Scheinberg Mila, Underwood Meghan, Sankey Matthew, Sanchez Thomas, Shah Ashish
Department of Orthopedics, University of Alabama, Birmingham, Alabama.
JBJS Essent Surg Tech. 2023 Nov 29;13(4). doi: 10.2106/JBJS.ST.22.00065. eCollection 2023 Oct-Dec.
Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.
Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.
Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial. The results of these techniques have varied, and none has gained clinical superiority over the other.
A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to the previously discussed methods of resection. That study by Gould et al. found that 85% of patients had a substantial reduction in pain, with mean visual analog scale (VAS) pain scores reducing from 8 to 10 preoperatively to 0 to 4 postoperatively. Moreover, alternative biological conduits, such as the greater saphenous vein, have proven to be costly in time and resources, as this structure is often utilized in cardiovascular bypass surgery and its harvest conveys a risk of iatrogenic nerve injury to the patient.Numerous studies focusing on excision of recurrent Morton neuromas via a plantar approach have found variable success rates. Of the patients surveyed in those studies, 75% reported substantial pain improvement. However, <50% of these queried patients reported complete pain relief. Studies analyzing the dorsal approach for revision Morton neuroma excision found similar success rates. Approximately 78% of patients reported good or excellent postoperative outcomes, and significant improvements were observed in patient postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores for pain interference, intensity, and global physical health. One study comparing outcomes following plantar versus dorsal approaches for recurrent Morton neuroma found no significant difference in postoperative patient outcomes. That study suggested that surgeons utilize the approach with which they are most comfortable. Gould et al. reported an 85% success rate with collagen conduit, which was similar to if not slightly improved compared with the other prior studies. The utilization of a collagen conduit technique thus offers comparable patient outcomes for patients with difficult neuromas.
Recurrent neuroma resection with the use of a collagen conduit has proven to provide satisfactory patient outcomes regarding pain and neuritis symptoms. The goal of any neuroma resection is to greatly diminish or entirely eliminate nerve pain. Based on the available evidence, there has been no proven clinical superiority of any particular technique over the others. However, in the present example case, the location of the patient's neuroma in this video makes it 85% likely that the patient will report satisfactory outcomes and 50% likely that the patient will be entirely symptom-free. At two weeks postoperatively, the patient reported well controlled pain, absence of burning or tingling sensation, full range of movement in the foot, and intact sensation throughout all major nerve distributions, including the saphenous; superficial peroneal nerve; deep peroneal nerve; and sural, medial, and lateral plantar nerves. However, sensation is absent distal to the site of a neuroma resection.
Careful preoperative planting is of utmost importance.Ruling out other potential pathologies is necessary to ensure proper outcomes.Meticulous dissection should be carried out, with delicate handling of the proximal nerve ending.Excision of the nerve should be done sharply through the healthy portion of the nerve.Appropriate sizing of the nerve conduit (with a commercially available industry sizer) should be performed.The nerve conduit should be passed dorsally and secured to the dorsal fascia without any tension.
MRI = magnetic resonance imagingUS = ultrasoundVAS = visual analog scale.
足踝部疼痛性神经瘤由于切除后持续疼痛或复发，常常带来治疗难题。疼痛性神经瘤的主要手术治疗方法包括单纯切除，并将残留神经末梢回缩至较不易受损伤的位置。对于复发性神经瘤，使用胶原导管是有益的，特别是在软组织覆盖选择有限的区域，并且该技术在手术效果方面已显示出85%的患者满意度。此外，使用胶原导管限制了深部软组织解剖的需求，并降低了通常与神经埋入相关的发病率。
具体步骤包括适当的体格检查、术前规划以及患者仰卧位摆放。患者仰卧，在同侧下肢下方放置下肢支撑垫，以便更好地观察足底表面。在大腿上放置一个非无菌止血带。标记出切口部位，做一个足底纵向切口，直到识别出近端健康神经——通常约1至2厘米，但切口可延长至6厘米。切口在跖骨之间进行，钝性分离至神经瘤。通过健康神经在远端锐性切除神经瘤，并放置一个鞭状缝线以方便胶原导管的放置。将胶原导管从背侧穿入跖间隙并固定于足背筋膜。用3-0尼龙水平褥式缝线缝合伤口。术后，对手术肢体应用柔软敷料，并建议患者两周内不负重。两周时，患者开始使用靴子进行部分负重，并开始物理治疗。无需使用抗生素，开具300毫克加巴喷丁并在六周随访时逐渐减量。在2、6、12、24和52周进行随访。在随访预约期间有必要监测感染迹象和症状、手术并发症以及神经瘤复发情况。
将神经瘤单纯切除并将近端埋入肌肉或骨内是一种常见的手术技术。然而，神经切除不充分或手术技术不佳可导致复发性神经瘤。对于对单纯切除无反应的神经瘤，已采用其他技术，包括烧灼、化学制剂、神经帽盖以及肌肉或骨埋入。这些技术的结果各不相同，没有一种在临床上优于其他技术。
一项分析胶原导管用于足踝部疼痛性神经瘤的研究表明，该技术是先前讨论的切除方法的一种安全且成功的替代方法。古尔德等人的该研究发现，85%的患者疼痛大幅减轻，平均视觉模拟量表（VAS）疼痛评分从术前的8至10降至术后的0至4。此外，其他生物导管，如大隐静脉，已证明在时间和资源方面成本高昂，因为该结构常用于心血管搭桥手术，其获取会给患者带来医源性神经损伤风险。众多专注于通过足底入路切除复发性莫顿神经瘤的研究发现成功率各不相同。在那些研究中接受调查的患者中，75%报告疼痛有显著改善。然而，这些被询问的患者中不到50%报告疼痛完全缓解。分析用于修订莫顿神经瘤切除的背侧入路的研究发现了类似的成功率。约有78%的患者报告术后效果良好或极佳，并且在患者术后的患者报告结局测量信息系统（PROMIS）疼痛干扰、强度和整体身体健康评分方面观察到显著改善。一项比较复发性莫顿神经瘤足底与背侧入路术后结局的研究发现，术后患者结局无显著差异。该研究表明外科医生应采用他们最熟悉的入路。古尔德等人报告胶原导管的成功率为85%，与其他先前研究相比即使没有略有提高也相似。因此，对于患有难治性神经瘤的患者，使用胶原导管技术可提供相当的患者结局。
使用胶原导管进行复发性神经瘤切除已证明在疼痛和神经炎症状方面能为患者提供满意的结局。任何神经瘤切除的目标都是大幅减轻或完全消除神经疼痛。基于现有证据，没有任何一种特定技术在临床上被证明优于其他技术。然而，在本示例病例中，该视频中患者神经瘤的位置使其有85%的可能性报告满意的结局，有50%的可能性完全无症状。术后两周，患者报告疼痛得到良好控制，无烧灼或刺痛感，足部活动范围完全正常，并且在所有主要神经分布区域包括隐神经、腓浅神经、腓深神经以及腓肠神经、足底内侧和外侧神经的感觉均完整。然而，在神经瘤切除部位远端感觉缺失。
仔细的术前规划至关重要。排除其他潜在病变对于确保良好结局是必要的。应进行细致的解剖，小心处理近端神经末梢。应通过神经的健康部分锐性切除神经。应使用市售的行业尺寸测量器对神经导管进行适当的尺寸测量。神经导管应从背侧穿过并固定于背侧筋膜，且无任何张力。
MRI = 磁共振成像；US = 超声；VAS = 视觉模拟量表
