Intermetatarsal Space Research Articles

A Characteristic Magnetic Resonance Imaging Finding to Identify Morton Neuroma: The Slug Sign.

Morton neuroma is a common cause of forefoot pain and sensory disturbances, but it is difficult to identify on magnetic resonance imaging (MRI). The aim of this study was to verify the usefulness of a characteristic MRI finding (slug sign) for identifying Morton neuroma and to clarify the relationship between excised neuroma characteristics and preoperative MRI findings. Twenty-two web spaces were retrospectively assessed from the second and third intermetatarsal spaces of 11 feet of 10 patients (7 women and 3 men, aged average 59.5 years) who underwent surgical excision of Morton neuroma between 2017 and 2022. Asymptomatic web spaces were used as control. Neuromas with 2 branches of the plantar digital nerves on axial T1-weighted MRI (MRI-T1WI) were considered the slug sign. We investigated the preoperative presence of the slug sign in Morton neuroma and asymptomatic control web spaces. We also investigated the relationship between the maximum transverse diameter of the excised specimen and that estimated on coronal MRI-T1WI. A total of 15 Morton neuromas were excised and assessed. The slug signs were present in 10 intermetatarsal spaces in 15 web spaces with Morton neuroma whereas the sign was found in 1 intermetatarsal space in 7 asymptomatic web spaces. The sensitivity and specificity for the slug sign to diagnose Morton neuroma was 66.7% and 85.7%, respectively. The positive and negative predictive values were 90.9% and 54.5%, respectively. The mean maximum transverse diameter of excised neuromas was 4.7 mm. The mean maximum transverse diameter of neuromas on coronal MRI-T1WI was 3.4 mm. A significant positive correlation was found between the maximum transverse diameters of excised specimens and diameters estimated on coronal MRI-T1WI (r = 0.799, P < .001). The slug sign may be a useful indicator of Morton neuroma on MRI to confirm nerve involvement after bifurcation. Level IV, retrospective series.

Endoscopic Resection of Horseshoe Ganglion of the Lateral Midfoot

A ganglion is the most common soft-tissue mass in the foot and can cause pain, paresthesia, or footwear problems. A ganglion can extend from the dorsum into the plantar compartment of the foot in the form of a horseshoe at the borders of the foot or in the form of an hourglass through the intermetatarsal space. Initial conservative management of a ganglion may entail observation and the use of padding for comfort, manual rupture, aspiration of the cyst contents, and steroid injection or sclerotherapy into the cyst. When the lesion is recurrent or painful, surgical excision is recommended. The purpose of this Technical Note is to describe the details of endoscopic resection of a horseshoe ganglion of the lateral midfoot. This technique has the advantages of being minimally invasive, with better cosmetic results and less surgical trauma to the soft tissue.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored “wrap-around” flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.

Revision Surgery for Recurrent Morton Neuroma with Use of a Collagen Conduit.

Ultrasound Guided Cryoablation of Morton’s Neuroma: Case Series Including Post-Ablation MRI Appearances

Category: Midfoot/Forefoot; Other Introduction/Purpose: Morton’s neuroma (MN) is a very common compressive neuropathy of the interdigital nerve. Non- operative management is recommended initially and many therapies have been described. Cryoablation has shown promising results, however there are limited published studies in the literature. The purpose of this study was to assess the safety and efficacy of Cryoablation in patients with MN. A secondary aim was to evaluate post-procedure MRI appearances. Methods: A retrospective analysis was completed for 24 MN treated between June 2021 and September 2022. All patients had refractory MN symptoms after previous US guided steroid and LA injection within the previous year. Three patients also had refractory symptoms after prior alcohol ablation. Cryoablation was performed as a single outpatient procedure under continuous US monitoring and local anesthesia with 1 cycle for average of 2 minutes. Telephone follow up by radiology department with a 0–10 visual analogue scale (VAS) score was performed at 6 weeks and 3 months post-ablation. The patients were also encouraged to submit patient reported outcomes to a British Foot and Ankle Society (BOFAS) online scoring database as facilitated by the surgical team. Post-ablation MRI was performed to evaluate for post-procedure appearances at various intervals between 3 to 14 months. Results: 24 MN were treated. The mean size of MN treated was 12.3mm. Technical success was 100% and all patients tolerated the procedure well under local anesthesia. Mean pre-procedure VAS pain score was 8, which reduced to 1 at 6 weeks, and 2 at 3 months follow up in the treated MN. There is high patient satisfaction with 20 cases (83%) very satisfied. Four cases had various persistent symptoms and would want to have it done again (17%). Post-ablation MRI showed various bone and soft tissue changes in the ablation zone. There were two cases of fibrosis in the intermetatarsal space and one residual neuroma observed on MRI, although the patients were asymptomatic in the ablation site. No complications occurred e.g. infection, fracture or thermal injury. Conclusion: In this small series, ultrasound guided Cryoablation was deemed safe and effective treatment for MN. Clinical advantages of the procedure are good patient tolerance, single outpatient procedure, high patient satisfaction and reduced risk of scarring or residual neuroma. Further controlled prospective studies would be beneficial.

Peripheral Nerve Stimulation for Chronic Foot Pain Induced by Morton Neuroma: A Novel, Personalized Approach in One Patient

BACKGROUND AND IMPORTANCE: Morton neuroma (MN) is a condition characterized by pain that is located within one or more intermetatarsal spaces of the forefoot. Numerous conservative measures are available for the management of mild-to-moderate MN cases. In more severe presentations, surgical interventions may be considered, including neuroma excision, cryogenic or radiofrequency ablation, and decompression. However, no standard treatments exist for occurrences of recurrent MN after surgery. Peripheral nerve stimulation is a neuromodulatory treatment that is highly effective for other neuropathic pain syndromes but remains underutilized for MN. CLINICAL PRESENTATION: Here, we present the operative technique and clinical outcome in a patient with chronic pain induced by MN who underwent bilateral implantation of peripheral nerve stimulation devices. In less than 12 months, the patient had near-complete resolution of chronic foot pain with no postoperative complications. DISCUSSION: We present the first published case and operative technique of successful peripheral nerve stimulator implantation as an effective treatment of MN. CONCLUSION: Peripheral nerve stimulator implantation is a promising and effective intervention that can be considered for refractory MN.

WITHDRAWN: Two-stage surgical treatment for medially angulated great toes in Apert feet by wedged corrective osteotomy with distraction of the inter-metatarsal space: A case report

One of most severe clinical problems related to Apert foot anomalies is medial angulation deformities of the great toe as the foot grows. The patient was a 22-month-old Japanese child with Apert syndrome, who had broad bilateral great toe showing medially angulated deformity. We performed two-stage surgical treatment including distraction of the remarkable narrowing the first inter-metatarsal space using an external distractor device, and the corrective wedge-osteotomy of the first metatarsal with a graft of wedged bone in the reverse direction and inter-positioning of the resected local bone between the first and second metatarsal to preserve the space. At 3 years after surgery, the patient did not have any disturbance of gait and could wear normal shoes without weight-bearing pain, and was satisfied with the appearance of the great toes. The two-stage surgical method could be an option for surgical treatment of Apert feet.

MODERN POSSIBILITIES OF ULTRASOUND SCAN IN DIAGNOSIS OF MORTON'S NEUROMA

About 60% of healthy people at least once in their lives complained of pain in the anterior foot that was diagnosed as Morton's neuroma. According to numerous resources, ultrasound scan is one of the leading methods for diagnosing the condition of the soft tissues in the foot, thus, this diagnostic technique can be considerably helpful in determining the nature and extent of the pathological condition and making the decision about the necessity of surgical treatment. Aim: to assess the potential of ultrasound investigation and to systematize the ultrasound criteria for Morton's neuroma using a two-dimensional mode, colour and energy mapping, and functional ultrasonography. Material and methods. We analyzed the findings obtained by the ultrasound scan of soft tissues in the foot of 26 people who complained of pain in the projection of 3-4 metatarsophalangeal joints. The following echographic data were evaluated: homogeneity, echogenicity, integrity of the soft tissues of the intermetatarsal spaces and tendons of the fingers, the presence of effusion in the articular capsules and tendon sheaths, the number of vascular signals in the affected area during power Doppler mapping. Results and discussion. In the control group of patients, the analysis of ultrasound has revealed the following echographic features: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic line with a clear acoustic shadow along it in all cases (100%); flexor tendons of the toes are located above the surfaces of the bones (100%); no masses are found in the intermetatarsal spaces in 100% of cases; the width of the intermetatarsal spaces is 5.0–9.0 mm in all cases (100%). In the main group of patients, the analysis of ultrasound findings has revealed the following structural changes: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic circular line with a clear acoustic shadow along it in 8 cases (30.7%); in 18 cases (69.3%) the contour of the cortical layer is uneven with a fuzzy acoustic shadow; flexor tendons of the toes are of reduced echogenicity and have heterogeneous structure in 16 cases (61.5%); space-occupying formations have been found in the intermetatarsal spaces of the III-IV toes in 24 cases (92.3%), and in the intermetatarsal spaces of the II-III toes and in 2 cases (7.7%); the width of the intermetatarsal spaces at the location of the mass formation in all cases (100%) is 10.0-15.0 mm. Conclusion. At the present, the access to ultrasound, its non-invasiveness, the absence of ionizing radiation, the possibility of dynamic observation, and relatively high accuracy in assessing the tibial nerve put it at the forefront in the diagnostic algorithm for detecting Morton's neuroma.

MORTON’S NEUROMA

Introduction: In 1876 American surgeon Thomas George Morton first detailed compressive neuropathy of the interdigital nerve of the forefoot. Mortons neuropathy occurs mostly. The condition is generated secondary to repeated pressure or irritation that leads to thickening of the nerve, located in the second or third intermetatarsal space. It is suggested that the use of pointed heel shoes could be a triggering factor for the development of this pathology due to the increased pressure on the forefoot. Objective: to describe the current information related to Mortons neuroma etiology, epidemiology, presentation, diagnosis, management and treatment. Methodology: a total of 39 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 29 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: Morton, neuroma, neuritis, neuralgia, interdigital. Results: it is more frequently present in the female sex, presenting a female:male ratio of 4:1 in some bibliographies and 5:1 in others. The average age at the time of surgery is 50 years old. In 21% of the cases the neuroma is bilateral, in 66% of the cases it is related to the third space, 2% to the fourth and 32% to the second. A study showed that the average diameter of Mortons neuroma was 4.1 mm in the asymptomatic staff versus 5.3 mm in the symptomatic group. Conclusions: This condition is certainly not a neuroma as it is a degenerative rather than neoplastic condition due to fibrosis of the digital nerve. The diagnosis is primarily clinical, where there may be altered sensation and a dorsal bulge. Examinations, investigations and non-surgical treatment are the same as those used in a primary neuroma. The use of orthoses and footwear modifications is indicated for conservative treatment. For surgical treatment, dorsal and plantar approaches are used, each with their advantages and disadvantages. The dorsal incision should be extended proximally to observe the residual limb, however sometimes exposure becomes difficult. The plantar approach provides better exposure for the nerve to be easily identified and resected, however the presence of painful scarring is notable. Other complications that may occur are atrophy, recurrence and chronic pain. KEY WORDS: Morton, neuroma, neuritis, neuritis, neuralgia, interdigital.

An angiosome-centred approach for TcpO2 electrode positioning.

Background: The latest guidelines propose a TcpO2 value of 30 mmHg to help to confirm the diagnosis of chronic limb threatening ischemia. However, placement of electrodes is not standardised. The relevance of an "angiosome-centred" approach for TcpO2 electrode positioning has never been evaluated. We therefore retrospectively analysed our TcpO2 results to study the impact of electrode placement on the different angiosomes of the foot. Patients and methods: Patients consulting the vascular medicine department laboratory for suspicion of CLTI using TcpO2 electrodes placement on the different angiosome arteries of the foot (first inter metatarsal space, lateral edge of the foot and plantar side of the foot) were included. As the mean intra-individual variation is reported to be 8 mmHg, a variation of mean TcpO2 for the 3 locations ≤8 mmHg was considered to be not clinically significant. Results: Thirty-four patients (34 ischemic legs) were analysed. The mean TcpO2 was higher at the lateral edge of the foot (55 mmHg) and plantar side of the foot (65 mmHg) than at the first intermetatarsal space (48 mmHg). There was no clinically significant variation of mean TcpO2 according to anterior/posterior tibial artery patency and fibular artery patency. This was present when stratifying on the number of patent arteries. Conclusions: The present study suggests that multi-electrode TcpO2 is not useful to assess tissue oxygenation in the different angiosomes of the foot to guide surgical decision; first intermetatarsal electrode alone would be preferred. TcpO2 seems rather to evaluate overall tissue oxygenation of the foot. Electrode location on the plantar side of the foot may overestimate results and lead to misinterpretation.

From second webspace syndrome to second cross over toe: Clinical and radiological findings following Weil osteotomy with no soft tissue procedure

BackgroundThe second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both.The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure. MethodsA retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery. ResultsTwenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001). ConclusionMedial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients. Level of evidenceLevel IV, retrospective case series

Anatomy of the Plantar Intermetatarsal Tunnel: A Cadaveric Study

The contents of the plantar intermetatarsal tunnel (PIMT) and the relationship between the common plantar interdigital nerve (CPIN) and the PIMT were recorded. The width of the PIMT was measured at the metatarsal neck (MTN), metatarsophalangeal (MTP) joint and the base of the proximal phalanx (BPP). The length of the deep transverse metatarsal ligament (DTML), the PIMT and the intracapsular ligament (ICL) were also measured. The PIMT was revealed to be a narrow osseofibrous tunnel divided into 3 segments by the DTML: the distal section, the area under the DTML (middle) and the proximal section. The length of the middle section was 12.77 mm in the second intermetatarsal (IM) space and 10.18 mm in the third IM space. The lengths of the distal sections were 15.52 and 14.95 mm in the second and third IM spaces, respectively. There was some soft tissue between the CPIN and PIMT, and the CPIN was observed not to glide freely within the tunnel. The widths of the PIMT at the MTN, MTP joint and BPP were respectively 2.87, 2.56, and 3.42 mm in the second IM space and 3.10, 2.68 and 3.61 mm in the third IM space. The ICL lies between the capsules of the MTP joint, and the length of the ICL was 2.76 and 3.03 mm in the second and third IM spaces, respectively. The PIMT was found to be a complex spatial structure, and the ICL might prevent the CPIN from being squeezed into the IM space.

Intermetatarsal ligament section assisted with sonography for the percutaneous surgery of Morton’s disease: Cadaveric study

BackgroundSurgical treatment of Morton’s neuroma remains controversial. Several surgical techniques have been described including percutaneous transection of the deep metatarsal transverse ligament (DMTL). PurposeTo evaluate the efficacy and safety of percutaneous release of the DMTL under ultrasound guidance for the treatment of Morton’s syndrome. Materials and methodologyPercutaneous release of the DMTL was performed with ultrasound guidance in 48 intermetatarsal spaces of 16 cadaveric specimens. Specimens were then dissected to assess the completion of the release and the presence of any injuries of the neurovascular and tendinous adjacent structures. ResultsThe DMTL was visualized with ultrasound in all cases. Complete release of the ligament was achieved in 87.5% (42/48) cases. One case of interdigital nerve injury was found. ConclusionPercutaneous release of DMTL with ultrasound guidance for the treatment of Morton’s disease has an acceptable rate of complications but care must be taken to ensure the complete release of the ligament.

Results in 7 Cases of Neurectomy With a Transverse Plantar Approach for Primary Morton’s Neuroma

Surgery is often performed for Morton’s neuroma when conservative treatment is ineffective. This study aimed to describe the surgical results of Morton’s neuroma. Six patients (7 feet) underwent neurectomy via a transverse plantar incision in the forefoot. Changes in perceived pain, function, and patient satisfaction were measured with a Visual Analog Scale, the American Orthopaedic Foot and Ankle Surgery Scale, and the Coughlin score, respectively. Six feet had neuromas in the third intermetatarsal space and 1 foot had neuromas in the third and second spaces. The mean preoperative and postoperative Visual Analog Scale scores were 7.14±0.69 and 1.86±0.69, respectively. The mean preoperative and postoperative American Orthopaedic Foot and Ankle Surgery scores were 69.71±6.73 and 94.86±3.93, respectively. Four patients were very satisfied, and 2 patients were just satisfied. The plantar surgical approach for the treatment of Morton’s neuroma has few complications with good functional results and patient satisfaction in this case series. Level of Evidence: Diagnostic Level IV—retrospective case series. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Pressure Pain Sensitivity in the Forefoot of Healthy Individuals.

The evaluation of musculoskeletal pain in podiatric medical practice is mainly based on anamnesis and manual examination. However, when manual palpation is performed, the digital pressure necessary to adequately explore the different structures of the foot is unknown. We evaluated the pressure pain threshold in forefoot structures to determine the intensity and duration of the stimulus as clinically relevant and representative. In a transversal analytical study of 15 healthy individuals, 16 forefoot points were explored with a handheld pressure palpometer calibrated to exert maximum pressing force of 1.0 or 2.0 kilogram-force (kgf) applied during 5 or 10 sec. The combinations of the different pressures and intervals were selected randomly. Participants had to self-rate the pressure pain sensitivity of each stimuli on a 100-mm horizontal line (0-100 numeric rating scale), setting the pain threshold to 50 (100 being pain as bad as it could be). Likewise, aftersensation and referred pain patterns were recorded. All participants indicated painful stimuli at some of the 16 forefoot points studied in the experimental protocol when pressure was applied with the 2.0-kgf palpometer; 53.3% showed evidence of pain at any forefoot point when the 1.0-kgf palpometer was used. The odds of evoking a painful sensation are 9.8 times higher when using a 2.0-kgf palpometer versus a 1.0-kgf palpometer. In addition, referred sensations were observed with a significantly higher frequency when applying the 2.0-kgf palpometer. Bone and soft structures show differences in pressure sensitivity, increasing significantly when applying higher pressure force. Soft structures, specifically intermetatarsal spaces, showed the lowest pain pressure thresholds. More research is needed to better understand pressure pain response.

A Systematic Review of the Management of Multiple Adjacent Morton's Neuromas in the Same Foot

Category:Midfoot/ForefootIntroduction/Purpose:The most common presentation of Morton's neuroma is that of a single neuroma in a single interdigital space. However, the occurrence of multiple neuromas in adjacent interdigital spaces of the same foot is not uncommon, with this scenario reported in 3-4% of all cases. Treatment of Morton's neuroma has been studied extensively, with most authors recommending surgical intervention only after failure of non-operative approaches such as steroid injection orthoses or shockwave therapy. Whilst systematic reviews on the management of Morton's neuroma have been performed previously, these focus on the treatment of a single neuroma in a single foot. This review aims to address this gap in the literature by systematically reviewing studies reporting treatment of multiple neuromas in adjacent intermetatarsal spaces of the same foot.Methods:A systematic review was performed according to PRISMA guidelines. A thorough computer-based search was performed by two reviewers independently in Pubmed, Embase, Cinahl, Emcare, Web of Science and Scopus databases using relevant terms such as 'interdigital', 'Morton's', 'intermetatarsal', 'neuroma', 'neuralgia', 'adjacent' and 'multiple'. Title/abstract and full text screening was performed independently by the same two reviewers, using a-priori selection criteria. All original research articles (randomised control trails, cohort studies and observational studies) reporting any management strategy for multiple adjacent Morton's neuromas in the same foot were included. Studies describing treatment of both single and multiple adjacent neuromas in the same article were included if results were clearly separated according to these distinct presentations. The methodological index for non-randomized studies (MINORS) was used to assess risk of bias and methodological quality of included studies.Results:A total of 253 unique articles were identified, with seven studies, including 383 patients included in the final review. Of these seven studies, four describe treatment of both single and multiple neuromas in the same article, whilst three include only patients with multiple adjacent neuromas in the same foot. Simultaneous excision using a single incision was the most common strategy, reported in three studies. Whilst two studies each reported use of simultaneous excision with two distinct incisions and delayed excision respectively. Of the four studies reporting treatment of both single and multiple neuromas, the pooled proportion of patients with the later presentation was 51/354 (14.4%). Only two studies, both describing simultaneous excision with a single incision, used scoring scales to assess treatment outcomes. These articles find significant increases in Manchester Oxford Foot questionnaire (MOXFQ), 12 item short form health survey (SF-12) and American Orthopaedic Foot & Ankle Society (AOFAS) scores.Conclusion:There is currently no evidence favouring use of a delayed excision or multiple incision approach in the treatment of multiple adjacent neuromas. However, there is a paucity of literature describing this presentation, with a number of studies failing to separate outcomes of single and multiple neuroma treatment. Given that the presentation of multiple adjacent neuromas may not be as rare as previously thought, it is important that further high-quality comparative research is performed to enable clinicians to draw firm, evidence-based conclusions to guide clinical practice. Future research should also investigate the role of alternative strategies such as non-operative treatment.

1283 The Management of Multiple Morton’s Neuromas in the Same Foot: A Systematic Review

Abstract Aim The optimal treatment strategy for the presentation of multiple Morton’s neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. This systematic review aims to summarise and assess the efficacy of current treatment strategies. Method A systematic review was performed using the PRISMA guidelines. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A computer-based search was completed in PubMed, Embase, Cinahl, Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. Two authors independently performed title/abstract and full text screening according to a-priori selection criteria. Considering the four studies reporting treatment of a cohort containing both patients with a single neuroma and those with multiple neuromas, the proportion of cases in the latter group was 51/354 (14.41%). Results A total of 253 articles were identified, with 7 articles, involving 383 patients being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, whilst two studies each describe simultaneous excision with two separate incisions and delayed excision, respectively. The proportion of patients Discussion There is no strong evidence favouring use of delayed excision or multiple incisions. However, there is currently a lack of evidence focusing on this presentation of neuroma specifically. A number of studies fail to separate results of single and multiple neuroma excision. Further high-quality research is therefore required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.

Ultrasound-guided treatment of Morton's neuroma.

Morton’s neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular degeneration, and deregulation of sympathetic innervation. Patients usually present with burning or sharp metatarsalgia at the dorsal or plantar aspect of the foot. The management of Morton’s neuroma starts with conservative measures, usually with limited efficacy, including orthotics and anti-inflammatory medication. When conservative treatment fails, a series of minimally invasive ultrasound-guided procedures can be employed as second-line treatments prior to surgery. Such procedures include infiltration of the area with a corticosteroid and local anesthetic, chemical neurolysis with alcohol or radiofrequency thermal neurolysis. Ultrasound aids in the accurate diagnosis of Morton’s neuroma and guides the aforementioned treatment, so that significant and potentially long-lasting pain reduction can be achieved. In cases of initial treatment failure, the procedure can be repeated, usually leading to the complete remission of symptoms. Current data shows that minimally invasive treatments can significantly reduce the need for subsequent surgery in patients with persistent Morton’s neuroma unresponsive to conservative measures. The purpose of this review is to present current data on the application of ultrasound for the diagnosis and treatment of Morton’s neuroma, with emphasis on the outcomes of ultrasound-guided treatments.

Peroneal Nerve Dysfunction in Patients with Clubfoot Deformity: Evaluation of Clinical Presentation and Treatment.

BackgroudComplete peroneal nerve dysfunction associated with congenital clubfoot is uncommonly reported. Our retrospective study highlights the recognition of clinical presentation and mid-term outcomes of treatment in these patients.MethodsEight out of 658 patients undergoing treatment for clubfoot were identified with unilateral complete peroneal nerve dysfunction associated with congenital clubfoot. Three patients presented primarily to our center; 5 were treated elsewhere initially. All patients were treated with Ponseti casts, Achilles tenotomy, and subsequent foot abduction bracing. Diagnosis of complete peroneal nerve dysfunction was confirmed using nerve conduction velocity studies in all patients. After full-time bracing, an insole polythene molded ankle foot orthosis was given. Three patients underwent tibialis posterior transfer to improve foot dorsiflexor power.ResultsThe mean age at presentation was 1.3 years (range, 1 week–5 years). All patients had prominence of lateral 3 metatarsal heads and dimpling of intermetatarsal spaces. At a mean follow-up of 5.1 years, mean shortening of 1.2 cm in tibia (range, 1–2.5 cm) and mean calf wasting of 4.4 cm were observed. There was no relapse of any clubfoot deformity till the final follow-up.ConclusionsProminence of lateral metatarsal heads and dimpling of intermetatarsal spaces should raise early suspicion of peroneal nerve dysfunction. Standard Ponseti protocol is useful in treatment of these patients. Tibialis posterior transfer to dorsum partially restores the ankle dorsiflexion.

Восстановление тканей опорных поверхностей стоп усовершенствованным методом fillet flap

Представлен собственный опыт применения метода digital fillet flap, в том числе предложенного лоскута переднебокового отдела подошвы с включением латеральной краевой артерии (arteriae plantaris lateralis digiti quinti, или fibular plantar marginal artery) и вариабельных подошвенных плюсневых артерий IV межплюсневого промежутка в сочетании с пластикой мягкими тканями V пальца, для восстановления длительно незаживающих ран и язв переднего отдела стопы у 5 пациентов. Показано, что данный способ позволяет восстанавливать дефект переднего отдела стопы подошвенным опороспособным лоскутом, имеющим множественное осевое кровоснабжение и чувствительную иннервацию. Предложен метод адаптации лоскута к поверхности раны, основанный на выполнении 3–5 радиальных разрезов длиной 2–3 мм мягких тканей гемисферических краев пальцевого лоскута без повреждения пальцевых сосудов и нервов, что позволяет снизить кривизну лоскута, минимизировать подлоскутное пространство, тканевое натяжение и закрыть большую раневую площадь. Лоскуты fillet flap были успешно применены для восстановления тканей нейротрофических язв и незаживающих ран переднего отдела стопы.