
Scientific Literature Review
Reviewed by: Eric J. Lew, DPM
Residency Program: Cleveland Clinic/Kaiser-Permanente
Podiatric Relevance:
A Morton neuroma is a multifactorial paroxysmal neuralgia to the third plantar web space that is commonly encountered by the foot and ankle physician. When non-surgical management of this lesion is unsuccessful, neurectomy is indicated. Several studies advocate a dorsal versus plantar longitudinal surgical approach. This study investigates the long-term outcomes, complications, and adverse events following neuroma excision through a distal transverse plantar incision.
Methods:
The study design consisted of a retrospective review of 168 consecutive patients who underwent surgical excision of a Morton neuroma. Inclusion criteria included patients who were refractory to non-operative treatment with symptoms consisting of pain and functional impairment. MRI was performed on all patients and diagnosis was confirmed with histological analysis. Operative technique was performed by the senior author utilizing a transverse plantar skin incision distal to the metatarsal head weight-bearing area. Postoperatively, a clinical examination and functional evaluation were performed by a single examiner who was not involved in the surgery using a three-step ordinal scale.
Results:
A total of 227 neuromas were excised from 160 patients with histological confirmation. The median age at the time of surgery was 52 + 12.5 years with the right foot involved in 21.3 percent (34 patients) of cases, and the left foot involved in 51.3 percent (82 patients). The median duration of follow-up was 7.1 + 3.9 years and return to regular activity was allowed at a median of 40 days. A good result was reported for 143 patients (89.4 percent), a fair result for eleven (6.9 percent), and a poor result for six (3.8 percent). The 11 patients with a fair result had no recurrence of the neuroma, however, reported scar-related symptoms such as skin hardening, loss of sensation at the incision site, discomfort wearing high-heeled shoes and local paresthesias. The six patients with a poor result reported persistent pain and paresthesias. They underwent reoperation at which time recurrence of a neuroma was confirmed histologically. Patients who were surgically treated for concomitant foot and ankle disorders displayed no significant differences in clinical outcomes versus those who underwent neurectomy alone. In addition, there was no significant clinical outcome between patients who had single neuroma excisions versus those who had multiple neuroma excisions.
Conclusions:
In this retrospective study, a distal transverse plantar incision provided marked reduction in pain and high overall patient satisfaction, as well as a low rate of complications. A weakness of this study was that no validated scores were used to assess outcomes. The study also lacks a control group for comparison. However, results of this study were at least comparable to studies evaluating other surgical approaches for the surgical treatment of a Morton neuroma.