Méd. Chir.

Pied (2015) 31:23-31

DOI 10.1007/s10243-015-0398-y

ORIGINAL ARTICLE / ARTICLE ORIGINAL

Our Experience in the Surgical Treatment of Morton’s Metatarsalgia

with a Minimally Invasive Surgery Technique*
Notre expérience chirurgicale sur le névrome de Morton avec la technique mini-invasive

O. Catani · G. Corrado · F. Sergio · M. Zappia · A. D’Apice

© Lavoisier SAS 2015

Abstract The authors, while analyzing the nosologic frame- ment place, in the authors’ opinion, this technique among
work of Civinini-Morton metatarsalgias, present their sur- the most effective minimally invasive surgical treatments.
gery case-study of 31 patients treated with a minimally inva-
sive percutaneous technique. In particular, the neurolysis of Keywords Morton’s neuroma · Morton’s metatarsalgia ·
the neuroma was performed through the percutaneous inci- Neurolysis of common plantar digital nerve · Surgical
sion of the transverse intermetatarsal ligament (TIML) and treatment of Morton’s neuroma · Interdigital nerve
through the distal metaphyseal osteotomy of the metatarsals compression syndrome · Distal metatarsal metaphyseal
contiguous to the involved intermetatarsal space, all of them osteotomy (DMMO)
being anatomical elements which identify the arch of the
involved metatarsal canal. Of pivotal importance are the Résumé Après une classification de la maladie, suivant les
results of radiographic tests showing, in all the cases, a mac- hypothèses pathogéniques et biomécaniques les plus
roscopic reduction of the diameter of the nerve affected by récentes, les auteurs décrivent leur expérience chirurgicale
nerve compression neuropathy. Furthermore, a remarkable sur 31 patients opérés avec la technique percutanée mini-
percentage of the patients (70%) were exclusively treated invasive. Onze patients en particulier ont été traités avec
with the osteotomy of the 3rd metatarsal. Such unusual pro- ostéotomie percutanée des deux têtes des métatarsiens con-
cedure proved to further facilitate the postoperative course of tigus et la section du ligament intermétatarsien de l’espace
the patient and the overcoming of some complications. The affligé (le troisième ou le deuxième espace intermétatarsien),
encouraging results obtained in this kind of surgical treat- tandis que 20 autres patients ont été traités avec ostéotomie
percutanée de la tête du troisième métatarsien et la section du
ligament intermétatarsien de l’espace affligé (troisième ou
O. Catani (*) deuxième espace intermétatarsien). Le résultat de la chirur-
Department of foot surgery, Nursing Home St. Rita, gie, validé par Vas Test et la production instrumentale post-
Via Appia Antica 83042 Avellino Atripalda, Italy opératoire (écho/IRM), est très encourageant, en particulier
e-mail : ottoflash@libero.it
en ce qui concerne la population de patients traités par ostéo-
G. Corrado tomie de la tête du troisième métatarsien.
Service Podiatry Clinic,
Nursing Home S. Maria della Salute Caserta, Italy
Mots clés Chirurgie percutanée · Neurolyse de Morton ·
F. Sergio Névrome de Morton
Department of Orthopaedics and Traumatology
Hospital San Rocco di Sessa Aurunca, Caserta, Italy

M. Zappia Introduction
Department of Medicine and Health Science,
University of Molise, Campobasso, Italy Civinini-Morton’s metatarsalgia, most commonly known as
A. D’Apice “Morton’s neuroma”, is a painful condition of the forefoot
School in Orthopedics and Traumatology, Second Hospital, that typically affects the 3rd or 2nd metatarsal space [1].
University of Naples, Italy Several authors, over the years, have suggested different sur-
gical techniques as possible solution to this pathology; we
* This article was presented during the SFMCP congress, 12th hereby present our results on a case-study of 31 patients trea-
December 2014. ted with percutaneous osteotomy in the attempt to
24 Méd. Chir. Pied (2015) 31:23-31

decompress the vascular-nervous bundle and at the same rosis of epineurium with disordered proliferation of
time to obtain a correct distribution of weight on the Schwann cells and fibroblasts with aspects of axonal demy-
forefoot. elination. Such histological framework seems degenerative
rather than proliferative and comparable to a perineural
fibroma or elastofibroma, typical of an entrapment neurop-
Etiology athy [13,16,26]. Although often not evident, alterations of
podalic support are always present. Tate and Rusin claim
Since the first publication by Civinini (1835) [2,3], several that in individuals with increased rearfoot varus, the tissues
authors have provided their scientific contribution in the under the 4th metatarsal head and between the 3rd and the
attempt to identify the etiopathogenesis of this condition, 4th metatarsals undergo friction for a longer time during
which still nowadays remains not entirely clear. In 1876, gait. The anastomosis between medial and lateral plantar
Thomas G. Morton described this condition by publishing nerves might be subject to abnormal pressure responsible
an article in the American Journal of the Medical Science for the neuroma [23]; on the other hand, in our opinion,
and reporting the results of 12 cases of severe metatarsalgia also in a pronated rearfoot (pronation syndrome, coxa-
affecting the 4th metatarsal head treated with the complete pedis dysplasia, pes cavus valgus, etc.) the absence of
resection of the metatarsophalangeal articulation of the 4th foot inversion during the transfer of weight bearing pres-
toe and all the surrounding neurovascular structures [4]. sure from the forefoot doesn’t allow the peroneus longus to
Betts was the first to suggest that the neuroma or the stabilize the 1st ray to the ground causing an insufficiency
inflamed nerves were the cause of pain due to microtrau- of the 1st metatarsal, a transfer of the weight bearing pres-
matic injuries and recommended the surgical excision of sure and an increase of the latter on the 2nd, 3rd and 4th
the interdigital nerve, pointing out that it was thicker than metatarsal bones which—being unable to bear it and in
the other interdigital nerves since it originated from the conditions of great instability—would bring on a claw toe
anastomosis of two nerves. He claimed that the interdigital to compensate, increasing the dorsiflexion of the metatar-
nerve of the 3rd space was involved due to its connection to sophalangeal articulations involved and causing the con-
the flexor digitorum brevis muscle (anastomotic branch) traction of the flexor digitorum brevis muscle. This would
and that during the dorsiflexion of the metatarsophalangeal further limit the adaptive ability of the nervous anastomosis
articulation it was stretched by the transverse metatarsal since the effect of the tendon lever arm of the muscle would
ligament due to its stiffness and therefore the inability to cause the adduction of the 4th metatarsal bone. It must be
adapt to weight bearing pressure while walking [5]. More noticed that if the rearfoot everts with the pronation, the
recent studies, by contrast, have questioned this theory, three central metatarsals evert as well, leading to a lateral
verifying that the anastotomic branch was absent in 73% displacement. Being the least movable of all, the 4th meta-
of the performed dissections [6], as suggested a few years tarsal represents the fulcrum around which the other meta-
earlier by Nissen [7] who proposed the vascular theory, tarsals rotate during their movement in anterolateral direc-
according to which the neuroma resulted from a nerve tion, letting the transverse intermetatarsal ligament pinch
ischemia. Mulder, by contrast, in 1951 described a thick- the vascular-nervous bundle. This movement of the meta-
ened intermetatarsal bursa as a factor contributing to the tarsal heads is only possible when the foot is pronated
development of the neuroma [8]. Also, Nissen and Shep- actively at the level of the subtalar joint, and it is probably
hard assumed that the thickened bursa contributed to the the most relevant mechanical factor leading to the develop-
symptomatology in some patients [9,10] while Gilmour, ment of Civinini-Morton metatarsalgia [14]. It is necessary
who studied it in detail, noticed that the bursa was always to bear in mind the functional relationship between the
thickened and that its changes inevitably caused a compres- astragalus foot and calcaneal foot and that the metatarsus,
sion of the vascular-nervous bundle [11,12]. At present, a “variable load structure” [15], becomes, in case of hyper-
like most of the authors [5,8,10–25], we think that pronation, “a constant load structure”, representing a pres-
Civinini-Morton metatarsalgia is a “Chronic Entrapment sure block on intermetatarsal tissues. This biomechanical
Neuropathy with Multifactorial Etiopathogenesis”; there- abnormality of the gait, if associated with other causes,
fore, the term “Neuroma” proves to be inaccurate, because, such as certain sports as well as shoes with flat insoles
despite the macroscopic aspect of the nerve in the involved (with little or no arch support) or with narrow toe box and
portion, the lesions affect the endoneurium and the vessel semi-rigid outsole, contributes to Civinini-Morton syn-
walls with edema, hyalinization and sclerosis [15,18]. With drome. This pathogenetic interpretation leads us to take
the worsening of the sclerosis, endoneurial vessels, and into consideration, while considering the surgical strategy
endoneurium itself, the number of the myelinated nerve of neurolysis, the distal metaphyseal osteotomy of the
fibers decreases [19,20,22] and their sheaths become thin- metatarsals involved in the entrapment syndrome, 1st of
ner giving rise to a thickening of perineurium and the scle- all of the 3rd metatarsal.