Aims

A local injection may be used as an early option in the treatment of Morton’s neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition.

Aims

Morton’s neuroma is common condition of the forefoot, but its aetiology remains unclear. Our aim was to evaluate the relationship between the width of the forefoot and the development of a Morton’s neuroma.

Aims

This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.

Aims

The objective of this double-blind randomised controlled trial was to assess whether ultrasound guidance improved the efficacy of corticosteroid injections for Morton’s neuroma (MN).

Introduction

Up to 70% of patients with symptomatic Morton's neuroma proceed to surgery having failed non-operative management. The success of surgical excision is up to 85% but carries with it significant morbidity. Radiofrequency ablation (RFA) is a less invasive alternative.

Background. Morton's Neuroma is a proximal neuralgia that affects the web spaces of the toes and is currently of unknown aetiology. Currently surgical excision is considered the gold standard treatment based on RCT and cohort studies. However patient derived outcomes have not previously been assessed. We addressed these aspects with our study. Methods. The validadated patient derived Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) was used to assess patient derived outcomes of surgery prospectively. The MOXFQ enables the generation of four scores, a combined global score as well as a pain, walking and social score. Participants were asked to fill out the 16 item questionnaire prior to surgery and were followed up after a minimum of 6 months. All participants were treated with neurectomy following clinical diagnosis. Results. 3 patients (13.6%) were lost to follow up. Final Cohort: 19 feet from 17 participants (F=16, M=1), mean age of 56. The mean reduction in the total MOXFQ score was significant (p=0.001). The pre surgical mean score was 38.1 (95% confidence interval = 33.4 - 42.8) and after a mean follow up period of 20 months was 13.1 (95% confidence interval = 7.5 – 18.6). The reductions observed in the three metric scores of pain, walking and social were all significant (p=0.005, p=0.008, p=0.006 respectively). Eighty four percent of patients in the study experienced a clinically significantly improved pain domain, 95% in the walking domain and 58% in the social domain of the MOXFQ. Conclusions. Surgical excision is an effective intervention for treating Morton's interdigital Neuroma with improvements seen in all three domains of the MOXFQ. The pain metric scores were consistent with previous studies. Neurectomy produces excellent functional improvements for patients. However patient derived social outcomes from surgical excision were slightly more modest than for those of pain and walking

Introduction: Tumours of the foot are rare, representing only 4 to 8 per cent of all bone and soft tissue tumours: a negligible number compared to degenerative, posttraumatic, vascular and metabolic diseases of this exposed region. Hence neoplasms of the foot are often diagnosed late and treated inadequately. Methods: The records of all tumours of the foot and ankle treated surgically at our institution in the period 1993 to 2007 were reviewed. Because of their non-neoplastic nature typical lesions of the foot such as plantar fibromatosis or Morton neuroma as well as ganglion and the like were not included in this study. History, location, radiographic and clinical findings were analysed, malignant tumours were followed up by X-ray and MRI. Results: Of the eighty-eight cases which were further investigated, there were forty-four bone tumours and forty-four neoplastic soft tissue lesions. Sixty-nine cases (78%) were benign tumours, half of them (35 cases) located in the bone and in the soft tissue (34 cases) respectively. There were forty-four male and female patients each, the mean age being 40 years (range 4 to 85) for all cases, 39 years for benign and 45 years for malign tumours respectively. There were nineteen malignant lesions, nine of which were bone tumours; the most common being chondrosarcoma (3) and osteosarcoma (3). Malignant soft tissue tumours (10) were very heterogeneous, clear cell sarcoma being the only tumour appearing at least twice. Out of thirty-four benign soft tissue tumours, pigmented villonodular synovitis (11), fibrous (9) and lipomatous (5) tumours have been the most frequent. Thirty five benign bone tumours included chondroma (10), solitary bone cyst (10), aneurysmatic bone cyst (3), osteoid-osteoma (3) and giant cell tumour (3). Conclusion: Knowledge of tumour prevalence under consideration of the patient’s age and location of the tumour is an important prerequisite for identifying neoplastic lesions of the foot

In this article, a definition of metatarsalgia is followed by an analysis of factors involved: biomechanical alterations, diseases of the forefoot and general diseases with an impact on the forefoot.

This is followed by a brief recall of the historical background and a description of the pathological anatomy and determining anatomic and biomechanical factors.

The frequency, symptoms and differential diagnosis are discussed together with the clinical, radiological, ultrasonographic and magnetic resonance imaging findings.

Conservative and surgical treatments are proposed together with a detailed description of the procedures and the supramalleolar anesthesia used in our department.

Forefoot reconstructive surgery can be complex and intricate, and even though performed by orthopaedic surgeons, it can be delicate, too. Despite the most ingenious techniques, patients routinely walk (stomp) all over this work, and the resulting forces applied to the foot have been extensively studied in gait analysis laboratories. But the everyday clinical challenge is how to employ durable reconstructive techniques, and how to salvage these case when they fail?. Hallux valgus surgery is replete with complications of malunion, non-union, over-correction and recurrence. Salvage often requires a revision of the patient’s expectations in addition to another surgery. First metatarso-phalangeal joint (MTP) arthrodesis, which has been demonstrated to have excellent functional outcomes, including return to sports activities, is an excellent salvage technique. Failed first MTP arthroplasty leaves a large bone defect, both in the metatarsal and phalanx. Salvage by arthrodesis requires bone grafting, rigid internal fixation, and long healing times. Tricortical iliac graft can be used to enhance restoration of length. Associated meta-tarsalgia may persist due to shortening of the first ray. Lesser metatarsal salvage sometimes can be accomplished with distal metaphyseal osteotomy. Some cases previously treated with a pan-metatarsal head resection can now be successfully salvaged by using these osteotomies to shorten multiple metatarsals. Meticulous technique is an advantage. First MTP arthrodesis itself can be complicated. One uncommonly recognized problem is the painful pressure under the residual sesamoid bone following an otherwise successful fusion. This is caused by arthritic enlargement of the sesamoid, and should be anticipate, and prevented by sesamoidectomy. Surgical technique for obtaining ideal position of the hallux will be presented. The distinction between true recurrence of interdigital (Morton’s) neuroma, and metatarsalgia can be subtle. The cause of failed neuroma surgery is as frequently an error in patient selection as it is failure of surgical technique. Case presentations will be employed to illustrate forefoot salvage principles

Aims: To evaluate the outcome of our consecutive series of patients who underwent revision surgery due to unresolved or recurrent symptoms after an initial procedure or procedures for interdigital neuroma excision. Methods: In a six year period 49 patients underwent revision neuroma surgery utilizing a dorsal approach. Sixty interspaces were re-explored. In addition, ten patients underwent primary neuroma resection from an adjacent interspace, while 19 patients underwent concomitant forefoot surgery. Results: The average duration of postoperative follow-up was 39.7 months. Fifteen patients (30.7%) were completely satis-þed, thirteen (26.5%) satisþed with minor reservations, ten (20.4%) satisþed with major reservations and eleven (22.4%) dissatisþed with the postoperative outcome. The exploration of two adjacent interspaces, the intraopera-tive þndings, the concomitant forefoot surgery and the previous attempts at re-exploration had an inßuence on the þnal outcome. Seven patients (14.3%) had no footwear restrictions, thirteen patients (26.5%) had mild, twenty-one (42.9%) had moderate and eight (16.3%) severe footwear restrictions. Nineteen patients (38.8%) had no activity restrictions, twenty-two (44.9%) had mild, eight (16.3%) moderate and none reported severe restrictions interfering with daily activities. Conclusions: Persistent or recurrent symptoms after nerve transection present a challenging problem for both the surgeon and the patient. Thorough preoperative discussion must be undertaken with the patient, providing the average rates of failure and the increased likelihood of footwear and activity restrictions

Acute trauma and repetitive nicrotrauma connected with certain athletic activities are oftenmentioned when describing the etiology of nerve entrapment syndromes. According to the literature it is obvious that nerve entrapment syndromes in athletes are not as rare as they were once considered to be. Certain sports or physical activities have been mentioned that lead to specific nerve entrapment syndromes – for example, cyclist’s palsy and bowler’s thumb. Unlike nerve entrapment syndromes, vascular and neurovascular syndromes in athletes seem to be more common and have been described in greater detail, while nerve entrapment syndromes in athletes have been reported only recently. To support this contention, I present currently available information about nerve entrapment syndromes in athletes. For each syndrome possible cause of compression, clinical symptoms and signs, and the most effective treatment is presented. On the upper extremity are described: spinal accessory nerve, thoracic outlet syndrome, brachial plexus, long thoracic nerve, suprascapular nerve, axillary nerve, musculocutaneous nerve, lateral ante-brachial cutaneous nerve, radial nerve above the elbow, radial tunnel syndrome, Wartenberg’s disease, distal posterior interosseous nerve, ulnar nerve at the elbow and in Guyon’s canal, median nerve at the elbow and in carpal canal, anterior interosseous nerve and digital nerves. The syndromes described on the lower extremity are: groin pain, piriformis muscle syndrome, pudendus nerve, meralgia paresthetica, sural nerve, common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, tarsal tunnel syndrome, the first branch of the lateral plantar nerve, medial plantar nerve (jogger’s foot) and interdigital neuromas (metatrsalgia. In conclusion I stress that nerve entrapment syndromes must be considered in the diferential diagnosis of pain in athletes

Aims: To evaluate the outcome of our consecutive series of patients who underwent revision surgery due to unresolved or recurrent symptoms after an initial procedure or procedures for interdigital neuroma excision. Methods: In a six year period 49 patients underwent revision neuroma surgery utilizing a dorsal approach. Sixty interspaces were re-explored. In addition, ten patients underwent primary neuroma resection from an adjacent interspace, while 19 patients underwent concomitant forefoot surgery. Results: The average duration of postoperative follow-up was 39.7 months. Fifteen patients (30.7%) were completely satisfied, thirteen (26.5%) satisfied with minor reservations, ten (20.4%) satisfied with major reservations and eleven (22.4%) dissatisfied with the postoperative outcome. The exploration of two adjacent interspaces, the intraoperative findings, the concomitant forefoot surgery and the previous attempts at re-exploration had an influence on the final outcome. Seven patients (14.3%) had no footwear restrictions, thirteen patients (26.5%) had mild, twenty-one (42.9%) had moderate and eight (16.3%) severe footwear restrictions. Nineteen patients (38.8%) had no activity restrictions, twenty-two (44.9%) had mild, eight (16.3%) moderate and none reported severe restrictions interfering with daily activities. Conclusions: Persistent or recurrent symptoms after nerve transection present a challenging problem for both the surgeon and the patient. Thorough preoperative discussion must be undertaken with the patient, providing the average rates of failure and the increased likelihood of footwear and activity restrictions

During a six-year period (January 1996 to January 2002 ), we re-explored 60 interspaces (49 patients, 49 feet) for recurrence or persistent symptoms after one or more previous procedures for excision of an interdigital neuroma. Ten patients underwent concomitant excision of a primary neuroma from an adjacent interspace, and 19 underwent concomitant forefoot surgery. The mean follow-up was 39.7 months (6 to 79). Evaluation included review of records and radiographs, clinical assessment, and a questionnaire regarding satisfaction, pain, restriction of footwear and activity. In total, 15 patients (30.7%) were completely satisfied, 13 (26.5%) were satisfied with minor reservations, ten (20.4%) were satisfied with major reservations and 11 (22.4%) were dissatisfied with the outcome. Of the 49 patients, 28 (57.2%) had no or mild pain, 29 (59.2%) had moderate or severe restriction of footwear and eight (16.3%) had moderate restriction of activity. Intra-operative findings, simultaneous surgery to adjacent interspaces, concomitant forefoot surgery and previous re-explorations did not significantly influence the outcome. Persistent or recurrent symptoms after transection of a nerve present a challenging problem for both the surgeon and patient. It is essential that there is a thorough pre-operative discussion with the patient, providing the rates of failure and the increased likelihood of restriction of footwear and activity after revision surgery

Eighty-two consecutive patients with forefoot pain and clinical signs strongly suggesting a neuroma all underwent ultrasound scan of both feet using a 10-5 MHz transducer where a well defined hypoechoic area defined a neuroma . All ultrasound positive feet had the lump excised surgically for histological studies. Plain x-rays were done on all symptomatic feet to exclude other pathology. Sixty-four feet had an ultrasound positive diagnosis. Of these, there were 82.3% female and 17.1% male (ratio 4.8:1 , p< 0.001). Thirty-six percent had bilateral neuromata but with only one side being symptomatic.59.5% of the neuroma were located in the interspace between the third and fourth toes whilst 41.5% were found in the interspace between the second and third toes. The size of the lesions varied from 3 to 11mm with a mean of 6.86mm. No lesion less than 5mm was symptomatic in our series. One false positive was noted in the series giving the test a sensitivity of 97.9% but the specificity was low at 50% as the scan negative feet were not surgically explored for ethical reasons. All surgically explored patients had become asymptomatic at an average of 5.3 weeks (range 4–24 weeks) post surgery. Thirty-three ultrasound negative patients treated non-operatively were completely asymptomatic at an average of 30 weeks (range 6–50 weeks). We conclude that an ultrasound scan is a cheap, non-invasive, time-efficient test useful in identifying interdigital neuroma as a cause of forefoot pain