First webspace Morton's neuroma case report with literature review

Morton's neuromas are benign lesions of the inter-digital nerves within the foot. They are most commonly found in the second and third webspace. Morton's neuroma of the first webspace is very rare. A case of a 42-year-old female who presented complaining of long standing forefoot pain is presented. The patient was diagnosed with a soft tissue tumor in the 1st webspace. An excisional biopsy of the tumour confirmed a Morton's neuroma. Very few cases of Morton's neuroma in the first webspace have been reported in the literature.     

HISTOLOGICAL COMPARISON OF THE THIRD INTERDIGITAL NERVE IN PATIENTS WITH MORTON'S METATARSALGIA AND CONTROL PATIENTS

This study compares the histology of the plantar-digital nerve supplying the third web space in asymptomatic patients with those who have clinically diagnosed Morton's metatarsalgia. Despite several studies concentrating on the histological changes in the interdigital nerve, the relevance of these changes is a matter of contention while the exact pathological process responsible for the symptoms has not been determined. The histological findings in control patients were identical to Morton's patients with the exception of demyelination, which was more common in the Morton's group. This suggests that the characteristic nodule and fibrotic changes seen in the interdigital nerves of patients with Morton's neuroma cannot account for the symptoms and that the changes seen in the neurovascular bundle are degenerative in origin and are found in asymptomatic patients.     

Contribution of a new electrophysiologic test to Morton's neuroma diagnosis

BackgroundMorton's neuroma causes metatarsalgia due to the interdigital neuropathy. The small nerve diameter compromises their evaluation in image studies. To overcome this problem we propose a new electrophysiological test.MethodsWe conducted a prospective case–control study performing a orthodromic electroneurography using subdermal electrodes in controls and patients to assess the validity. Additionally all patients were tested with magnetic resonance. Some patients required surgery and subsequent histological evaluation.ResultsThe new ENG procedure showed higher sensitivity and specificity. Methodological standardization was easy and the test was well tolerated by the subjects.ConclusionsOur test demonstrated remarkable diagnostic efficiency, and also was able to identify symptomatic patients undetected by magnetic resonance, which underlines the lack of correlation between the size and intensity of the lesion. This new electrophysiological method appears to be a highly sensitivity, well-tolerated, simple and low-cost for Morton's neuroma diagnosis.     

Regenerative surgery of the complications with Morton's neuroma surgery: use of platelet rich plasma and hyaluronic acid

Morton's neuroma is an entrapment neuropathy of the plantar digital nerve. We treated five patients with wound dehiscence and tendon exposure, after Morton's neuroma surgery excision using a dorsal approach. In this article we describe our technique. From July 2010 to August 2011, at the Department of Plastic and Reconstructive Surgery, University of Rome ‘Tor Vergata’, five patients (four females and one male), with ages ranging between 35 and 52 years, were treated with a combination of PRP (platelet rich plasma) and HA (hyaluronic acid). Thirty days following surgery, all patients showed a complete healing of the wound. The use of this technique for the treatment of postoperative wound dehiscence and tendon exposure has proven as satisfactory.     

Misdiagnosis of plexiform neurofibroma of the medial plantar nerve: Case report

Plexiform neurofibromas are benign tumors of the peripheral nerve. Diagnosis may be challenging, if they present mimicking other peripheral nerve pathologies.We report the case of a patient who had severe foot pain, which progressively hampered her walking ability, erroneously attributed to recurrent Morton's neuroma. Diagnosis of plexiform neurofibroma of her right medial plantar nerve was made 15 years after the appearance of symptoms.Pain and function recovered after radical neurotomy of the medial plantar nerve. A correct diagnosis is an essential starting point in the treatment of neurofibromas and a misdiagnosis may lead to an inappropriate treatment.     

Minimally Invasive Intermetatarsal Nerve Decompression for Morton's Neuroma: A Review of 27 Cases

Minimally invasive nerve decompression for operative management of Morton's neuroma has been shown to be an effective alternative to neurectomy; however, little is known about postoperative outcomes. In this retrospective case series, we reviewed 27 procedures in 25 patients who underwent minimally invasive nerve decompression as primary surgical management for Morton's neuroma. Most subjects (22, or 88%) had 12 or more months of health plan enrollment postoperatively; 3 (12%) had 4 to 7 months of enrollment after the procedure. Postoperative patient satisfaction, complications and the need for a follow-up neurectomy were ascertained from medical record review. Additionally, demographic and clinical data were extracted from electronic sources. Patient satisfaction was unknown for 5 (18.5%) of the 27 procedures. Among the 22 (81.5%) procedures for which there were valid patient satisfaction data, patient satisfaction was excellent for 11 (50%); good for 2 (9.1%), and poor for 9 (40.9%). During the follow-up period, 5 (18.5%) patients required an open neurectomy. Among the 6 (22.2%) patients who presented without a Mulder's sign on physical exam preoperatively, 83% reported excellent results. Minimally invasive nerve decompression may not be as effective as previously seen; however, it may be indicated in patients presenting with absence of a Mulder's sign, a physically small or nascent neuroma.     

Treatment of Recalcitrant Intermetatarsal Neuroma With 4% Sclerosing Alcohol Injection: A Pilot Study

The purpose of this investigation was to conduct a prospective trial to assess the effectiveness of a 4% sclerosing alcohol injection in a small group of patients with intermetatarsal neuromas who had failed previous conservative therapies including corticosteroid injections. Six patients with 8 neuromas were followed for a mean 346 days. A weekly series of 3-9 injections containing 1 mL of the 4% alcohol sclerosing solution were given based on patient response to treatment. Pre- and posttreatment surveys consisting of both objective and subjective findings including a visual analog pain scale were collected. The average pretreatment visual analog pain rating was 7.5 +/- 1.14. The average posttreatment visual analog pain rating was 1.38 +/- 2.39 with an average reduction of 6.13. The average reported improvement in symptoms was 73%. Five of the 6 patients would recommend the treatment to a friend or family member. No complications were encountered. Two neuromas in 2 patients failed the sclerosing injection course: 1 ultimately responded to antiinflammatory use and the other underwent excision.     

Mitchell's osteotomy in the management of hallux valgus: An Indian perspective

Background:

Hallux valgus is a common condition that affects the forefoot. A large number of procedures are described for managing this condition. Mitchell''s osteotomy and its modifications are being widely used for treating hallux valgus. However, most of the studies describe the results from the developed world. We present results of the classic Mitchell''s osteotomy in hallux valgus in Indian subcontinent.

Materials and Methods:

Forty eight adult patients (including 12 bilateral ones) in the age range of 18–60 years with hallux valgus were managed with the classic Mitchell''s osteotomy. Pain over the bunion was the reason for surgery in 53 of 60 feet and cosmesis in the remaining 7 feet. Patients with hallux valgus angle more than 20° and not responding to a trial of conservative treatment were included. Patients having metatarsophalangeal (MTP) joint osteoarthritis (Grade II and higher), hallux rigidus, rheumatoid arthritis, and with subluxation of MTP joint were excluded from the study. Further, patients with first metatarsal more than 3 mm shorter than second metatarsal were also excluded.

Results:

The average follow-up period is 3 yrs (range 18months – 6yrs). About 55 feet (83%) were painless after surgery. Forty-two (70%) patients were happy with the cosmetic results of the surgery. Metatarsalgia was the reason for dissatisfaction with the procedure in five patients. The average correction of hallux valgus and the intermetatarsal angles achieved was 19.7° and 6.9°, respectively. Using the Broughton and Winson scoring system, 37 (61.7%) feet had excellent results, 18 (30%) had good, and five (8.3%) feet had a poor results.

Conclusion:

The classic Mitchell''s procedure is a simple procedure and gives good cosmetic and radiological results.     

Trends In Acoustic Neuroma Management: A 20-Year Review of the Oxford Skull Base Clinic

Objective To describe the change in the management of acoustic neuromas at one United Kingdom center over a 20-year period and to compare this with what is known regarding trends in practice on a national and international scale.Design, Setting, and Participants Data was collected prospectively on all patients attending the Oxford Skull Base Clinic between 1990 and 2009.Main Outcome Measures The proportion of patients managed initially by observation versus radiotherapy versus surgery was recorded for each year.Results Significantly more patients received radiation treatment (instead of surgery) between 2000 and 2009 when compared with 1990 to 1999. Compared with national audit data, the Oxford Skull Base Clinic treats a higher proportion of patients with radiotherapy and significantly lower proportion with surgery, though the trend nationally is toward more observation and radiotherapy and less surgery.Conclusion Surgery will remain crucial in the management of some patients with acoustic neuromas (usually those with the larger tumors where radiosurgery is recognized to be less appropriate), but using current trends to predict future practice would suggest that alternative nonmicrosurgical treatment may play an increasingly important role in the future.     

Iselin's Disease: A Systematic Review

Iselin's disease was first described in 1912. It is a condition affecting the tuberosity of the base of the fifth metatarsal. It has been described as a traction apophysitis predominately affecting adolescents, in particular those who partake in regular sporting activity. The condition is rarely reported and likely to remain undiagnosed, possibly mistaken for a fracture. The present report reviewed the available published data to highlight this condition as a differential diagnosis in patients with fifth metatarsal pain. Investigations, treatments and outcomes into this condition are described, to support the management and diagnosis of this condition.     

Post-operative Outcomes for Vascular Rings: A Systematic Review and Meta-analysis

ObjectivesVascular rings may cause tracheal and/or oesophageal compression. For many patients, symptoms/signs have been present for a long period before diagnosis. However, in the era of prenatal diagnosis, some units advocate universal early surgery. The risks and efficacy of surgery must be known to adequately counsel for the operation. This meta-analysis sought to define the morbidity and mortality associated with surgical correction, and persistent post-operative symptoms.MethodsPubMed, Cochrane Library and CINAHL databases were searched for studies that described the outcome of patients undergoing surgery for a double or right aortic arch (DAA or RAA). Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled rates of mortality, surgical complications, reintervention, and persistent follow-up symptoms.ResultsNineteen eligible studies were included comprising 18 studies describing outcomes for DAA surgery and 15 for RAA surgery. For DAA surgery, overall mortality rate was 0% [95% confidence interval (CI) 0.0–1.0], post-surgical complication rate 18% [95% CI: 12.0–23.0], prevalence of reintervention 3% [95% CI: 1.0–5.0] and prevalence of symptoms at last follow-up was 33% [95% CI: 17.0–52.0]. For RAA surgery, overall pooled mortality was 0% [95% CI: 0.0–0.0], prevalence of post-surgical complications was 15% [95% CI: 8.0–23.0], reintervention rate was 2% [95% CI: 0.0–4.0], prevalence of symptoms at last follow-up was 40% [95% CI: 26.0–55.0].ConclusionsWhile surgery to correct a vascular ring is safe, the rate of persistent symptoms is high and further strategies must be sought to reduce this burden.     

Evidence-Based Rationale for Percutaneous Fixation Technique of Displaced Intra-Articular Calcaneal Fractures: A Systematic Review of Clinical Outcomes

Displaced intra-articular fractures of the calcaneus are complex and have a high degree of morbidity. Percutaneous fixation techniques have been advocated in an effort to minimize postoperative complications. We performed a systematic review of the clinical outcomes to describe and ascertain the different techniques and clinical outcomes for percutaneous treatment of displaced intra-articular calcaneal fractures. A review was performed using PubMed and Google Scholar, from January 2000 to December 2012, with studies ranging from case reports to prospective studies. The inclusion criteria consisted of percutaneous fixation techniques with objective findings (Sander's classification and Bohler's angle measurements) and clinical outcome scoring and complication and subtalar fusion rates. The exclusion criteria included studies with open or limited open procedures, the use of external fixation, the use of bone substitutes alone, and pathologic or open fractures. Data and evidence with a combination of objective findings and clinical outcomes are lacking. Several techniques for percutaneous fixation have been described, including Schanz pins and Kirschner wires, cannulated screws, arthroscopically guided percutaneous fixation, and application of bone substitute. A myriad of techniques are available for percutaneous intra-articular calcaneal fixation. The results from the current data appear to be promising; however, the lack of statistical power and inconsistent documentation have made it difficult to determine any superiority. The complication rates were much lower than those with open procedures, regardless of the technique. The percutaneous fixation technique appears to be a favorable option for displaced intra-articular calcaneal fractures.     

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.     

A Retrospective Review of the Weil Metatarsal Osteotomy for Lesser Metatarsal Deformities: An Intermediate Follow-up Analysis

The purpose of this retrospective clinical study was to determine the clinical results of the Weil metatarsal osteotomy. There were 51 patients (89 procedures), consisting of 10 males and 41 females, with a mean 53.1 +/- 11.9 years. Patients were evaluated for subjective improvement on a scale from 0 to 10, and asked if they would repeat the procedure. They were evaluated functionally using the American Orthopedic Foot and Ankle Society's lesser metatarsal rating scale, and assessed for toe purchase and range of motion. Thirty-nine point two percent of patients reported a complete resolution of pain (10/10 points), with 13.7% reporting a score of < or = 5/10. Eighty percent of the patients would repeat the procedure. The most common complication was toe elevation in 33% of patients. Joint range of motion was reduced in most cases. Thirty five patients experienced no pain at end range of motion, 6 related significant pain and 9 patients experienced some pain. Patients who underwent the procedure as a prophylactic measure along with a first ray procedure formed a significant subgroup (31%). These patients also scored well in comparison to the remainder of patients, with a mean subjective score of 8.4/10 as compared with 7.9/10 for the remainder of patients. The prophylactic group also demonstrated a median functional rating scale score of 90, versus 80 for the remainder of patients. These findings suggest that the Weil metatarsal osteotomy is a useful procedure for metatarsalgia and may also be useful in preventing lesser metatarsalgia in conjunction with first metatarsal surgery.     

Percutaneous Needle Fasciotomy versus Collagenase Injection for Dupuytren’s Contracture: A Systematic Review of Comparative Studies

Introduction  The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren’s contracture. Materials and Methods  A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren’s contracture. Results  Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates. Conclusion  For the treatment of Dupuytren’s contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.     

Consecutive Kummell's Disease Combined with Parkinson's Disease and Experienced Internal Fixation Failure: A Case Report and Literature Review

BackgroundThe continuous occurrence of Kummell''s disease is extremely rare in clinical practice, and its treatment is difficult. The study aimed to present a rare case of consecutive Kummell''s disease combined with Parkinson''s disease (PD) and experienced internal fixation failure.Case presentationA 69‐year‐old female patient had a history of PD for 10 years, and was treated by posterior decompression, fixation, and fusion because of Kummell''s disease of T12 with neurological damage. The patient''s back pain and lower limb pain were significantly improved after surgery. Twenty‐two months later, the patient was rehospitalized for Kummell''s disease of L4 with neuropathic pain of left lower extremity. She received almost identical surgical procedures as T12 lesion, and the difference was no L4 vertebroplasty preformed due to the fact that the L4 vertebrae collapse was not obvious, the intravertebral vacuum cleft (IVC) range was small, and the pedicle screw fixation strength was high. The pain symptoms were significantly relieved after operation. Unfortunately, there was a complication of internal fixation failure that occurred a month later, and a revision operation was carried out.ConclusionOsteoporosis combined with PD may lead patients to become prone to consecutive Kummell''s disease, and patients are prone to experience failure of internal fixation. Bone cement filling of vertebral IVC and effective support of anterior vertebral column are very important procedures to ensure the clinical efficacy of treating Kummell''s disease.     

Dorello's Canal for Laymen: A Lego-Like Presentation

Objective Dorello''s canal was first described by Gruber in 1859, and later by Dorello. Vail also described the anatomy of Dorello''s canal. In the preceding century, Dorello''s canal was clinically important, in understanding sixth nerve palsy and nowadays it is mostly important for skull base surgery. The understanding of the three dimensional anatomy, of this canal is very difficult to understand, and there is no simple explanation for its anatomy and its relationship with adjacent structures. We present a simple, Lego-like, presentation of Dorello''s canal, in a stepwise manner.Materials and Methods Dorello''s canal was dissected in five formalin-fixed cadaver specimens (10 sides). The craniotomy was performed, while preserving the neural and vascular structures associated with the canal. A 3D model was created, to explain the canal''s anatomy.Results Using the petrous pyramid, the sixth nerve, the cavernous sinus, the trigeminal ganglion, the petorclival ligament and the posterior clinoid, the three-dimensional structure of Dorello''s canal was defined. This simple representation aids in understanding the three dimensional relationship of Dorello''s canal to its neighboring structures.Conclusion Dorello''s canal with its three dimensional structure and relationship to its neighboring anatomical structures could be reconstructed using a few anatomical building blocks. This method simplifies the understanding of this complex anatomical structure, and could be used for teaching purposes for aspiring neurosurgeons, and anatomy students.