The Comparison of Postoperative Outcomes in Morton's Neuroma Excision Between Plantar vs Dorsal Approach: A Systematic Review and Meta-Analysis

Abstract

Category: Midfoot/Forefoot; Other Introduction/Purpose: Morton’s neuroma, also known as interdigital neuroma, is an enlargement of the plantar digital nerve between the metatarsal head, and a well-recognized source of metatarsalgia. Surgical treatment becomes a viable option when nonsurgical methods are ineffective, and neurectomy of the affected nerve has been the predominant and standard procedure for Morton’s neuroma. There are several surgical approaches commonly used for Morton’s neuroma neurectomy, including dorsal longitudinal approach, plantar longitudinal approach, and plantar transverse approach. Current literature lacks comprehensive information comparing the clinical outcomes of the plantar and dorsal approach for Morton's neuroma neurectomy. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of neurectomy for Morton's neuroma, focusing on the differences between the plantar and dorsal approach. Methods: This comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. The search was carried out on June 16th, 2023. The inclusion criteria for articles in this study were as follows: (1) Patients diagnosed with Morton’s neuroma who underwent surgical excision; (2) Studies that compared clinical outcomes following Morton’s neuroma excision between the dorsal and plantar approaches, and reported on at least one of these outcome measures: postoperative visual analog scale (VAS) pain scores; postoperative clinical functional scores; postoperative scar tenderness; postoperative sensory loss; histopathology; patient satisfaction; time to weight bearing; reoperations; and any other postoperative complications, such as infection. Our review was focused on the comparison of postoperative clinical outcomes and complications associated with neurectomy for Morton's neuroma, between the plantar and dorsal approach. Results: Total eight studies were included in this study. 237 neuromas underwent excision using the plantar approach, while 312 neuromas were treated via the dorsal approach. A significantly higher rate of postoperative reduced sensory was found in the dorsal group: 48.5% (64/132) Vs. 62.0% (80/129) with the relative ratio (RR) of 0.79 (95% CI, 0.64-0.97). A significantly higher rate of postoperative scar tenderness was noted in the plantar group: 6.7% (32/192) Vs. 6.2% (14/225) with the RR of 2.27 (95% CI, 1.28-4.04). Regarding the histopathology findings, 99.3% (143/144) and 97.1% (134/138) accuracy rate was confirmed in the plantar group and dorsal group, respectively, with the RR of 1.02 (95% CI, 0.98-1.07). No significant difference in reoperation rates and postoperative complications was observed between the two groups. Conclusion: This study compared postoperative outcomes following Morton’s neuroma excision between the dorsal and plantar approach. Our findings indicated a notably higher incidence of scar tenderness in patients with the plantar approach, whereas sensory loss was more prevalent in those with the dorsal approach. Additionally, the plantar approach showed a tendency of more precise removal of Morton's neuroma based on histopathological evaluation. We recommend detailed discussions with patients prior to surgery to weigh the advantages and disadvantages of each approach. Further RCTs with larger cohorts are necessary to reach a strong consensus.