(PDF) Treatment of Morton’s neuroma: A systematic review

Review

Treatment

of

Morton’s

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:

Morton’s

neuroma

Treatment

Surgery

Inﬁltrative

Conservative

A

B

S

T

R

A

C

T

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.

©

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.

Inﬁltrative

treatment

.

00

3.5.3.

Operative

treatment

.

00

3.6.

Secondary

outcomes

.

00

3.6.1.

Conservative

treatment

.

00

3.6.2.

Inﬁltrative

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)

xxx–xxx

G

Model

FAS

1031

No.

of

Pages

11

Please

cite

this

article

in

press

as:

S.

Valisena,

et

al.,

Treatment

of

Morton’s

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

Conﬂict

of

interest

.

00

Acknowledgements

.

00

References

.

00

1.

Introduction

Morton’s

neuroma

(MN)

is

a

degenerative

neuropathy

featuring

ﬁbrosis

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],

inﬂammatory

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

inﬁltrations

and

then

surgery,

if

the

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

inﬁltrative

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

deﬁne

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

Morton’s

neuroma

treatment.

Primary

outcome

deﬁnes

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

Johnson’s

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

inﬁltrations

6–12

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

deﬁnes

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

ﬁrst,

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

identiﬁed

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

“Morton’s

neuroma”,

“neuroma”,

“sur-

gery”,

“inﬁltrative”,

“conservative”,

“treatment”.

We

have

included

prospective

and

retrospective

case

series

and

randomized

controlled

trials

(RCTs)

which

assess

the

results

of

conservative,

inﬁltrative

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

Morton’s

(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

conﬁrmed

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

inﬁltrative

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

Review

[17].

Studies

with

follow-up

periods

and

outcomes

not

clearly

deﬁned

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)

xxx–xxx

G

Model

FAS

1031

No.

of

Pages

11

Please

cite

this

article

in

press

as:

S.

Valisena,

et

al.,

Treatment

of

Morton’s

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

deﬁned

as

failures.

The

procedure

used

for

the

papers

selection

is

described

in

the

ﬂow

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

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



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

average

duration

and

range

of

the

follow-up,

type

of

treatment,

numbers

of

conﬁrmed

MNs,

numbers

of

cases

conﬁrmed

by

histological

examination,

clinical

outcomes,

complications,

therapeutical

failures).

From

the

original

data

set,

only

the

following

items

were

selected:

information

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

inﬂuence

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

deﬁned

the

level

of

risk

as

high,

low

or

indeﬁnite.

We

drew

up

a

table

to

evaluate:



the

suitability

of

the

study

design;



any

misclassiﬁcation

bias

due

to

the

diagnosis

used

to

deﬁne

the

sample;



information

bias,

checking

if

the

inclusion

and

exclusion

criteria

were

described

for

all

the

patients;



selection

bias,

deﬁned

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

patient’s

mistake

in

reporting

clinical

data;



reporting

bias,

reporting

not

in

line

with

the

speciﬁc

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

ﬁrst

screening

we

examined

41

full

texts.

In

a

second

phase,

we

excluded

studies

with

a

high

number

of

patients

affected

by

non-Morton’s

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-Morton’s

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)

xxx–xxx

3

G

Model

FAS

1031

No.

of

Pages

11

Please

cite

this

article

in

press

as:

S.

Valisena,

et

al.,

Treatment

of

Morton’s

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.

(24–60)

Open

Plantar

group:

69

29

(24–46)

Nerve

resection-plantar

incision

68/73

4/69

0

Dorsal

group:

56

37

(24–60)

Nerve

resection-dorsal

incision

52/59

10/56

3/56

Bauer

et

al.

2015

[36]

Retrospective

case

series

Open:

26

24

(24–84)

Open

neurectomy

dorsal

incision

24/26

1/26

M.I.S.:

26

M.I.S.:

Percutaneous

metatarsal

osteotomies

and

ligament

release

23/26

1/26

Biasca

et

al.

1999

[35]

Retrospective

case

series

19

15

(8–21)

Partial

neurectomy-dorsal

incision

14/19

n.a.

Dereymaeker

et

al.

1996

[21]

Retrospective

case

series

31

44,7

(14–71)

Open:

excision-dorsal

incision

(+

adapted

shoes/inner

soles)

26/32

0

1/31

Faraj

et

al.

2010

[37]

Retrospective

case

series

36

18

(13–54)

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

(120–240)

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

(120–146)

Open

neurectomy-dorsal

incision

13/13

11/13

n.a.

Pace

et

al.

2010

[38]

Retrospective

case

series

78

54

(9–96)

Open:

neurectomy-dorsal

incision

76/78

18/78

8/78

Park

et

al.

2013

[39]

Retrospective

comparative

series

84

n.s.

(n.s.)

Open:

decompression–dorsal

incision

for

both

groups

DTML

release:

46

(No

of

Morton)

26,2

(24,7–27,7)

DTML

release

(Group

A)

42/46

3/46

2/46

Osteotomy+

release:

40

(No

of

Morton)

26,3

(23,6–29)

Metatarsal

shortening

osteotomy

and

DTML

release

(Group

B)

40/40

2/40

0

Ruuskanen

et

al.

1994

[13]

Retrospective

case

series

45

72

(24–144 )

Open:

neurectomy-dorsal

incision

47/58

0

5/45

Vito

et

al.

2003

[24]

Retrospective

case

series

78

n.s.

(n.s–128)

Open:

Decompression

with

relocation-dorsal

incision

78/82

n.a.

4/82

Akermark

et

al..

2008

[44]

Prospective

case

series

55

29

(24–46)

Open:

Nerve

resection-plantar

incision

55/59

3/55

0

Barrett

et

al.

1994

[20]

Prospective

case

series

17

6

(9–12)

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

(6–72)

Open:

neurectomy-dorsal

incision

17/25

n.a.

0

Akermark

et

al.

2013

[45]

RCT

76

34

(28–42)

Open

Plantar

group:

35

34

(28–39)

Nerve

resection-plantar

incision

32/35

5/35

n.a.

Dorsal

group:

41

33

(28–42)

Nerve

resection-dorsal

incision

38/41

6/41

2/41

Colgrove

et

al.

2000

[14]

RCT

44

n.s.

(1–48)

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

Inﬁltrative

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

(24–55)

Phenol

injection-dorsal

approach

57/71

0

4/65

4

S.

Valisena

et

al.

/

Foot

and

Ankle

Surgery

xxx

(2017)

xxx–xxx

G

Model

FAS

1031

No.

of

Pages

11

Please

cite

this

article

in

press

as:

S.

Valisena,

et

al.,

Treatment

of

Morton’s

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

inﬁltrative

[41–45]

and

17

about

operative

treatment

[37–40].

They

included

17

retrospective

case

series

(11

about

operative

and

6

about

inﬁltrative

treatment);

9

prospective

case

series

(4

about

operative

and

5

about

inﬁltrative

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

inﬁltrations

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

inﬁltrative

[25,26]

and

one

about

conservative

treatment

[27].

In

6

other

studies,

all

concerning

inﬁltrative

treatment,

the

diagnosis

was

clinical-radiological;

in

these

works,

Ultra

Sound

(US)

were

used

to

verify

the

clinical

ﬁnding

[28–32].

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

3–12

months,

or

inﬁltra-

tive

therapy,

with

1–3

corticosteroid

injections.

The

patients

treated

with

corticosteroid

had

previously

undergone

conservative

treatment

without

improvements.

Some

of

them

had

received

corticosteroid

injections

without

beneﬁt

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

inﬁltrative

treatment

focused

on

alcohol

injections,

3

on

radio-frequency

ablation

and

2

on

corticosteroid

injections.

The

follow-up

period

was

14

months.

The

study

Treatment of Morton’s neuroma: A systematic review

Abstract and Figures