Tumours of the foot: A 10 years retrospective analysis.

INTRODUCTION: The foot is a complex structure composed of several tissues, each of which can be the origin of the proliferation and development of the tumour. Most lesions about the foot are reactive or inflammatory, but some are true neoplasms. METHOD: This is a retrospective analysis of 4997 patient records treated in the Orthopaedic Oncology Unit of University Malaya Medical Centre, Malaysia, between 1 January 2010 to 31 December 2020. Demographic data of 195 patients with foot tumours were analysed out of 4997 neoplasm patients. RESULTS: There were 195 cases of foot tumours: 148 were benign, and 47 were malignant. 47 were bone tumours, 4 were metastases, and 144 were soft tissue tumours. Six patients succumbed to the disease, two cases of giant cell tumour (GCT) and one patient with synovial sarcoma had a recurrence. Treatment of foot tumours was wide resection in general. However, in metastasis cases, amputation was done. The majority of tumours were in the toes and dorsum of the foot. Soft tissue tumours of the foot occur in the elderly population in contrast to bone tumours, mainly in the second decade of life. The gender distribution was almost equal for foot tumours. Ganglion and Giant Cell Tumour of the bone are the commonest benign soft tissue and bone tumours. The most common malignant soft tissue and bone tumours are malignant melanoma and chondrosarcoma. The amputation rate is 5.64% the recurrence rate is 1.54%. Mortality rate is 3.08%. The MSTS score is 79%, and the TESS score is 76.23%. CONCLUSION: Foot tumours are relatively rare, mostly originating from soft tissue and exhibiting a benign nature. Nonetheless, a noteworthy proportion-approximately a quarter of these tumours-demonstrate malignancy. The surgical interventions undertaken in managing these tumours and associated functional outcomes generally yield acceptable results.

[Comparison of talonavicular-cuneiform joint fusion with bone grafting and without bone grafting in treatment of Müller-Weiss disease].

Objective: To compare the effectiveness of talonavicular-cuneiform joint fusion with iliac bone grafting and without bone grafting in the treatment of Müller-Weiss diseases (MWD). Methods: The clinical data of 44 patients (44 feet) with MWD who received talonavicular-cuneiform joint fusion between January 2017 and November 2022 and met the selection criteria was retrospectively analyzed. Among them, 25 patients were treated with structural iliac bone grafting (bone grafting group) and 19 patients without bone grafting (non-bone grafting group). There was no significant difference ( P>0.05) in age, gender composition, body mass index, disease duration, affected side, Maceira stage, and preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, anteroposterior/lateral Meary angle, and Pitch angle between the two groups. Operation time, operation cost, and postoperative complications were recorded in the two groups. AOFAS and VAS scores were used to evaluate the function and pain degree of the affected foot. Meary angle and Pitch angle were measured on the X-ray film, and the joint fusion was observed after operation. The difference (change value) of the above indexes before and after operation was calculated for comparison between groups to evaluate the difference in effectiveness. Results: The operation was successfully completed in both groups, and the incisions in the two groups healed by first intention. The operation time and cost in the bone grafting group were significantly more than those in the non-bone grafting group ( P<0.05). All patients were followed up. The median follow-up time was 41.0 months (range, 16-77 months) in the non-bone grafting group and 40.0 months (range, 16-80 months) in the bone grafting group. There was skin numbness of the medial dorsalis of the foot in 1 case, internal fixation stimulation in 2 cases, and pain at the iliac bone harvesting area in 1 case of the bone grafting group. There was skin numbness of the medial dorsalis of the foot in 1 case and muscle atrophy of the lower limb in 1 case of the non-bone grafting group. There was no significant difference in the incidence of complications between the two groups ( P>0.05). At last follow-up, the AOFAS scores of the two groups significantly improved when compared with those before operation, while the VAS scores significantly decreased, the anteroposterior/lateral Meary angle and Pitch angle significantly improved, and the differences were significant ( P<0.05). There was no significant difference in the change values of outcome indicators between the two groups ( P>0.05). There was no delayed bone union or bone nonunion in both groups, and joint fusion was achieved at last follow-up. Conclusion: In the treatment of MWD, there is no significant difference in effectiveness and imaging improvement of talonavicular-cuneiform joint fusion combined with or without bone grafting. However, non-bone grafting can shorten the operation time, reduce the cost, and may avoid the complications of bone donor site.

Müller-Weiss Disease: Midfoot Arthrodesis in Reduction vs Malreduction.

BACKGROUND: Midfoot arthrodesis is regarded as the main surgical approach for treating Müller-Weiss disease (MWD). This study aimed to investigate the incidence of postoperative pain during MWD treatment through midfoot reduction or malreduction during arthrodesis and to explore the factors influencing postoperative pain in patients with MWD. METHODS: A total of 67 patients with MWD were recruited and divided into two groups according to whether midfoot alignment was reduced: reduction group (n = 38) and malreduction group (n = 29). Demographic characteristics before the operation and at the last follow-up, as well as clinical and radiographic parameters, were compared between the two groups. Clinical parameters included the American Orthopaedic Foot & Ankle Society score and visual analog scale score, whereas radiographic parameters included the calcaneal pitch angle, lateral Meary's angle, talometatarsal-1 angle dorsoplantar (TMT1dp), talocalcaneal angle dorsoplantar (Kite angle), talonavicular coverage angle, and medial navicular pole extrusion. Postoperative complications and incidence of midfoot pain were evaluated at the last follow-up visit. RESULTS: The reduction group exhibited better clinical and radiological parameters, including the TMT1dp and medial navicular pole extrusion, than the malreduction group at the last follow-up (all P < .05). However, the calcaneal pitch angle, lateral Meary's angle, Kite angle, and talonavicular coverage angle did not significantly differ between the two groups (all P > .05). The overall incidence of midfoot pain was 26.4%. The reduction group showed a lower incidence of medial pain than the malreduction group (15.7% vs. 40.0%, P < .05). Regression analysis revealed that midfoot abduction, represented by the TMT1dp, was a critical factor for midfoot arthrodesis failure and that medial navicular pole extrusion was not correlated with postoperative midfoot pain. CONCLUSION: Midfoot reduction arthrodesis yields better clinical outcomes than malreduction arthrodesis. The TMT1dp, representing midfoot abduction, is a key factor for midfoot arthrodesis failure. The extruded medial navicular bone may not affect postoperative medial midfoot pain. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Novel Update on the Management of Müller-Weiss Disease: Presentation of a Treatment Algorithm.

OBJECTIVE: Müller-Weiss disease (MWD) is a challenging condition involving the perinavicular region in the initial stages and subsequently the entire foot in the later stages. The goal of this article is to describe the pathomechanics, clinical evaluation, and nonoperative and operative treatment, including a treatment algorithm, based on current evidence and the combined authors' experience. DESIGN: We review the related articles and summarize the information about this condition. RESULTS: A number of related articles reveal that the treatments should focus on the management of degenerative regions and deformity correction to restore normal foot alignment and provide pain relief. CONCLUSION: This systematic review proposes a treatment algorithm that is comprehensive and practical to apply for the management of MWD.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease.

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma.

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Müller-Weiss disease: a functional and quality of life assessment.

PURPOSE: Evaluate the functional health status and quality of life of patients diagnosed with Müller-Weiss disease and, secondarily, determine the influence of factors such as gender, social status, race, body mass index, and surgical and non-surgical treatment in patient outcome. METHODS: This study included 30 affected feet (18 patients) with follow-up from 2002 to 2016. Five patients were excluded from reassessment, resulting in 20 feet (13 patients). Questionnaires for functional and quality of life assessments were administered, and statistical analysis was performed. RESULTS: Patients with obesity had poor functional results and low quality of life rates. Regarding quality of life, mainly in the mental health domain, there was a significant difference (p < 0.001) that was not observed in other domains investigated, except for surgical treatment, which was superior to non-surgical treatment in terms of the physical domain (p = 0.024). Bilateral treatment was also superior to unilateral treatment in Coughlin's classification (71.4% versus 66.7%). CONCLUSIONS: Müller-Weiss disease evolved with poor functional results and low quality of life rates in patients with obesity, with no method of treatment influence on patient outcome, except for the SF-12 physical domain, where surgical treatment showed better results than conservative treatment.

Towards understanding Müller-Weiss disease from an analysis of 95 cases.

BACKGROUND: The single existing classification of Müller-Weiss Disease (MWD), based solely upon Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. METHODS: Navicular compression, medial extrusion, metatarsal lengths, Kite's, lateral and dorsoplantar talo-first metatarsal angles were measured in 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. RESULTS: Group 1 "early-onset" MWD feet (n = 11) had greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had lateral navicular fracture. Only 1 had moderate degeneration at the talonavicular joint (TNJ) with none requiring surgery yet. Group 2 "Müller-Weissoid" feet (n = 23) had radiologically normal navicular in their fifties and developed MWD on average 5 years later. They had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 "late-onset" MWD presented in the sixth decade. Only TNJ was involved in Group 3 A (n = 16). Group 3B (n = 20) affected TNJ more than NCJ and had the greatest number of Maceira stage V disease. Group 3 C "reverse Müller-Weiss disease", which affected NCJ more than TNJ (n = 25), had greatest midfoot abduction and overlength of the second metatarsal. No fracture occurred in group 3 A compared to 65% and 32% in groups 3B and 3 C, respectively. CONCLUSIONS: With need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatments. We theorize pathogenetic pathways in the various groups.

Evaluation of locking compression plate fixation of the distal phalanx to the hoof wall as a potential therapy for laminitis.

BACKGROUND: Surgical stabilisation of the distal phalanx (DP) is a potential therapeutic strategy for severe acute laminitis. OBJECTIVE: To evaluate the effects of locking compression plate (LCP) fixation of the DP to the dorsal hoof wall. STUDY DESIGN: Ex vivo and in vivo experiments. METHODS: A T-shaped LCP was applied to one limb per pair in six pairs of cadaver forelimbs subjected to a combination of thermally induced lamellar failure and vertical load to simulate severe acute laminitis. Standard radiographic measurements were used to compare DP displacement. The LCP was then applied to one forefoot in 12 healthy Standardbred horses either standing (n = 6) or under general anaesthesia (n = 6). Lameness was evaluated daily, then horses were euthanised (day 8) and lamellar tissue analysed using light microscopy, histomorphometery and molecular markers of apoptosis. RESULTS: In the cadaver limb model, LCP fixation prevented the significant changes in hoof-distal phalanx distance, coronary extensor process distance and sole depth that characterised DP displacement in untreated limbs (p < 0.05). Application of the construct in vivo was well tolerated with minimal lameness (10/12 horses were sound at the trot on day 8); however, histology revealed dorsal lamellar pathology consistent with laminitis, but with extensive keratinocyte apoptosis. Adjacent to the LCP, caspase-3 positive cell counts were approximately 20-fold higher than control (p < 0.001). MAIN LIMITATIONS: Pathology was evaluated at a single time point. Microvascular perfusion was not evaluated. CONCLUSIONS: Rigid fixation of the DP to the hoof capsule was achieved with the LCP construct in a cadaver limb laminitis model. In live horses, LCP fixation caused regional lamellar pathology with extensive apoptosis, likely due to disturbed lamellar microvascular perfusion and/or mechanostasis. Understanding these mechanisms is critical for refinement of the technique in order to avoid iatrogenic lamellar damage.

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.

Lesions found at foot trimming of dairy goats: Baseline data for comparing lesions and locomotion scoring.

Data on the foot lesions of housed dairy goats, especially those that are not lame, is sparse. In this study, visits were made to four farms for whole herd locomotion scoring after milking and to observe routine foot trimming. During trimming, the amount of trimming required for each hoof was recorded, alongside the presence of lesions. The process was repeated at the next routine foot trim on three of the four farms (on Farm 1 whole herd locomotion scoring after milking was not feasible). Across both visits, 3445 locomotion scores were recorded, alongside 3850 trimming and lesion records. There were large differences between farms and visits in the proportion of lame goats (6.7 to 25.5%) and in the proportion of goats which needed a substantial trim of all four feet (15.1-33.1%). Hoof lesions were observed in 65.5% of trimmed goats. We defined lesions by their site and presence of separation and/or granuloma, with white line separation being the most commonly recorded lesion (41.5% of goats). On all visits on the three farms which were locomotion scored, the number of goats recorded as lame was lower than the number observed with white line lesions, but the relative proportion ranged from 17% to 95.4%. Separations were much more common than granulomas, as granulomas were usually accompanied by separation. Toe lesions were much more likely to be associated with granulomas than white line lesions, with 91.5% of toe separations having granulomas but only 10.6% of white line separations. This study provides useful baseline data for comparing lesions and locomotion scoring between goat herds but also identifies areas where we need more data and more consensus.

Postoperative MRI of the Ankle and Foot.

Many surgical procedures and operations are used to treat ankle and foot disorders. Radiography is the first-line imaging for postoperative surveillance and evaluation of pain and dysfunction. Computed tomography scans and MR imaging are used for further evaluation. MR imaging is the most accurate test for soft tissues assessments. MR imaging protocol adjustments include basic and advanced metal artifact reduction. We chose a surgical approach to select the common types of procedures and discuss the normal and abnormal postoperative MR imaging appearances, highlighting potential complications. This article reviews commonly used surgical techniques and their normal and abnormal MR imaging appearances.

NEMISIS: Neuropathic Minimally Invasive Surgeries. Charcot Midfoot Reconstruction, Surgical Technique, Pearls and Pitfalls.

The last decade has seen a significant development in early surgical intervention for patients with or at risk of ulceration owing to deformity resulting from the sequalae of diabetic foot disease. Midfoot Charcot neuroarthropathy is the most common deformity; its correction is enabled by specialized surgical implants designed to maintain surgical corrections. There has also been an increasing number of orthopedic foot and ankle surgeons, with a specific interest in diabetic foot disease who provide early surgical correction in patients identified as high risk. Minimally invasive surgery using percutaneous incisions completes the triumvirate, facilitating earlier surgical intervention to decrease reulcerations.

Managing Acute Fore- and Midfoot Fractures in Patients with Diabetes.

Few is investigated about the management of acute fore- and midfoot injuries in diabetics. With well controlled diabetes, indications and techniques are similar to non-diabetics. With poorly controlled diabetes, medical optimization should be exercised. Stable internal fixation in case of surgical treatment and prolonged offloading independent of the choice of treatment are advised. With manifest Charcot neuroarthropathy, the goal is to achieve a plantigrade, stable foot that is infection- and ulcer-free and ambulant with orthopaedic shoes. If operative treatment is chosen, the concept of superconstructs in combination with prolonged protection in a well-padded total contact cast is applied.

Efficacy of Triple and Talonavicular Arthrodesis for the Treatment of III-V Müller-Weiss Disease.

Müller-Weiss Disease (MWD) is a rare foot disease with unclear etiology but frequently occurred in women. Due to the resistance to conservative treatment, surgical therapy has gradually occupied a necessary position in the clinical management of MWD. Joint fusion surgery is a commonly used treatment for MWD, which could effectively alleviate pain, correct deformation, and restore function. A total of 12 MWD patients (III-V stage) were enrolled in this study. All patients showed no significant improvement in conservative treatment and further received the triple and talonavicular arthrodesis. All patients were followed up with an average follow-up of 16.8 ± 1.19 months (mean ± SD). The triple and talonavicular arthrodesis significantly ameliorated the pain and walking dysfunction in the affected foot. The American Orthopedic Foot Andankle Society (AOFAS) scores dramatically increased from 43.4 ± 16.1 to 85.3 ± 6.2. Meanwhile, the conducting of triple and talonavicular arthrodesis improved the X-ray length (15.5 ± 0.8 vs. 14.3 ± 0.9 cm) and arch height (18.6 ± 0.9 vs. 10.2 ± 0.7 mm) and reduced the Meary-Tomeno angle (1.3 ± 2.5 vs. 2.14 ± 4.8°). The triple and talonavicular arthrodesis achieved a satisfying therapeutic effect on MWD patients at the III-V stage, which improved patients' outcomes and the quality of life.

Radiographic features of subungual keratoacanthomas in dogs.

Subungual keratoacanthoma (SK) is a digital neoplasm that has rarely been reported in dogs and carries an excellent prognosis following surgical removal. Radiographic features of canine SK have only been briefly discussed in two prior case reports. Both articles described extensive distal phalangeal osteolysis, a feature more commonly associated with malignant digital neoplasms (e.g., subungual squamous cell carcinoma (SCC) or melanoma). This retrospective case series aimed to further characterize radiographic findings of histologically confirmed canine SK. Seven dogs met the inclusion criteria, with a total of seven affected digits. All seven digits (100%) had osteolysis of the distal phalanx's ungual process and crest, as well as regional soft tissue swelling. Osteolysis of the ungual process was severe in all cases, with complete destruction in six of seven digits (86%). Partial ungual crest geographic and expansile osteolysis was noted in four of seven digits (57%), while two digits (28%) had complete ungual crest destruction. Seven of seven digits (100%) had a radiographically thickened claw, and two of seven digits (28%) had associated lysis of the distal aspect of the middle phalanx. Based on these findings, an osteolytic subungual mass should not be considered pathognomonic for malignant neoplasia. Observing the imaging features previously described should prompt veterinarians to consider SK as a differential diagnosis.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma.

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14-189) months. The mean age was 49 (range 15-71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

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

BACKGROUND: Surgical treatment of Morton's neuroma remains controversial. Several surgical techniques have been described including percutaneous transection of the deep metatarsal transverse ligament (DMTL). PURPOSE: To evaluate the efficacy and safety of percutaneous release of the DMTL under ultrasound guidance for the treatment of Morton's syndrome. MATERIALS AND METHODOLOGY: Percutaneous 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. RESULTS: The 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. CONCLUSION: Percutaneous 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.

Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton's neuroma and correlation with intraoperative anatomical variations.

BACKGROUND: Morton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT). OBJECTIVES: This retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve. MATERIAL AND METHODS: The study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016. RESULTS: The mean pre-operative Giannini score of 13 (0-30) improved to 61 (20-80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin's criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome. CONCLUSION: Dividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible. LEVEL OF EVIDENCE: Level IV - Case Control Retrospective study.

Presurgical Perspective and Postsurgical Evaluation of Morton's Neuroma and Other Nerve Lesions.

Magnetic resonance imaging (MRI) is a robust method used for both preoperative and postoperative evaluation of Morton's neuroma and other neural lesions. MRI is used to confirm the diagnosis and for precise localization, estimation of outcome, and differential diagnoses. The differential diagnoses include mechanically induced plantar plate ruptures with associated Morton's neuroma-like tumors in the intermetatarsal/interdigital spaces; mechanical fibrosis cushion formations and pseudo bursae in the plantar foot adipose tissue; rheumatologic affections, such as rheumatoid nodules, gouty nodules, and intermetatarsal bursitis; and lastly the tenosynovial giant cell tumor (formerly called pigmented villonodular synovitis). In the postoperative evaluation after resection of Morton's neuroma, the same differential diagnoses must be considered as in the preoperative evaluation. Similarly, a high prevalence (up to 25%) of asymptomatic Morton's neuroma-like findings in the intermetatarsal and interdigital spaces should be kept in mind when interpreting postoperative recurrent forefoot pain after Morton's neuroma resection.