ArticlePDF AvailableLiterature Review

Treatment of Morton’s neuroma: A systematic review

Authors:

Abstract and Figures

Background The treatment of Morton’s neuroma (MN) can be operative, conservative and infiltrative. Our aim was the evaluation of evidence on outcomes with different types of conservative, infiltrative and surgical treatment in patients affected by primary MN. Methods The bibliographic search was conducted in MEDLINE, Cochrane Library, DARE. Only studies in English were collected. The last search was in August 2015. Case series and randomized controlled trials (RCTs) assessing patients’ satisfaction or pain improvement at an average follow-up of at least 6 months after treatment of primary MN were included. Two reviewers selected the studies, evaluated their methodological quality, and retrieved data independently. Results Of 283 titles found, only 29 met the inclusion criteria. Data showed better outcomes with operative treatment. Conclusions The evaluated case series and few RCTs showed better results with invasive treatment. More and better RCTs which evaluate risk-benefit ratio are required to confirm these results.
Content may be subject to copyright.
Review
Treatment
of
Mortons
neuroma:
A
systematic
review
Silvia
Valisena,
MD
a,
*,
Gianfranco
John
Petri,
MD
b
,
Andrea
Ferrero,
MD
b
a
Service
of
Traumatology,
Regional
Hospital
of
Bellinzona,
Via
Ospedale,
Bellinzona,
Switzerland
b
Clinica
Luganese
Moncucco,
Via
Moncucco
10,
Lugano,
Switzerland
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
13
December
2016
Received
in
revised
form
17
February
2017
Accepted
28
March
2017
Available
online
xxx
Keywords:
Mortons
neuroma
Treatment
Surgery
Inltrative
Conservative
A
B
S
T
R
A
C
T
Background:
The
treatment
of
Mortons
neuroma
(MN)
can
be
operative,
conservative
and
inltrative.
Our
aim
was
the
evaluation
of
evidence
on
outcomes
with
different
types
of
conservative,
inltrative
and
surgical
treatment
in
patients
affected
by
primary
MN.
Methods:
The
bibliographic
search
was
conducted
in
MEDLINE,
Cochrane
Library,
DARE.
Only
studies
in
English
were
collected.
The
last
search
was
in
August
2015.
Case
series
and
randomized
controlled
trials
(RCTs)
assessing
patients
satisfaction
or
pain
improvement
at
an
average
follow-up
of
at
least
6
months
after
treatment
of
primary
MN
were
included.
Two
reviewers
selected
the
studies,
evaluated
their
methodological
quality,
and
retrieved
data
independently.
Results:
Of
283
titles
found,
only
29
met
the
inclusion
criteria.
Data
showed
better
outcomes
with
operative
treatment.
Conclusions:
The
evaluated
case
series
and
few
RCTs
showed
better
results
with
invasive
treatment.
More
and
better
RCTs
which
evaluate
risk-benet
ratio
are
required
to
conrm
these
results.
©
2017
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Contents
1.
Introduction
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
2.
Methods
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
2.1.
Criteria
for
considering
studies
for
this
review
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
2.2.
Data
collection
and
analysis
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
2.3.
Assessment
of
risk
of
bias
in
included
studies
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
2.4.
Data
synthesis
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.
Results
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.1.
Papers
selection
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.2.
Description
of
included
studies
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.3.
Participants
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.4.
Treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.5.
Primary
outcomes
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.5.1.
Conservative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.5.2.
Inltrative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.5.3.
Operative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.6.
Secondary
outcomes
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.6.1.
Conservative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.6.2.
Inltrative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.6.3.
Operative
treatment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.7.
Risk
of
bias
in
the
included
studies
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.7.1.
Case
series
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
3.7.2.
Randomized
controlled
trials
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
4.
Discussion
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
*
Corresponding
author
at:
Viale
Stazione
30,
Bellinzona
6500,
Switzerland.
E-mail
address:
silvia.valisena@gmail.com
(S.
Valisena).
http://dx.doi.org/10.1016/j.fas.2017.03.010
1268-7731/©
2017
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Foot
and
Ankle
Surgery
xxx
(2017)
xxxxxx
G
Model
FAS
1031
No.
of
Pages
11
Please
cite
this
article
in
press
as:
S.
Valisena,
et
al.,
Treatment
of
Mortons
neuroma:
A
systematic
review,
Foot
Ankle
Surg
(2017),
http://dx.doi.
org/10.1016/j.fas.2017.03.010
Contents
lists
available
at
ScienceDirect
Foot
and
Ankle
Surgery
journa
l
home
page
:
www.e
lsevier.com/loca
te/fas
4.1.
Summary
of
the
evidences
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
4.2.
Limitations
of
the
studies
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
5.
Conclusions
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Conict
of
interest
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Acknowledgements
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
References
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
1.
Introduction
Mortons
neuroma
(MN)
is
a
degenerative
neuropathy
featuring
brosis
of
the
common
interdigital
nerve
[1].
It
is
a
common
pathology
mainly
affecting
middle
age
women,
although
there
is
lack
of
data
on
its
frequency
[2].
Its
incidence
in
UK
was
50.2%
for
men
and
87.2%
for
women
per
100,000
of
patients
presenting
to
primary
care
[3].
Four
aetiopathogenetic
theories
have
been
proposed
[4],
chronic
traction
damage
[2],
inammatory
environment
due
to
intermetatarsal
bursitis
[5],
compression
by
the
deep
transverse
intermetatarsal
ligament
[6,7],
and
ischemia
of
vasa
nervorum
[8].
The
treatment
for
MN
is
initially
conservative,
progressing
to
inltrations
and
then
surgery,
if
the
previous
steps
fail,
according
to
the
therapeutical
algorithm
available
in
literature
[2,9,10].
The
treatments
considered
as
conservative
consist
in
patients
education
on
avoidance
of
tight
shoes,
manipulation
and
use
of
insoles
or
other
special
orthotic
appliances.
The
inltrative
treatments
include
injections
of
local
anaes-
thetics,
steroids
or
alcohol
and
percutaneous
radio-frequency
ablation.
The
surgical
treatments
consist
of
neurectomy
or
neurolysis,
which
can
be
performed
open,
either
via
a
dorsal
or
plantar
approach,
or
mini-invasive.
The
latter
is
aimed
at
decompressing
the
nerve
by
division
of
the
deep
intermetatarsal
ligament,
either
endoscopically
or
percutaneously.
The
studies,
which
assess
the
results
of
treatment,
have
a
follow-up
from
one
week
[11]
to
10
years
[12,13].
The
length
of
follow-up
allows
to
identify
durable
results
and
to
dene
complications
of
treatment,
failures
and
recurrences.
According
to
Mann,
it
takes
one
year
following
neurectomy
to
develop
a
symptomatic
amputation
neuroma,
after
a
pain-free
postoperative
period
[14].
The
aim
of
this
review
is
to
compare
the
outcomes
of
the
different
types
of
Mortons
neuroma
treatment.
Primary
outcome
denes
which
treatment
provides
the
best
result
at
an
average
follow-up
of
at
least
6
months
in
terms
of
patients
satisfaction,
improvement
of
pain
and
other
symptoms.
Patients
satisfaction
is
based
on
Johnsons
scale
[15]
and
other
scales.
Pain
was
measured
with
VAS
and
other
scales
(number
rating
scale,
NRS).
The
follow-
up
of
studies
on
conservative
treatment
usually
lasts
for
few
weeks
to
6
months,
in
case
of
inltrations
612
months,
for
surgical
studies
it
can
last
for
years.
To
compare
the
results
of
all
types
of
therapy
we
have
chosen
a
6-month
follow-up.
Secondary
outcome
denes
the
evaluation
of
complications,
recurrences
and
failures
for
each
type
of
treatment.
Such
events
are
complementary
to
the
primary
outcome.
It
is
important
to
distinguish
between
mere
adverse
events
and
recurrences.
The
rst,
such
as
haematoma,
infection,
postoperative
pain,
allergic
reactions
to
injected
drugs
are
only
a
temporary
setback,
whereas
the
second
can
have
a
long-term
impact
on
patients
quality
of
life.
2.
Methods
2.1.
Criteria
for
considering
studies
for
this
review
Studies
were
identied
by
searches
in
electronic
libraries,
trial
registries
and
bibliographic
quotations.
Two
reviewers
(A.F.
and
S.
V.)
independently
carried
out
the
bibliographic
searches
and
studies
selections,
holding
into
account
the
inclusion
and
exclusion
criteria
(described
later).
Cases
of
disagreement
were
arbitrated
by
a
third
reviewer
(G.J.P.).
The
authors
of
the
selected
studies
were
never
contacted.
Searches
were
carried
out
on
MEDLINE
(1946
to
August
2015),
Cochrane
Library
(1979
to
August
2015),
DARE
(1995
to
August
2015),
ClinicalTrials.gov
and
PROSPERO
by
combining
Mortons
neuroma,
neuroma,
sur-
gery,
inltrative,
conservative,
treatment.
We
have
included
prospective
and
retrospective
case
series
and
randomized
controlled
trials
(RCTs)
which
assess
the
results
of
conservative,
inltrative
and
operative
treatments
in
patients
with
diagnosis
of
primary
MN,
excluding
stump
neuroma
and
recur-
rences,
with
a
mean
follow-up
of
at
least
6
months.
We
excluded
papers
in
languages
other
than
English,
case
reports
and
animal
studies.
We
excluded
studies
in
which
X-rays
and
histology
showed
that
a
sizable
proportion
of
patients
presented
pathologies
other
than
Mortons
(usually
bursitis
and
synovitis)
and
in
which
the
results
were
cumulative
and
did
not
differentiated
the
neuroma
from
the
other
forms
of
metatarsalgia.
One
such
study,
even
if
excellent
from
a
methodological
point
of
view,
was
excluded
on
account
of
31%
ultrasound
conrmed
bursitis
[16].
Many
studies
on
primary
MN
exclude
patients
with
rheumatoid
arthritis,
diabetes
mellitus
and
foot
deformities.
Many
others
do
not
state
whether
such
conditions
are
cause
for
exclusion.
A
few
studies
do
include
some
such
patients.
Because
of
such
disparity
we
decided
not
to
consider
those
conditions
as
exclusion
criteria.
We
did
not
exclude
papers
on
the
basis
of
publication
date
or
status.
We
excluded
studies
which
presented
bias
with
overestimation
of
results,
as
for
protocol
analysis
in
controlled
randomized
trials.
One
important
requirement
for
inclusion
was
that
the
primary
outcome
be
assessed
after
a
mean
follow-up
of
6
months.
This
was
an
arbitrary
choice
based
on
the
observation
that
studies
on
conservative
and
inltrative
treatment
have
a
mean
follow-up
usually
inferior
to
6
months.
Therefore
our
choice
of
6
months
allowed
us
to
compare
studies
on
the
three
types
of
treatment.
Furthermore,
it
is
twice
the
length
of
follow-up
reported
in
a
previous
Cochrane
Review
[17].
Studies
with
follow-up
periods
and
outcomes
not
clearly
dened
were
excluded.
The
evaluation
of
the
secondary
outcome
was
added
to
our
protocol
secondarily
because,
during
selection
of
the
articles,
we
often
noticed
that
complications
and
recurrences
were
either
unreported
or
cumulated
as
adverse
events.
Moreover,
some
authors
report
reoperation
rates
without
naming
their
causes.
Assessing
the
correct
reporting
of
complications
and
recurrences
is
useful
to
identify
cases
of
excessively
positive
reporting
of
results.
2
S.
Valisena
et
al.
/
Foot
and
Ankle
Surgery
xxx
(2017)
xxxxxx
G
Model
FAS
1031
No.
of
Pages
11
Please
cite
this
article
in
press
as:
S.
Valisena,
et
al.,
Treatment
of
Mortons
neuroma:
A
systematic
review,
Foot
Ankle
Surg
(2017),
http://dx.doi.
org/10.1016/j.fas.2017.03.010
Patients
with
recurrence
or
needing
further
injections
or
reoperation
were
dened
as
failures.
The
procedure
used
for
the
papers
selection
is
described
in
the
ow
chart
in
Fig.
1.
2.2.
Data
collection
and
analysis
We
created
a
chart
for
data
extraction;
it
was
tested
at
interim
analysis
and
subsequently
implemented
with
the
secondary
outcome
related
columns.
The
extraction
of
the
data
has
been
performed
by
two
authors
in
independent
way.
There
have
not
been
cases
of
disagreements
among
the
analyses
of
the
two
authors.
From
every
included
study
we
have
drawn
out
information
related
to:
demographic
data
(number
of
participants,
number
of
MNs
affected
feet,
median
age
and
range
for
every
sample
of
patients);
clinical
data
(duration
of
the
symptoms
before
treatment,
type
and
duration
of
any
previous
treatment,
average
duration
and
range
of
the
follow-up,
type
of
treatment,
numbers
of
conrmed
MNs,
numbers
of
cases
conrmed
by
histological
examination,
clinical
outcomes,
complications,
therapeutical
failures).
From
the
original
data
set,
only
the
following
items
were
selected:
information
related
to
the
number
of
participants,
average
duration
and
range
of
the
follow-up,
type
of
surgery,
outcomes,
complications,
failures.
We
have
performed
a
weighted
average
in
order
to
reduce
the
inuence
of
the
sample
size
on
the
frequency
of
the
outcome
for
every
type
of
treatment.
2.3.
Assessment
of
risk
of
bias
in
included
studies
We
followed
the
bias
assessment
process
as
described
in
the
Cochrane
Handbook
[18],
making
it
suitable
for
the
case
series.
For
every
bias,
we
dened
the
level
of
risk
as
high,
low
or
indenite.
We
drew
up
a
table
to
evaluate:
the
suitability
of
the
study
design;
any
misclassication
bias
due
to
the
diagnosis
used
to
dene
the
sample;
information
bias,
checking
if
the
inclusion
and
exclusion
criteria
were
described
for
all
the
patients;
selection
bias,
dened
as
a
sequential
ordering
bias
of
the
patients
for
the
case
series
and
according
to
the
variables
pointed
out
by
the
Cochrane
Handbook
for
the
randomized
control
trials
(RCTs);
performance
and
detection
bias
for
the
RCTs
and
even
for
the
case
series,
when
they
indicated
if
the
blinding
for
the
outcome
assessors
had
been
performed
for
the
patients
or
for
the
medical
staff;
recall
bias,
evaluation
of
any
patients
mistake
in
reporting
clinical
data;
reporting
bias,
reporting
not
in
line
with
the
specic
statement
of
the
study
or
omission
of
any
clinical
data
or
results;
attrition
bias:
this
term
was
used
both
for
RCTs
and
observational
studies;
consequently,
when
this
bias
was
present,
the
term
used
in
the
table
was
for
protocol
analyses.
Case
series
do
not
use
a
rigorous
methodology,
according
to
their
low
level
of
evidence.
Case
series
with
a
low
risk
of
results
overestimation
and
with
suitable
methodological
characteristics
were
included.
2.4.
Data
synthesis
We
presented
the
outcome
(in
Tables
1
and
2)
as
an
absolute
number
to
perform
the
weighted
average
for
every
column.
For
this
reason,
we
performed
proportions
to
convert
the
frequency
from
relative
to
absolute
when
the
paper
reported
the
result
only
in
percentage.
This
conversion
was
possible
only
for
the
papers
in
which
the
general
number
of
the
studied
population
was
known
and
a
protocol
analysis
was
not
performed.
We
did
not
perform
a
meta-analysis
to
the
interim
analyses,
because
most
of
the
studies
were
observational.
It
was
not
possible
to
perform
a
meta-analysis
for
the
included
RCTs
either,
because
of
the
high
degree
of
heterogeneity,
as
already
found
by
other
authors
[17].
3.
Results
3.1.
Papers
selection
At
the
beginning
of
our
sensitive
research,
we
had
283
papers.
After
a
rst
screening
we
examined
41
full
texts.
In
a
second
phase,
we
excluded
studies
with
a
high
number
of
patients
affected
by
non-Mortons
metatarsalgia
in
which
the
demarcation
between
the
sub-populations
was
not
possible.
We
only
kept
the
papers
in
which
the
number
of
patients
potentially
affected
by
a
non-Mortons
metatarsalgia
was
thought
to
be
very
low
(less
than
5
patients).
Some
other
papers
were
excluded
for
different
reasons:
studies
that
described
a
treatment
algorithm
without
specifying
the
duration
of
each
stage;
studies
that
did
not
describe
the
outcome
in
terms
of
patients
satisfaction
and
improving
symptoms;
studies
that
did
not
use
the
same
outcome
measures
described
in
methods;
283 titles/abstracts – 260 MEDLINE
– 13 Cochrane Library
– 1 DARE
– 8 ClinicalTrials.gov
– 1 PROSPERO
7 redundant studies
eli
minated
276 titles/abstracts examined
235 studies
eli
minated
– 37 full texts not available
– 198 not meeting inclusion criteria
41 full
texts
examined
12 studies not
meeting
inclusion
criteria
29 studies
included
in
the qualitativ
e
anal
y
sis
Fig.
1.
Flow
chart:
procedure
for
paper
selection.
S.
Valisena
et
al.
/
Foot
and
Ankle
Surgery
xxx
(2017)
xxxxxx
3
G
Model
FAS
1031
No.
of
Pages
11
Please
cite
this
article
in
press
as:
S.
Valisena,
et
al.,
Treatment
of
Mortons
neuroma:
A
systematic
review,
Foot
Ankle
Surg
(2017),
http://dx.doi.
org/10.1016/j.fas.2017.03.010
Table
1
Clinical
data:
outcomes
of
the
included
studies
(presented
as
absolute
numbers).
Study
and
year
Study
design
Participant
No.
Mean
F-U
in
months
(F-U
range)
Treatment
Overall
satisfaction
a
Complications
a
Failures
a
Surgical
treatment
Akermark
et
al.
2008
(Feb)
[19]
Retrospective
case
series
145
n.s.
(2460)
Open
Plantar
group:
69
29
(2446)
Nerve
resection-plantar
incision
68/73
4/69
0
Dorsal
group:
56
37
(2460)
Nerve
resection-dorsal
incision
52/59
10/56
3/56
Bauer
et
al.
2015
[36]
Retrospective
case
series
Open:
26
24
(2484)
Open
neurectomy
dorsal
incision
24/26
1/26
1/26
M.I.S.:
26
M.I.S.:
Percutaneous
metatarsal
osteotomies
and
ligament
release
23/26
1/26
1/26
Biasca
et
al.
1999
[35]
Retrospective
case
series
19
15
(821)
Partial
neurectomy-dorsal
incision
14/19
n.a.
n.a.
Dereymaeker
et
al.
1996
[21]
Retrospective
case
series
31
44,7
(1471)
Open:
excision-dorsal
incision
(+
adapted
shoes/inner
soles)
26/32
0
1/31
Faraj
et
al.
2010
[37]
Retrospective
case
series
36
18
(1354)
Open:
neurectomy
30/36
Plantar
group:
20
(Feet
No)
Plantar
incision
11/36
1/36
Dorsal
group:
22
(Feet
No)
Dorsal
incision
6/36
0
Kasparek
et
al.
2013
[22]
Retrospective
case
series
81
180
(120240)
Open:
excision-dorsal
incision
(55
cases
with
DTML
transection;
56
without
DTML
transection)
90/98
73/111
n.a.
Lee
et
al.
2011
[12]
Retrospective
case
series
13
126
(120146)
Open
neurectomy-dorsal
incision
13/13
11/13
n.a.
Pace
et
al.
2010
[38]
Retrospective
case
series
78
54
(996)
Open:
neurectomy-dorsal
incision
76/78
18/78
8/78
Park
et
al.
2013
[39]
Retrospective
comparative
series
84
n.s.
(n.s.)
Open:
decompressiondorsal
incision
for
both
groups
DTML
release:
46
(No
of
Morton)
26,2
(24,727,7)
DTML
release
(Group
A)
42/46
3/46
2/46
Osteotomy+
release:
40
(No
of
Morton)
26,3
(23,629)
Metatarsal
shortening
osteotomy
and
DTML
release
(Group
B)
40/40
2/40
0
Ruuskanen
et
al.
1994
[13]
Retrospective
case
series
45
72
(24144 )
Open:
neurectomy-dorsal
incision
47/58
0
5/45
Vito
et
al.
2003
[24]
Retrospective
case
series
78
n.s.
(n.s128)
Open:
Decompression
with
relocation-dorsal
incision
78/82
n.a.
4/82
Akermark
et
al..
2008
[44]
Prospective
case
series
55
29
(2446)
Open:
Nerve
resection-plantar
incision
55/59
3/55
0
Barrett
et
al.
1994
[20]
Prospective
case
series
17
6
(912)
M.I.S.:
Endoscopic
decompression
15/17
2/17
n.a.
Nashi
et
al.
1997
[23]
Prospective
case
series
52
36
(n.s.)
Open
neurectomy
Plantar:
26
Plantar
incision
17/26
7/26
1/26
Dorsal:
26
Dorsal
incision
21/26
4/26
1/26
Valente
et
al.
2008
[40]
Prospective
case
series
25
45
(672)
Open:
neurectomy-dorsal
incision
17/25
n.a.
0
Akermark
et
al.
2013
[45]
RCT
76
34
(2842)
Open
Plantar
group:
35
34
(2839)
Nerve
resection-plantar
incision
32/35
5/35
n.a.
Dorsal
group:
41
33
(2842)
Nerve
resection-dorsal
incision
38/41
6/41
2/41
Colgrove
et
al.
2000
[14]
RCT
44
n.s.
(148)
Open-dorsal
incision
1/44
0
Resection:
22
Resection
19/22
n.a.
0
Neuroma
intermuscular
transposition:
22
Neuroma
intermuscular
transposition
21/22
1/22
0
Study
and
year
Study
design
Participant
No
Mean
F-U
in
months
(F-U
range)
Treatment
Overall
satisfaction
Complications
Failures
Conservative
treatment
Kilkmartin
et
al.
1994
[27]
RCT
23
n.s.
(n.s.)
Orthosis
n.a.
11/23
Supination
orthosis:
10
10,1
Supination
with
cobra
orthosis
(treatment
A)
5/10
Pronation
orthosis:
11
11,09
Pronation
with
reverse
cobra
orthosis
(treatment
B)
5/11
Study
and
year
Study
design
Participant
No
Mean
F-U
in
months
(F-U
range)
Treatment
Overall
satisfaction
a
Complications
a
Failures
a
Inltrative
treatment
Chuter
et
al.
2013
[41]
Retrospective
case
series
25
6
(6)
US-guided
radiofrequency
ablation
26/30
1/25
3/25
Magnan
et
al.
2005
[42]
Retrospective
case
series
65
36
(2455)
Phenol
injection-dorsal
approach
57/71
0
4/65
4
S.
Valisena
et
al.
/
Foot
and
Ankle
Surgery
xxx
(2017)
xxxxxx
G
Model
FAS
1031
No.
of
Pages
11
Please
cite
this
article
in
press
as:
S.
Valisena,
et
al.,
Treatment
of
Mortons
neuroma:
A
systematic
review,
Foot
Ankle
Surg
(2017),
http://dx.doi.
org/10.1016/j.fas.2017.03.010
studies
that
provided
data
that
we
could
not
use
to
perform
weighted
average;
studies
with
protocol
analysis.
At
the
end
of
the
skim
process,
our
systematic
review
was
based
on
29
studies.
3.2.
Description
of
included
studies
As
shown
in
Table
1,
the
29
studies
concerned
different
approaches
to
MN:
1
was
about
the
conservative,
11
were
about
inltrative
[4145]
and
17
about
operative
treatment
[3740].
They
included
17
retrospective
case
series
(11
about
operative
and
6
about
inltrative
treatment);
9
prospective
case
series
(4
about
operative
and
5
about
inltrative
treatment);
3
RCTs
(2
about
operative
and
1
about
conservative
treatment).
The
inclusion
of
only
one
study
on
conservative
treatment
is
a
limitation,
but
it
must
be
stressed
that
most
such
studies
have
a
follow-up
of
one
month.
3.3.
Participants
The
total
number
of
participants
affected
by
primary
MN
was
2021,
of
which
21
treated
conservatively,
1041
by
inltrations
and
959
surgically.
Median
age
was
43
for
conservative
and
51,4
for
operative
treatment.
The
diagnosis
was
clinical
for
9
studies:
6
about
operative
[19
24],
2
about
inltrative
[25,26]
and
one
about
conservative
treatment
[27].
In
6
other
studies,
all
concerning
inltrative
treatment,
the
diagnosis
was
clinical-radiological;
in
these
works,
Ultra
Sound
(US)
were
used
to
verify
the
clinical
nding
[2832].
In
some
studies
about
operative
treatment,
the
differential
diagnosis
(DD)
was
supported
by
X-rays.
In
some
others,
patients
underwent
X-rays,
US
and/or
MRI
for
the
DD.
The
ex
juvantibus
diagnosis,
with
corticosteroid
injection,
was
used
in
just
one
case.
In
3
studies
the
diagnostic
method
was
not
mentioned.
Most
of
the
operated
patients
(10/17
studies)
had
formerly
experienced
conservative
treatment
for
312
months,
or
inltra-
tive
therapy,
with
13
corticosteroid
injections.
The
patients
treated
with
corticosteroid
had
previously
undergone
conservative
treatment
without
improvements.
Some
of
them
had
received
corticosteroid
injections
without
benet
before
undergoing
radio
ablation.
3.4.
Treatment
Sixteen
studies
about
operative
treatment
focused
on
open
and
2
on
mini-invasive
technique.
Seven
of
the
16
studies
about
open
techniques
were
compara-
tive;
4
of
these
compared
the
results
of
the
same
operative
technique
performed
via
plantar
or
dorsal
approach,
while
the
other
3
evaluated
different
operative
approaches.
The
most
frequent
was
dorsal.
In
14
studies
the
nerve
was
excised,
whereas
in
4
studies
it
was
decompressed
by
division
of
the
intermetatarsal
transverse
deep
ligament.
The
follow-up
period
was
46
months.
Six
studies
concerning
inltrative
treatment
focused
on
alcohol
injections,
3
on
radio-frequency
ablation
and
2
on
corticosteroid
injections.
The
follow-up
period
was
14
months.
The
study
concerning
conservative
treatment
focused
on
the
use
of
the
orthoses.
The
follow-up
period
was
about
10.5
months.
Table
1
(Continued)
Study
and
year
Study
design
Participant
No
Mean
F-U
in
months
(F-U
range)
Treatment
Overall
satisfaction
a
Complications
a
Failures
a
Moore
et
al.
2012
[25]
Retrospective
case
series
29
13
(336)
Radiofrequency
thermoneurolysis
26/29
1/29
2/29
Mozena
et
al.
2007
[26]
Retrospective
case
series
42
11
(224)
Alcohol
injection
30/49
3/42
12/42
Musson
et
al.
2012
[32]
Retrospective
case
series