Treatment of a patient with chronic causalgia after surgical removal of the neuroma in the second interdigital space

Cover Page

Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription Access

Abstract

BACKGROUND: Morton’s neuroma is a common pathology of the forefoot. Etiopathologically, this disease can be attributed to nerve fibrosis, not a tumor. We now have various therapeutic options for neuromas, the most frequent of which is traction neurectomy. Recurrent pain affects up to 35% of patients with traction neurectomy, and one-third have recurrent stump neuroma produced by the proliferation of fibrous scar tissue around the remaining nerve elements. Conservative treatment methods are more commonly used to treat recurrent neuromas and residual pain, but surgical therapy is required in some cases. Despite the relatively high prevalence, the treatment of such patients is a challenging task for orthopedic traumatologists.

CLINICAL CASE DESCRIPTION: We show the effective treatment of a patient with stump neuroma and primary Morton’s neuroma in two stages. The second interdigital space nerve was transposed, and the deep, transverse metatarsal ligament of the third interdigital space was dissected in the first stage. The second stage consists of removing the sensitive scar, resecting the plantar nerve of the third interdigital space, and performing a Weil osteotomy.

CONCLUSION: Consistent use of conservative surgical procedures, appropriate revision of the subcutaneous nerve, and excision of a sensitive scar allows for a successful therapeutic outcome, pain alleviation, and the ability to wear normal shoes.

About the authors

Daria A. Bolshakova

European Clinic of Sports Traumatology and Orthopedics ECSTO; Russian University of Peoples’ Friendship

Author for correspondence.
Email: dasha.bolsh@gmail.com
ORCID iD: 0009-0003-3332-9267

Post-Graduate Student, Traumatologist-Orthopedist

Russian Federation, Moscow; Moscow

Andrey A. Kardanov

European Clinic of Sports Traumatology and Orthopedics ECSTO

Email: akardanov@emcmos.ru
ORCID iD: 0000-0003-2866-2295
SPIN-code: 5134-8123

MD, Dr. Sci. (Med.), Traumatologist-Orthopedist

Russian Federation, Moscow

Musa N. Maysigov

European Clinic of Sports Traumatology and Orthopedics ECSTO

Email: mmaysigov@emcmos.ru
ORCID iD: 0000-0002-2096-5876

MD, Cand. Sci. (Med.), Traumatologist-Orthopedist

Russian Federation, Moscow

Andrey V. Korolev

European Clinic of Sports Traumatology and Orthopedics ECSTO; Russian University of Peoples’ Friendship

Email: akorolev@emcmos.ru
ORCID iD: 0000-0002-8769-9963
SPIN-code: 6980-6109

MD, Dr. Sci. (Med.), Traumatologist-Orthopedist

Russian Federation, Moscow; Moscow

References

  1. Thomajan CH. A Method for Entubulating Exposed Nerve Ends Following Neurectomy Using a Porcine Extracellular Matrix Nerve Cap. Foot & Ankle Specialist. 2022;15(6):579–585. doi: 10.1177/19386400221106642
  2. Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton’s neuroma: is it always symptomatic? American journal of roentgenology. 2000;175(3):649–653. doi: 10.2214/ajr.175.3.1750649
  3. Zanetti M, Ledermann T, Zollinger H, Hodler J. Efficacy of MR imaging in patients suspected of having Morton’s neuroma. American Journal of Roentgenology. 1997;168(2):529–532. doi: 10.2214/ajr.168.2.9016241
  4. Zanetti M, Weishaupt D. MR Imaging of the Forefoot: Morton Neuroma and Differential Diagnoses. Seminars in Musculoskeletal Radiology. 2005;9(3):175–186. doi: 10.1055/s-2005-921938
  5. Climent JM, Mondéjar-Gómez F, Rodríguez-Ruiz C, Díaz-Llopis I, Gómez-Gallego D, Martín-Medina P. Treatment of Morton Neuroma with Botulinum Toxin A: A Pilot Study. Clinical Drug Investigation. 2013;33(7):497–503. doi: 10.1007/s40261-013-0090-0
  6. Goud A, Khurana B, Chiodo C, Weissman BN. Women’s Musculoskeletal Foot Conditions Exacerbated by Shoe Wear: An Imaging Perspective. Am J Orthop (Belle Mead NJ). 2011;40(4):183–91.
  7. Mann RA, Reynolds JC. Interdigital Neuroma — A Critical Clinical Analysis. Foot & Ankle. 1983;3(4):238–243. doi: 10.1177/107110078300300411
  8. Wu KK. Morton’s interdigital neuroma: A clinical review of its etiology, treatment, and results. The Journal of Foot and Ankle Surgery. 1996;35(2):112–119. doi: 10.1016/s1067-2516(96)80027-5
  9. Jain S, Mannan K. The Diagnosis and Management of Morton’s Neuroma: A Literature Review. Foot & Ankle Specialist. 2013;6(4):307–317. doi: 10.1177/1938640013493464
  10. Bhatia M, Thomson L. Morton’s neuroma — Current concepts review. J Clin Orthop Trauma. 2020;11(3):406–409. doi: 10.1016/j.jcot.2020.03.024
  11. Colò G, Rava A, Samaila EM, Palazzolo A, Talesa G, Schiraldi M, Magnan B, Ferracini R, Felli L. The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art. Acta Bio Medica Atenei Parmensis. 2020;91(4-S):60–68. doi: 10.23750/abm.v91i4-S.9713
  12. Park CH, Chang MC. Forefoot disorders and conservative treatment. Yeungnam University Journal of Medicine. 2019;36(2):92–98. doi: 10.12701/yujm.2019.00185
  13. Saygi B, Yildirim Y, Saygi EK, Kara H, Esemenli T. Morton neuroma: comparative results of two conservative methods. Foot & Ankle International. 2005;26(7):556–559. doi: 10.1177/107110070502600711
  14. Thomson L, Aujla R, Divall P, Bhatia M. Non-surgical treatments for Morton’s neuroma: A systematic review. Foot and Ankle Surgery. 2020;26(7):736–743. doi: 10.1016/j.fas.2019.09.009
  15. Di Caprio F, Meringolo R, Eddine MS, Ponziani L. Morton’s interdigital neuroma of the foot: A literature review. Foot and Ankle Surgery. 2018;24(2):92–98. doi: 10.1016/j.fas.2017.01.007
  16. Gougoulias N, Lampridis V, Sakellariou A. Morton’s interdigital neuroma: instructional review. EFORT Open Reviews. 2019;4(1):14–24. doi: 10.1302/2058-5241.4.180025
  17. Munir U, Tafti D, Morgan S. Morton Neuroma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
  18. Ruiz SF, Olleta NP, Muñoz PT, Álvarez LG, Martínez AM. Short term comparison between blind and ultrasound guided injection in morton neuroma. European Radiology. 2019;29(2):620–627. doi: 10.1007/s00330-018-5670-1
  19. Lizano-Díez X, Ginés-Cespedosa A, Alentorn-Geli E, Pérez-Prieto D, González-Lucena G, Gamba C, de Zabala S, Solano-López A, Rigol-Ramón P. Corticosteroid Injection for the Treatment of Morton’s Neuroma: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial. Foot & Ankle International. 2017;38(9):944–951. doi: 10.1177/1071100717709569
  20. Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. The Journal of Foot and Ankle Surgery. 1999;38(6):403–408. doi: 10.1016/s1067-2516(99)80040-4
  21. Gurdezi S, White T, Ramesh P. Alcohol Injection for Morton’s Neuroma: A Five-Year Follow-Up. Foot & Ankle International. 2013;34(8):1064–1067. doi: 10.1177/1071100713489555
  22. Perini L, Perini C, Tagliapietra M, Varotto D, Valcarenghi A, Postorino A, Volpe A. Percutaneous alcohol injection under sonographic guidance in Morton’s neuroma: follow-up in 220 treated lesions. La radiologia medica. 2016;121(7):597–604. doi: 10.1007/s11547-016-0622-9
  23. Campbell CM, Diamond E, Schmidt WK, Kelly M, Allen R, Houghton W, Brady KL, Campbell JN. A randomized, double-blind, placebo-controlled trial of injected capsaicin for pain in Morton’s neuroma. Pain. 2016;157(6):1297–1304. doi: 10.1097/j.pain.0000000000000544
  24. Chuter GSJ, Chua YP, Connell DA, Blackney MC. Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton’s) neuroma. Skeletal Radiology. 2013;42(1):107–111. doi: 10.1007/s00256-012-1527-x
  25. Frush K, Niester A. Revision of Recurrent Neuromas. Clinics in Podiatric Medicine and Surgery. 2020;37(3):521–532. doi: 10.1016/j.cpm.2020.03.007
  26. Lee KT, Kim JB, Young KW, Park YU, Kim JS, Jegal H. Long-Term Results of Neurectomy in the Treatment of Morton’s Neuroma: More Than 10 Years’ Follow-up. Foot & Ankle Specialist. 2011;4(6):349–353. doi: 10.1177/1938640011428510
  27. Richardson DR, Dean EM. The Recurrent Morton Neuroma: what now? Foot and Ankle Clinics. 2014;19(3):437–449. doi: 10.1016/j.fcl.2014.06.006
  28. Pereira R, Dauphinee D, Frania S, Garrett A. Clinical evaluation of an innovative nerve termination cap for treatment and prevention of stump neuroma pain: Results from a prospective pilot clinical study. Foot & Ankle Surgery: Techniques, Reports & Cases. 2022;2(2):100179. doi: 10.1016/j.fastrc.2022.100179
  29. Adnan FA, Acuth H. The outcome after using two different approaches for excision of Morton’s neuroma. Chinese Medical Journal. 2010;123(16):2195.

Supplementary files

Supplementary Files
Action
1. JATS XML
Download
2. Fig. 1. Staged magnetic resonance imaging MRI of patient S.: a — september 2020: two hypointensive lesion in the second and third interdigital spaces; b — september 2021: two hypointensive lesion in the second and third interdigital spaces. When compared with MRI from 2020, an increase in signal intensity (decrease fibrosis density).

Download (84KB)
Indexing metadata
3. Fig. 2. The first stage of surgical treatment: a — revision of the second plantar nerve: separation of the stump, pronounced adhesive process; b — nerve stump after resection, the end of the nerve is acutely formed, a 2% lidocaine solution is injected into of the nerve trunk; c — the formed nerve stump is integrated in the transverse head of M. adductor hallucis, fixed by the absorbable thread PDS 5/0.

Download (413KB)
Indexing metadata
4. Fig. 3. The second stage of surgical treatment: a — the appearance of the postoperative scar, hypertrophied areas of connective tissue; b — small plantar approach for revision the hypertrophied scar; c — dorsal approach, the arrow shows Morton’s neuroma; d — the appearance of the plantar scar 3 months after surgery; e — the resected section of the third interdigital nerve obtained by us, directed at histological examination.

Download (438KB)
Indexing metadata
5. Fig. 4. The graph of the pain assessed by the patient on a visual analog scale VAS, from the debut moment of the disease to six months after the final stage of surgical treatment.

Download (203KB)
Indexing metadata

Copyright (c) 2023 Eco-Vector

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies