Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma

2019 ◽  
Vol 40 (9) ◽  
pp. 1032-1036 ◽  
Author(s):  
Tammer Raouf ◽  
Ryan Rogero ◽  
Elizabeth McDonald ◽  
Daniel Fuchs ◽  
Rachel J. Shakked ◽  
...  
Keyword(s):  
Case Series ◽  
Postoperative Treatment ◽  
Preoperative Imaging ◽  
Pathology Report ◽  
Morton’S Neuroma ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Imaging Results ◽  
Histopathologic Diagnosis ◽  
Morton's Neuroma

Background: Recent studies have demonstrated that clinical diagnosis of Morton’s neuroma is highly correlated with operative and histopathologic diagnosis, whereas others have questioned the cost-effectiveness of intraoperative histopathology of excised specimens. The purpose of this study was to determine the utility of both preoperative imaging and intraoperative histology in the treatment of Morton’s neuroma in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes. Methods: A retrospective review was performed on all patients who underwent operative resection suspected Morton’s neuroma with 4 fellowship-trained foot and ankle surgeons between 2007 and 2017. Procedures were excluded from the study if the pathology report was not available for review. Diagnoses were made either by clinical examination and/or by the results of preoperative imaging. All pathology reports were reviewed to determine the final diagnosis, considered the “gold standard.” Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton’s neuroma. Two hundred eighty-seven procedures in 269 patients with 313 clinically suspected neuromas met inclusion criteria. Results: Of the 313 suspected neuromas, 309 (98.7%) were confirmed Morton’s neuromas on histopathologic examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179 (57.2%) suspected neuromas, with magnetic resonance imaging (MRI) and ultrasonography used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 using both. The total estimated cost of histopathologic analysis for the cohort was $143 667, and the estimated combined cost of preoperative imaging and intraoperative histopathology in our cohort totaled $278 567. Conclusion: Our study found that the diagnosis of Morton’s neuroma could be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis. Level of Evidence: Level IV, retrospective case series.

Ultrasound Guided Alcohol Ablation of Morton's Neuroma

2012 ◽  
Vol 33 (3) ◽  
pp. 196-201 ◽  
Author(s):  
Rachel E. Musson ◽  
Jasdev S. Sawhney ◽  
Leslie Lamb ◽  
Antony Wilkinson ◽  
Haron Obaid
Keyword(s):  
Case Series ◽  
Visual Analogue Score ◽  
Safe Procedure ◽  
Ultrasound Guided ◽  
Morton’S Neuroma ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Alcohol Injection ◽  
Alcohol Ablation ◽  
Morton's Neuroma

Background: Morton's neuroma is a common cause of metatarsalgia. This study evaluated the efficacy of ultrasound guided alcohol injection as a treatment for this condition. Method: Data from 87 treatment courses were included in this study with a mean follow of 14.3 months. Results: Technical success was 100%. One patient developed symptoms consistent with an allergic reaction to the injection and one patient declined further injection because of periprocedural pain. Partial or total treatment response was achieved in 66%, with 32% of patients having complete resolution of pain. The median visual analogue score (VAS) decreased from 8 pre-procedure to 4 post-procedure ( p < 0.0001). Procedural success was greater in patients under 55 years old and in those with solitary neuromas. Seventeen patients (20%) went on to have surgery due to continuing pain. Conclusion: Ultrasound guided alcohol ablation for the treatment of Morton's neuroma was a safe procedure that significantly reduced pain and may offer an alternative therapy to surgery. Level of Evidence: IV; Retrospective Case Series

Interdigital Commissural Approach for Morton’s Neuroma

2020 ◽  
Vol 41 (10) ◽  
pp. 1226-1233
Author(s):  
Juan Manuel Yañez Arauz
Keyword(s):  
Minimally Invasive ◽  
Case Series ◽  
Complication Rates ◽  
Morton’S Neuroma ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Long Term Outcome ◽  
Significant Difference ◽  
Morton's Neuroma

Background: Morton’s neuroma is a frequent cause of metatarsalgia. Operative treatment is indicated if nonoperative management has failed. The objective of the present study was to describe a technique of Morton’s neuroma excision by a minimally invasive commissural approach and evaluate the long-term outcome and complications. Methods: A retrospective study of 108 patients with Morton’s neuroma treated surgically with a commissural approach between September 1990 and December 2010 was performed. The surgical technique is described. Clinical outcomes and complications were evaluated. The average follow-up was 121 months. Eleven patients were men and 97 women. The average age was 49.4 years; 56.8% neuromas were at the third space and 43.2% at the second space. Six patients presented 2 neuromas in the same foot, and 9 patients had bilateral neuroma. Results: The visual analog scale (VAS) average pain score was 5.4 points preoperatively and 0.2 points at the final follow-up. The author found a significant difference between the VAS scores preoperatively and postoperatively ( P < .01). Excellent and good satisfaction outcomes were achieved in 93.6%. The postoperative complication incidence was 3%. Conclusion: The author believes a minimally invasive commissural approach has advantages over a dorsal or plantar incision. It is a simple and reproducible technique, with satisfactory outcomes, low complication rates, and a quick return to usual activities. Level of Evidence: Level IV, retrospective case series.

scholarly journals The Value of Preoperative Imaging and Intraoperative Histopathology in Morton’s Neuroma

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0035
Author(s):  
Tammer Raouf ◽  
Ryan Rogero ◽  
Elizabeth McDonald ◽  
Daniel Fuchs ◽  
Rachel J. Shakked ◽  
...  
Keyword(s):  
Chart Review ◽  
Histopathological Examination ◽  
Postoperative Treatment ◽  
Preoperative Imaging ◽  
Pathology Report ◽  
Histopathological Diagnosis ◽  
Morton’S Neuroma ◽  
Pathologic Diagnosis ◽  
Morton's Neuroma ◽  
Pathology Reports

Category: Lesser Toes Introduction/Purpose: Morton’s neuroma is an interdigital abnormality of the nerve between the lesser metatarsal heads, most commonly between the third and fourth metatarsals. Recent studies have demonstrated that clinical diagnosis is highly correlated with intraoperative and histopathological diagnosis, and other studies have questioned the cost-effectiveness of intraoperative histopathology of an excised neuroma to confirm the diagnosis or rule out occult malignancy. The purpose of this study is to determine the utility of preoperative imaging and intraoperative histology in making an accurate diagnosis, guiding treatment decisions, and altering clinical outcomes. We also investigate the potential savings of a more streamlined diagnostic algorithm. Methods: A retrospective review was performed on all patients that underwent surgical resection of a suspected Morton’s neuroma with 4 fellowship-trained foot & ankle surgeons from 2007 to 2017. Patients were excluded from the study if the pathology report was not available for review. In all cases, chart review was undertaken to determine the method of initial diagnosis. Diagnoses were made either by the clinical examination of the operating surgeon and/or by the results of preoperative magnetic resonance imaging (MRI) and/or ultrasound. Operative reports were examined to determine if excised specimens were sent for histopathological analysis. All pathology reports were reviewed to determine the final diagnosis, considered the “gold standard”. Postoperative chart notes were reviewed to determine if any treatment regimen was altered based on the pathology report revealing an alternate diagnosis other than Morton’s neuroma. Results: Three-hundred twenty-seven patients with 354 clinically suspected neuromas were identified through retrospective chart review, and 287 patients with 313 clinically suspected neuromas met inclusion criteria. Of the 313 suspected neuromas with accompanying pathology reports, 309 (98.7%) were confirmed Morton’s neuroma upon histopathological examination. For no patient did the results of the pathology report alter the postoperative treatment course. Preoperative imaging results were available for 179/313 (57.2%) suspected neuromas, with MRI and ultrasound being used to preoperatively image 121 and 71 suspected neuromas, respectively, including 13 with both. The total estimated cost of pathological analysis at our institution for the 287 patients in our study was $131,733, and the potential total combined cost savings by eliminating preoperative imaging and intraoperative histopathology in our cohort totals $266,632. Conclusion: Our study demonstrates that the diagnosis of Morton’s neuroma can be made clinically with extreme accuracy and positive predictive value, calling into question the utility and costs of other imaging modalities and intraoperative sampling for histopathologic diagnosis. Furthermore, in only 4 cases did the pathologic diagnosis disagree with the diagnosis based on clinical exam and imaging, and in none did the pathologic diagnosis alter the course of treatment. Without more clear evidence that these modalities increase diagnostic accuracy, change the course of treatment, or improve patient care, we recommend that preoperative advanced imaging and histopathological examination not be routinely performed.

Ultrasound-Guided Hyaluronic Acid Injection for the Management of Morton’s Neuroma

2017 ◽  
Vol 39 (2) ◽  
pp. 201-204 ◽  
Author(s):  
Kang Lee ◽  
Il-Yeong Hwang ◽  
Chang Hyun Ryu ◽  
Jae Woo Lee ◽  
Seung Woo Kang
Keyword(s):  
Hyaluronic Acid ◽  
Case Series ◽  
Functional Improvement ◽  
X Rays ◽  
Ultrasound Guided ◽  
Morton’S Neuroma ◽  
Level Of Evidence ◽  
Hyaluronic Acid Injection ◽  
Acid Injection ◽  
Morton's Neuroma

Background: Morton’s neuroma is one of the common causes of forefoot pain. In the present study, hyaluronic acid injection was performed on patients to determine the efficacy and adverse effects of hyaluronic acid in management of Morton’s neuroma. Methods: Eighty-three patients with Morton’s neuroma in their third intermetatarsal space with definite Mulder’s click were included in the study. Those with severe forefoot deformities such as forefoot cavus or hallux valgus on plain X-rays were excluded. Ultrasound-guided hyaluronic acid injections were performed on all patients weekly for 3 weeks. Pain during walking using visual analogue scale (VAS) and AOFAS Forefoot Scale were prospectively evaluated preinjection, and at 2, 4, 6, 12 months postinjection. Results: Significant improvement in VAS and AOFAS Forefoot Scale were seen overall at 2 months after hyaluronic acid injections ( P < .05). Then, there were almost no changes after 4 months, continuing until 12 months. The mean VAS was decreased from 73.1 initially to 23.0 at 12 months and AOFAS Forefoot Scale was increased from 32.2 to 86.5. There were no complications which occurred. Conclusion: In the present study, ultrasound-guided hyaluronic injection was clinically effective for pain relief and functional improvement for at least 12 months in patients with Morton’s neuroma. However, numbness associated with Morton’s neuroma should be addressed more cautiously since it may persist without much improvement. Level of Evidence: Level IV, retrospective case series.

scholarly journals Corticosteroid Injection for the Treatment of Morton’s Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

2017 ◽  
Vol 38 (9) ◽  
pp. 944-951 ◽  
Author(s):  
Xavier Lizano-Díez ◽  
Alberto Ginés-Cespedosa ◽  
Eduard Alentorn-Geli ◽  
Daniel Pérez-Prieto ◽  
Gemma González-Lucena ◽  
...  
Keyword(s):  
Local Anesthetic ◽  
Corticosteroid Injection ◽  
Controlled Trial ◽  
Case Series ◽  
Control Group ◽  
Placebo Control ◽  
Morton’S Neuroma ◽  
Level Of Evidence ◽  
Morton's Neuroma ◽  
And Function

Background: The effectiveness of corticosteroid injection for the treatment of Morton’s neuroma is unclear. In addition, most of the studies related to it are case-control or retrospective case series. The purpose of this study was to compare the effectiveness between corticosteroid injection associated with local anesthetic and local anesthetic alone (placebo control group) for the treatment of Morton’s neuroma. Methods: Forty-one patients with a diagnosis of Morton’s neuroma were randomized to receive 3 injections of either a corticosteroid plus a local anesthetic or a local anesthetic alone. The patients and the researcher who collected data were blinded to the treatment groups. The visual analog scale for pain and the American Orthopaedic Foot & Ankle Score (metatarsophalangeal/interphalangeal score) were obtained at baseline, after each injection, and at 3 and 6 months after the last injection. Results: There were no significant between-group differences in terms of pain and function improvement at 3 and 6 months after treatment completion in comparison with baseline values. At the end of the study, 17 (48.5%) patients requested surgical excision of the neuroma: 7 (44%) in the experimental group and 10 (53%) in the control group ( P = 1.0). Conclusion: The injection of a corticosteroid plus a local anesthetic was not superior to a local anesthetic alone in terms of pain and function improvement in patients with Morton’s neuroma. Level of Evidence: Level I, randomized controlled trial.

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton’s Neuroma: Short-term Results

2020 ◽  
pp. 193864002095785
Author(s):  
Mohamed Abdelaziz Elghazy ◽  
Kathryn C. Whitelaw ◽  
Gregory R. Waryasz ◽  
Daniel Guss ◽  
Anne H. Johnson ◽  
...  
Keyword(s):  
Case Series ◽  
Operative Management ◽  
Pain Scale ◽  
Morton’S Neuroma ◽  
Short Term ◽  
Level Of Evidence ◽  
Symptom Exacerbation ◽  
Morton's Neuroma ◽  
Neuroma Formation

Background Although the precise pathoetiology of Morton’s neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. Materials and methods Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton’s neuroma and who then underwent isolated IML decompression without neuroma resection. Results A total of 12 patients underwent isolated IML decompression for Morton’s neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. Conclusion Isolated IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. Level of Evidence: Level IV: Case series

Outcomes of Tibialis Anterior Tendon Reconstruction with Autograft or Allograft

2021 ◽  
pp. 107110072110299
Author(s):  
Octavian Andronic ◽  
Ines Unterfrauner ◽  
Lukas Jud ◽  
Benjamin Fritz ◽  
Arnd F. Viehöfer ◽  
...  
Keyword(s):  
Tibialis Anterior ◽  
Patient Reported Outcomes ◽  
Short Form ◽  
Case Series ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Tibialis Anterior Tendon ◽  
Imaging Results ◽  
Patient Reported ◽  
American Orthopaedic

Background: In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes. Methods: Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot. Results: Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side. Conclusion: Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions. Level of Evidence: Level IV, retrospective case series.

scholarly journals Lateral open wedge calcaneus osteotomy with bony allograft augmentation in adult acquired flatfoot deformity. Clinical and radiological results

2021 ◽  
Author(s):  
Gabriele Colo’ ◽  
Mattia Alessio Mazzola ◽  
Giulio Pilone ◽  
Giacomo Dagnino ◽  
Lamberto Felli
Keyword(s):  
Range Of Motion ◽  
Case Series ◽  
Deformity Correction ◽  
Tibialis Posterior ◽  
Open Wedge ◽  
Foot And Ankle ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Adult Acquired Flatfoot Deformity

Abstract The aim of this study is to evaluate the results of patients underwent lateral open wedge calcaneus osteotomy with bony allograft augmentation combined with tibialis posterior and tibialis anterior tenodesis. Twenty-two patients underwent adult-acquired flatfoot deformity were retrospectively evaluated with a minimum 2-year follow-up. Radiographic preoperative and final comparison of tibio-calcaneal angle, talo–first metatarsal and calcaneal pitch angles have been performed. The Visual Analog Scale, American Orthopedic Foot and Ankle Score, the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure were used for subjective and functional assessment. The instrumental range of motion has been also assessed at latest follow-up evaluation and compared with preoperative value. There was a significant improvement of final mean values of clinical scores (p < 0.001). Nineteen out of 22 (86.4%) patients resulted very satisfied or satisfied for the clinical result. There was a significant improvement of the radiographic parameters (p < 0.001). There were no differences between preoperative and final values of range of motion. One failure occurred 7 years after surgery. Adult-acquired flatfoot deformity correction demonstrated good mid-term results and low recurrence and complications rate. Level of evidence Level 4, retrospective case series.

Plafond Malreduction and Talar Dome Impaction Accelerates Arthrosis After Supination-Adduction Ankle Fracture

2021 ◽  
pp. 107110072110060
Author(s):  
Michael F. Githens ◽  
Malcolm R. DeBaun ◽  
Kimberly A Jacobsen ◽  
Hunter Ross ◽  
Reza Firoozabadi ◽  
...  
Keyword(s):  
Case Series ◽  
High Energy ◽  
Ankle Fractures ◽  
Posttraumatic Arthritis ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Radiographic Findings ◽  
Posttraumatic Arthrosis ◽  
Patient Reported

Background: Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis. Methods: A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented. Results: A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series. Conclusion: Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted. Level of Evidence: Level IV, retrospective case series.

Clinical Outcomes of Percutaneous Plantar Fasciotomy Using Microdebrider Coblation Wand

2019 ◽  
Vol 41 (2) ◽  
pp. 187-192
Author(s):  
Ricardo E. Colberg ◽  
Monte Ketchum ◽  
Avani Javer ◽  
Monika Drogosz ◽  
Melissa Gomez ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
Plantar Fasciitis ◽  
Case Series ◽  
Successful Outcome ◽  
Oral Steroid ◽  
Tarsal Tunnel ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Plantar Fasciotomy

Background: Plantar fasciitis is the most common cause of heel pain in adults. Multiple conservative treatment plans exist; however, some cases do not obtain significant clinical improvement with conservative treatment and require further intervention. This retrospective case study evaluated the success rate of percutaneous plantar fasciotomy and confounding comorbidities that negatively affect outcomes. Methods: A series of 41 patients treated with percutaneous plantar fasciotomy using the Topaz EZ microdebrider coblation wand were invited to participate in this retrospective follow-up study, and 88% ( N = 36) participated. A limited chart review was completed and the patients answered a survey with the visual analog scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire. Average outcomes were calculated and 45 variables were analyzed to determine if they were statistically significant confounders. Patients had symptoms for an average of 3 years before the procedure and were contacted for follow-up at an average of 14 months after the procedure. Results: The average VAS for pain score was 1.3 ± 1.8 and the average FAAM score was 92 ± 15. Eighty-nine percent of patients had a successful outcome, defined as FAAM greater than 75. In addition, patients at 18 months postprocedure reported complete or near-complete resolution of symptoms with an FAAM score greater than 97. Concurrent foot pathologies (eg, tarsal tunnel syndrome), oral steroid treatment prior to the procedure, and immobilization with a boot prior to the procedure were statistically significant negative confounders ( P < .05). Being an athlete was a positive confounder ( P = .02). Conclusion: Percutaneous plantar fasciotomy using a microdebrider coblation was an effective treatment for plantar fasciitis, particularly without concurrent foot pathology, with a low risk of complications. Level of Evidence: Level IV, retrospective case series.

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