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. Methods. A total of 91 patients were assessed for this trial, of whom 45 were subsequently included and randomized into two groups. One patient was lost to follow-up, leaving 22 patients (24 feet) in each group. The patients in the hyaluronic acid group were treated with three ultrasound-guided injections (one per week) of hyaluronic acid (Osteonil Plus). Those in the corticosteroid group were treated with three ultrasound-guided injections (also one per week) of triamcinolone (Triancil). The patients were evaluated before treatment and at one, three, six, and 12 months after treatment. The primary outcome measure was the visual analogue scale for pain (VAS). Secondary outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complications. Results. Both groups showed significant improvement in VAS and AOFAS scores (p < 0.05) after 12 months. The corticosteroid group had a significantly greater reduction in VAS and increase in AOFAS scores compared with the hyaluronic acid group, at one, three, and six months, but with no significant difference at 12 months. There were no complications in the hyaluronic acid group. There were minor local complications in six patients (six feet) (25.0%) in the corticosteroid group, all with discolouration of the skin at the site of the injection. These minor complications might have been due to the three weekly injections of a relatively high dose of corticosteroid. No patient subsequently underwent excision of the neuroma. Conclusion. An ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton’s neuroma at many timepoints. Thus, a corticosteroid injection should be regarded as a primary option in the treatment of these patients, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated. Cite this article: Bone Joint J 2024;106-B(10):1093–1099

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. . Patients and Methods. Between January 2013 and May 2016, a total of 84 consecutive patients (17 men, 67 women) with a unilateral Morton’s neuroma were enrolled into the study. The involved and uninvolved feet of each patient were compared. A control group of patients with symptoms from the foot, but without a neuroma who were matched for age, gender, affected side, and web space location, were enrolled. The first to fifth intermetatarsal distance, intermetatarsal angle and intermetatarsal distance of involved web space on standing radiographs were assessed. Results. The inter- and intra-observer reliability was excellent. The three parameters did not differ significantly between the involved and uninvolved feet. Neither did they differ significantly between the patients and the controls. Conclusion . We conclude that there is no significant relationship between the width of the forefoot and the development of a Morton’s neuroma. Cite this article: Bone Joint J 2017;99-B:365–8

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. Patients and Methods. Between May 2006 and April 2013, we prospectively studied 99 consecutive patients (111 feet) who were to undergo excision of a Morton’s neuroma. There were 78 women and 21 men with a mean age at the time of surgery of 56 years (22 to 78). Patients completed the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF-12) and a supplementary patient satisfaction survey three months pre-operatively and six months post-operatively. Results. Statistically significant differences were found between the mean pre- and post-operative MOXFQ and the physical component of the SF-12 scores (p = 0.00081 and p = 0.00092 respectively). Most patients reported their overall satisfaction as excellent (n = 49, 49.5%) or good (n = 29, 29.3%), but ten patients were dissatisfied, reporting poor (n = 8, 8.1%) or very poor (n = 2, 2.0%) results. Only 63 patients (63%) were pain-free at follow-up: in eight patients (8.1%), the MOXFQ score worsened. There was no statistically significant difference in outcome between surgery on single or multiple sites. However, the MOXFQ scores were significantly worse after revision surgery (p = 0.004). Conclusions. The patient-reported outcomes after resection of a symptomatic Morton’s neuroma are acceptable but may not be as good as earlier studies suggest. Surgery at several sites can be undertaken safely but caution should be exercised when considering revision surgery. Cite this article: Bone Joint J 2016;98-B:1376–81

Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle

We used freeze-thawed muscle grafts to restore continuity to the affected nerve in 22 painful cutaneous neuromas. In 11 of the 15 neuromas in the upper limb, pain was partially or completely relieved; in six of these there was some recovery of distal sensation. Partial pain relief was achieved in only two of the seven neuromas in the lower limb. The difference is attributed to the longer grafts required in the lower limb

A stump neuroma is caused by the disorganised growth of axon cylinders into proliferating granulation tissue, but this is stopped by an undamaged epineural sleeve. We report experiments in the rat in which the epineural sleeve of the stump of the sciatic nerve was freed from nerve fascicles for about 5 mm and then sealed with a synthetic tissue adhesive. Neuroma formation was largely prevented in comparison with the results of other methods. This new technique has been used to treat 68 painful neuromas in 36 patients. All but three of the patients were cured or improved and none were made worse

We investigated 29 cases, diagnosed clinically as having Morton’s neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome. Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions. There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery. Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment. There is no requirement for ultrasound or MRI in patients who are thought to have a Morton’s neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases

We describe four women and two men who had persistent wrist pain and reduced function after minor operations on the dorsum, usually for ganglia. They had diffuse pain and paraesthesia over the dorsum of the wrist, thumb, index and middle fingers, which was worse and different from that before operation. They all had temporary relief of symptoms after block of the posterior interosseous nerve with bupivacaine. Later, excision of the terminal branches of the nerve at the wrist cured three patients completely and gave marked improvement in the other three, with no complications. Great care is required at operations on the dorsum of the wrist, but pain from a neuroma can be relieved by local excision

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty

The April 2015 Foot & Ankle Roundup. 360 . looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

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). . Patients and Methods. In all, 50 feet (40 patients) were recruited for this study but five feet were excluded due to the patients declining further participation. The mean age of the remaining 36 patients (45 feet) was 57.8 years (standard deviation (. sd. ) 12.9) with a female preponderance (33F:12M). All patients were followed-up for 12 months. Treatment was randomised to an ultrasound guided (Group A) or non-ultrasound guided (Group B) injection of 40 mg triamcinolone acetonide and 2 ml 1% lignocaine, following ultrasound confirmation of the diagnosis. . Results. The mean visual analogue score for pain improved significantly in both groups (Group A – from 64 mm, . sd. 25 mm to 29 mm, . sd. 27; Group B – from 69 mm, . sd. 23 mm to 37 mm, . sd. 25) with no statistical difference between them at all time-points. The failure rate within 12 months of treatment was 11/23 (48%) and 12/22 (55%) in Groups A and B, respectively (p = 0.458). The improvement in Manchester Oxford Foot Questionnaire Index and patient satisfaction favoured Group A in the short-term (three months) that almost reached statistical significance (p = 0.059 and 0.066 respectively). However, this difference was not observed beyond three months. . Conclusion. This study has shown that ultrasound guidance did not demonstrably improve the efficacy of corticosteroid injections in patients with MN. Take home message: In the presence of a clear diagnosis of MN, a trained clinician who understands the forefoot anatomy may perform an injection without ultrasound guidance with good and safe results. Cite this article: Bone Joint J 2016;98-B:498–503

We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery. Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

In a series of 64 ligamentous injuries of the knee, 33 were explored through a medial incision and 31 through a long lateral incision. Sensibility of the skin, the occurrence of neuromas, and discomfort during kneeling were evaluated three and six years postoperatively. The lateral incisions produced less dysaesthesia, fewer neuromas and less discomfort on kneeling

The formation of a painful neuroma after operations on the medial or lateral sides of the elbow is a common problem. Our aim was to determine the relationship of the cutaneous nerves to the three usual skin incisions around the elbow. In 18 freshly frozen cadaver arms we made three standard 16 cm incisions in the skin medially, laterally, and posteriorly and explored them using loupe magnification. The number of nerves crossing each incision was determined by gross observation and their diameter measured by electronic microcallipers. In ten arms, biopsies of the nerves in each incision were sent for histological examination. We found significantly more cutaneous nerves crossing the medial and lateral incisions than the posterior. The diameter of the nerves crossing the posterior incision was significantly smaller than those crossing the lateral incision. Cutaneous nerves are at considerable risk of injury when medial or lateral incisions are used to approach the elbow, but the posterior approach carries less hazard. The routine use of the posterior incision may reduce the incidence of symptomatic paraesthesia and the formation of a painful neuroma after operation

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.

The October 2023 Wrist & Hand Roundup³⁶⁰ looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

Aims

The aim of this study was to determine the rate of indocyanine green (ICG) staining of bone and soft-tissue tumours, as well as the stability and accuracy of ICG fluorescence imaging in detecting tumour residuals during surgery for bone and soft-tissue tumours.

Aims

This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur.

Osteoarthritis (OA) is a highly prevalent degenerative joint disorder characterized by joint pain and physical disability. Aberrant subchondral bone induces pathological changes and is a major source of pain in OA. In the subchondral bone, which is highly innervated, nerves have dual roles in pain sensation and bone homeostasis regulation. The interaction between peripheral nerves and target cells in the subchondral bone, and the interplay between the sensory and sympathetic nervous systems, allow peripheral nerves to regulate subchondral bone homeostasis. Alterations in peripheral innervation and local transmitters are closely related to changes in nociception and subchondral bone homeostasis, and affect the progression of OA. Recent literature has substantially expanded our understanding of the physiological and pathological distribution and function of specific subtypes of neurones in bone. This review summarizes the types and distribution of nerves detected in the tibial subchondral bone, their cellular and molecular interactions with bone cells that regulate subchondral bone homeostasis, and their role in OA pain. A comprehensive understanding and further investigation of the functions of peripheral innervation in the subchondral bone will help to develop novel therapeutic approaches to effectively prevent OA, and alleviate OA pain.

Cite this article: Bone Joint Res 2022;11(7):439–452.

Aims

Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon.

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

1. A clinical test of diagnostic significance in Morton's metatarsalgia is described. 2. Findings at operation in twelve cases are recorded. 3. The causation of the digital neuroma is discussed

A woman with neurofibromatosis (von Recklinghausen's disease) presented with a giant plexiform neuroma of the arm and chest wall, with dysplastic scoliosis and a pseudarthrosis of the humerus. Her arm resembled that of the "Elephant Man" described by Sir Frederick Treves

Recurrent dislocation of peroneal tendons is uncommon and there are few reports of the long-term results after repair. The Singapore operation, first described in 1985, is an anatomical repair based on the Bankart-like lesion seen in the superior peroneal retinaculum. We reviewed 21 patients after a mean follow-up of 9.3 years, and found no recurrence. Eighteen had good functional results and had returned to their previous levels of vocational and sports activities. The three fair results were due to painful scars or neuromas

Most techniques described for the correction of hallux valgus require exposure of the distal aspect of the first metatarsal. A dorsomedial incision is often recommended. Texts counsel against damaging the dorsal digital nerve, as a painful neuroma is an unwelcome surgical complication. Our study on cadavers aimed to investigate the anatomy of the dorsomedial cutaneous nerve in the metatarsophalangeal region, with special reference to surgical incisions. A constant, previously unrecognised branch of the nerve was identified. This branch is likely to be damaged if a dorsomedial approach is used. It is recommended that a mid-medial incision be used instead, i.e. at the junction of the plantar and dorsal skin

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

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

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Abstract

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Aims

The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

The August 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Learning the Pavlik; MRI and patellar instability; Cerebral palsy and hip dysplasia; ‘Pick your poison’: elastic nailing under the spotlight; Club feet and surgery; Donor site morbidity in vascularised fibular grafting; Cartilage biochemistry with hip dysplasia; SUFE and hip decompression: a good option?

While many forefoot procedures may be performed as a day case, there are no specific guidelines as to which procedures are suitable. This study assessed the early post-operative pain after forefoot surgery performed a day case, compared with conventional inpatient management.

A total of 317 consecutive operations performed by a single surgeon were included in the study. Those eligible according to the criteria of the French Society of Anaesthesia (SFAR) were managed as day cases (127; 40%), while the remainder were managed as inpatients.

The groups were comparable in terms of gender, body mass index and smoking status, although the mean age of the inpatients was higher (p < 0.001) and they had higher mean American Society of Anaesthesiologists scores (p = 0.002). The most severe daily pain was on the first post-operative day, but the levels of pain were similar in the two groups; (4.2/10, sd 2.5 for day cases, 4.4/10, sd 2.4 for inpatients; p = 0.53). Overall, 28 (9%) of patients who had their surgery as a day case and 34 (11%) of inpatients reported extreme pain (≥ 8/10). There were more day case patients rather than inpatients that declared their pain disappeared seven days after the surgery (p = 0.02). One day-case patient with excessive bleeding was admitted post-operatively.

Apart from the most complicated cases, forefoot surgery can safely be performed as a day case without an increased risk of pain, or complications compared with management as an inpatient.

Cite this article: Bone Joint J 2015;97-B:1645–50.

The October 2013 Foot & Ankle Roundup³⁶⁰ looks at: Operative treatment of calcaneal fractures advantageous in the long term?; Varus ankles and arthroplasty; Reducing autograft complications in foot and ankle surgery; The biomechanics of ECP in plantar fasciitis; Minimally invasive first ray surgery; Alcohol: better drunk than injected?; Is it different in the foot?; It’s all about the temperature

The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the ankle. However, the longevity of the implants is still far from that of total knee and hip arthroplasties.

The aim of this review is to outline a diagnostic and treatment algorithm for the painful TAA to be used when considering revision surgery.

Cite this article: Bone Joint J 2017;99-B:5–11.