Steven Kodros

• Morton’s neuromas are felt to be secondary to perineural fibrosis that develops around the interdigital nerve. About 90% of Morton’s neuromas occur in the third interspace.

• Only about 10% of Morton’s neuromas occur in the second interspace. Therefore, remember to consider other possible causes for metatarsalgia symptoms in this area.

1. Patients with Morton’s neuromas who have failed nonoperative treatment (e.g., accommodative shoes, metatarsal pad, cortisone injection)

1. Dysvascular disease

2. Patients with conditions that may increase the risk of wound healing problems (e.g., peripheral vascular disease, diabetes mellitus, heavy tobacco use) (relative)

1. If circulatory status is questionable (e.g., elderly patients, diabetics, etc.), consider obtaining noninvasive arterial blood flow studies (with absolute toe pressures).

2. Inform patients about permanent numbness of affected toes that results from successful neuroma excision.

1. The procedure can be done under an ankle block with the use of monitored anesthesia care and intravenous sedation. Alternatively, general or other methods of regional anesthesia can be employed.

2. An ankle tourniquet (just above the malleoli) is utilized and set at 250 mm Hg.

3. A small laminar spreader, which can be placed between the respective metatarsals, facilitates exposure.

1. Perform the ankle block prior to prepping and draping the extremity. This helps ensure that there is an adequate amount of time for the block to achieve optimal effectiveness after it has been performed.

2. Elevating the limb for a couple of minutes before tourniquet inflation can exsanguinate the foot.

3. When the proximal portion of the nerve is excised, be sure that a hemostat clamp is used to apply distally directed longitudinal traction on the nerve. A Freer elevator can be used retract the soft tissues proximally and then the nerve should be transected sharply as proximal as possible within the wound. These efforts allow the proximal end of the cut nerve to retract proximally within the midfoot and thereby minimize the risk of developing a symptomatic stump neuroma.