Should You Excise Morton's Neuroma?

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Using a hemostat, one may see the bulbous, white and glistening nerve mass and dissect it.
Following the dissection and transection of the digital branches, one should proceed to insert an Inge Lamina spreader, as seen above, in the proximal intermetatarsal space. Doing this will separate the metatarsals well enough to help ensure accurate prox
Once you visualize the nerve as it courses plantar to the muscle belly, utilize a Ragnell retractor, as seen above, to elevate the lumbrical muscle belly.
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Author(s): 
By Lynnelle R. Gabriel, DPM

How To Deal With Complications
Surgical resection of the nerve is not without complications. One may counteract a hematoma within the dead space intraoperatively with cauterizing bleeders, using Surgicel when necessary to control bleeding, and performing deep subcutaneous closure. Stump neuromas and reoccurrence of pain can be devastating to the patient. One may help prevent this with accurate proximal dissection.
Digital and/or metatarsal phalangeal mechanical instability may occur if you do not ensure meticulous intrinsic dissection. Repairing a severed intrinsic tendon intraoperatively and strapping the adjacent digits postoperatively may be helpful. Patients may feel firm, palpable, adherent scar tissue within the surgical site plantarly but it usually resolves within six to eight weeks. One can minimize intermetatarsal fibrosis and adherent scar formation by applying pressure over the incision site with moleskin, using topical skin scar reducers and emphasizing early physical therapy.

A minimally invasive nerve decompression may also have postoperative complications. One should watch out for postoperative web space maceration. I have also noted a significant increase of forefoot contusion postoperatively compared to the excision. Is this from the severing of the vascular structures or from releasing proximal muscle belly fibers? It may be a combination of both.

In Conclusion
Various new surgical techniques, such as minimally invasive nerve decompression, have emerged in recent years for the treatment of intermetatarsal neuroma. While I have found that using a minimally invasive nerve decompression technique can reduce the length of the scar, recovery time and adherent scar tissue, long-term follow-up studies are needed.
Clearly, there are still some unanswered questions. When releasing the deep transverse intermetatarsal ligament only, does this ligament regrow or reattach as suggested by Mann and Reynolds?2 Or is this scar tissue and not regrowth of the ligament, which may still create an impingement/entrapment of the nerve? Once the ligament is released, does the nerve heal and correct itself? Are the weightbearing forces of the forefoot so great that doing just a release is not enough? How does this change the overall structure of the foot or does it?
With all these unanswered questions, we have yet to determine if releasing the deep transverse intermetatarsal ligament and leaving the nerve intact is a successful surgical option. I have found that surgical removal of the neuroma has been successful in my practice. However, as with all surgical procedures, success and the result of surgical removal must depend on an accurate diagnosis, meticulous operative technique and conscientious postoperative management.

Dr. Gabriel is a Fellow of the American College of Foot and Ankle Surgeons. She practices in the Wood Lands, Houston and Conroe, Texas.

Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.




References:

References

1. McGlamry, Volume II, page 313. Comprehensive Textbook of Foot Surgery.

2. Mann R, Reynolds JC. Interdigital neuroma: a critical clinical analysis. Foot and Ankle. 3(4):238-243, 1983.

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