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Neurectomy with Interpositional Nerve Grafting: A Novel Technique for the Treatment of Morton's Neuroma
Imran Ratanshi, MD, MSc, Thomas E.J. Hayakawa, MD, FRCS(C) and Jennifer L. Giuffre, MD, FRCS(C)
Department of Surgery/Section of Plastic Surgery, University of Manitoba, Winnipeg, MB, Canada
PURPOSE OF STUDY: Recurrence rates for "Morton's neuroma" following neurectomy have been reported to range from 14% to 21%. Unfortunately, secondary surgery for recurrent cases carries a failure rate of up to 80%. To our knowledge, interpositional nerve grafting has not been attempted to help reduce recurrence of secondary neuromas. Here, we present a series of 8 cases employing the novel use of interpositional nerve grafting, which we postulate may alleviate recurrent neuralgia and address post-excisional sensory deficits in the affected webspace. METHODOLOGY: A retrospective chart review of 9 adult patients (total 10 neuromas) who underwent elective excision of a Morton's neuroma with interpositional nerve grafting from August, 2003, to March, 2012, was undertaken. Patients with a follow-up period less than 12 months were excluded from the study. All patients underwent surgical treatment after failing non-operative measures. The surgical technique involved neurolysis of the involved common digital nerve within the intermetatarsal space and accurate delineation of the length of Morton's neuroma to be excised. Distal to the neuroma, and distal to the bifurcation of the common digital nerve, a segment of proper digital nerve coursing into an adjacent toe was isolated. This segment, equal in length to the defect created by neuroma excision was harvested as an autogenous interpositional nerve graft. The graft was sutured proximally to the common digital nerve at the proximal limit of the Morton's neuroma resection. The distal neurrorhaphy was performed between the nerve graft and the proper digital nerve of the toe opposite the one where the nerve graft had been harvested. At final follow-up, patients were assessed for neuroma recurrence, 2-point-discrimination, subjective changes in pain and numbness, and overall satisfaction. RESULTS: Seven patients (5F:2M; age range 18-71; 8 neuromas) were included in the study. Neuroma size ranged from 7 to 14 mm as confirmed by MRI. Seven of the 8 cases involved the 3rd intertarsal space, and 1 involved the 2nd intertarsal space. The average procedure time was 53 ± 13 minutes (range 37-82 minutes). All 8 cases had complete resolution of pain and no evidence of recurrence. All patients returned to full weight-bearing status. Sensation to the grafted hemi-web space returned in all but 1 case. Wound dehiscence secondary to hematoma formation occurred in 1 case. No other wound complications were reported. CONCLUSIONS: Interpositional nerve grafting may be a useful adjunct to excision of Morton's neuroma to reduce recurrence rates.
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