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BACKGROUND: Only few studies have compared plantar and dorsal incisions in the treatment of primary intermetatarsal Morton's neuroma (PIMN). The results and guidelines are, however, still controversial, mainly due to confounding factors and study design. The present study is an attempt to systematically compare the two approaches.
MATERIALS AND METHODS: With a 2- to 5-year followup, we retrospectively compared the results of 125 patients (132 feet) with PIMN. All specimens had histology assessments. Longitudinal plantar incisions were performed by one experienced surgeon (n = 69) and dorsal incisions by another (n = 56). Records were reviewed, questionnaires evaluated, and physical examinations performed by one of two independent orthopaedic surgeons. RESULTS: Histology verified nerve resections in all specimens except in three cases of missed nerves in the dorsal group. There were significant differences, in favor of the plantar group, regarding long-term sensory loss, postoperative sick-leave weeks and complications. The clinical outcome regarding postoperative pain at followup and overall satisfaction rating were similar.
CONCLUSION: We conclude that the two surgical approaches were comparable for clinical outcome and patient satisfaction at followup, whereas significant differences, in favor of plantar incisions, were present regarding residual sensory loss and number of complications. The more serious complication with the dorsal approach, missed neuroma, may result in an increased risk of failure with the dorsal incision.
Re: Plantar versus dorsal incision for Morton's neuroma
A prospective 2-year follow-up study of plantar incisions in the treatment of primary intermetatarsal neuromas (Morton's neuroma).
Akermark C, Saartok T, Zuber Z. Foot Ankle Surg. 2008;14(2):67-73.
BACKGROUND: The aim of this prospective study, with a mean 29 (minimum 24) months follow-up was to evaluate the outcome of surgical treatment with a longitudinal, plantar incision of primary Morton's neuromas.
METHODS: All 55 patients (59 feet) had their pre-and post-operative pain assessed using VAS, and pre-operative radiographs evaluated. Two independent orthopedic surgeons performed the follow-up examinations.
RESULTS: Histology confirmed positive neuromas in all cases and there were only three minor complications. There was 88% reduction of pain at follow-up and 86% of all patients rated the overall satisfaction with the results as excellent or good. For those patients engaged in sports activities, the corresponding figure was 93%.
CONCLUSIONS: Surgery with a plantar incision seems to be a reliable and safe intervention of primary Morton's neuromas, with only limited number of minor complications and a subjective satisfactory outcome, well in accordance with other studies, using different, surgical approaches.
When nonsurgical treatment of a Morton neuroma is unsuccessful, neurectomy is indicated. The purpose of the present retrospective study was to evaluate the long-term outcomes, complications, and adverse events following a distal plantar transverse incision for the excision of an intermetatarsal neuroma.
We conducted a retrospective review of 168 consecutive patients who underwent surgical excision of a Morton neuroma that had been unresponsive to nonsurgical treatment. The clinical diagnosis was confirmed by means of magnetic resonance imaging and histological analysis. All patients underwent excision of the neuroma through a distal transverse plantar approach; concomitant foot and ankle disorders were also treated. Postoperatively, a three-grade patient satisfaction scale was administered to assess the results of the procedure and a clinical examination was performed for all patients.
One hundred and sixty patients (204 feet, 227 neuromas) were assessed at a median of 7.1 ± 3.9 years (range, one to twenty-one years) postoperatively. A good result was reported for 143 patients (89.4%); a fair result, for eleven (6.9%); and a poor result, for six (3.8%). The eleven patients with a fair result reported scar-related symptoms such as skin hardening, loss of sensation at the incision site, discomfort wearing shoes with high heels, and local paresthesias with no recurrence of the neuroma. The six patients with a poor result reported pain and paresthesias, and the recurrence of a neuroma was confirmed at the time of reoperation.
Producing a marked reduction in pain and high overall patient satisfaction, a distal transverse plantar incision is comparable with other surgical approaches for the surgical treatment of a Morton neuroma.
Re: Plantar versus dorsal incision for Morton's neuroma
A Prospective Randomized Controlled Trial of Plantar Versus Dorsal Incisions for Operative Treatment of Primary Morton’s Neuroma
Christian Åkermark, Hans Crone, Anne Skoog, Lars Weidenhielm Foot & Ankle International April 5, 2013
Background: There are a great number of studies on the outcome of surgery for Morton’s neuroma. However, there is a lack of controlled trials to determine the outcome in general and for the 2 most used surgical approaches. This prospective and randomized trial studied the outcome and adverse events of resected primary Morton’s neuromas, comparing plantar and dorsal incisions.
Methods: Seventy-six patients were randomized to treatment with either a plantar or a dorsal incision by 2 senior surgeons. Questionnaires were evaluated and physical examinations performed at baseline and at 3 and 12 months postoperatively by the treating surgeon and at a mean of 34 months (range, 28-42 months) by an independent surgeon. The follow-up rate was 93%.
Results: Histological examination of specimens verified resection of nerves in all cases except 1, which was in the dorsal group (artery). The main outcome variable, pain at daily activities, was significantly reduced by 96% (plantar) and 97% (dorsal) and restrictions in daily activities were reduced by 77% (plantar) and 67% (dorsal) at the final follow-up. Scar tenderness was noted by 3% (plantar) and 0% (dorsal) at the final evaluation. Clinically good results with surgery were noted in 87% (plantar) and 83% (dorsal) of cases. There were 5 complications in the plantar group and 6 in the dorsal group, with a difference in type of complications.
Conclusions: This study demonstrated 87% (plantar) and 83% (dorsal) clinically good outcomes and no significant differences between the procedures in regard to pain, restrictions in daily activities, and scar tenderness. However, there was a difference between the groups in the type of complications.