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Deep Transverse Metatarsal Ligament Transection in Morton's Neuroma

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Deep Transverse Metatarsal Ligament Transection in Morton's Neuroma Deep Transverse Metatarsal Ligament Transection in Morton’s Neuroma Excision: A Cadaveric Study Examining Effects on Metatarsal Alignment Nathaniel Preston, DPM1, Daniel Peterson, DPM2, Jamey Allen, DPM3, Jeffrey Whitaker, DPM, FACFAS4, Jill Kawalec-Carroll, PhD5 1Podiatric Surgery Resident, Grant Medical Center, Columbus, OH 2Podiatric Surgery Resident, Detroit Medical Center, Detroit, MI 3Podiatric Surgery Resident, Cambridge Health Alliance, Cambridge, MA 4Division Head and Associate Professor, KSUCPM, Independence, OH 5Assistant Professor and Division Head of Research, KSUCPM, Independence, OH Introduction Results In the dorsal incisional approach for Morton’s neuroma, it is Nine out of the ten legs prepared were used for data collection. The limb excluded from the study was secondary to a severe rigid required to transect the Deep Transverse Metatarsal ligament plantarflexion deformity of the ankle joint. Of the nine limbs used, one had an inadvertent lateral disarticulation at the ankle (DTML) that lies in the interspace between the 3rd and 4th joint during the month cycling period of simulated weight bearing. As a result, the data were not able to be collected for this limb metatarsal heads. The DTML is an important structure in the after one week of simulated weight bearing. stability of the metatarsophalangeal joint (MPJ) as it acts as a tether to bind the metatarsal heads together. Each MPJ has a A statistical significant difference was noted with IMA 1-2 and IMA 1-4. IMA 1-2 at 1 week and also at 1 month cycling times showed plantar thickening of the capsule or volar plate to which the statistical significant difference from pre-operative IMA 1-2 (p<0.05). Also, IMA 1-2 after 1 month cycling time showed statistical DTML can adhere and maintain a transverse arch at the level of significant difference from post-operative IM 1-2 (p<0.05). The average increase in IMA 1-2 from pre-operative to 1 month cycling the metatarsal heads. Weakening of the DTML can result in time was 2.18 degrees. The power of the analyses for IMA 1-2 was 0.992. various pathologies including: hallux abducto valgus, tailor’s Regarding the IMA 1-4, data recorded at 1 week and also at 1 month cycling times showed statistical significance from pre- bunion, metatarsus primus varus, and forefoot splay. operative IMA 1-4 (p<0.05). The average increase in IMA 1-4 from pre-operative to 1 month cycling time was 1.79 degrees. The The purpose of this study is to evaluate the relationship between power of the analyses for IM 1-4 angles was 0.953. the transection of the DTML in the 3rd intermetatarsal space as There was no statistical significant difference found in IMA 2-3, IMA 3-4, IMA 4-5, IMA 3-5, or IMA 2-5. The results for this study are seen with the dorsal incisional approach for Morton’s neuroma summarized in the clustered column graph. (Figure 4) excision and the overall effects on the metatarsal alignment. Methods Figure 4 – Change in biomechanical angles Ten human cadaveric lower extremity limbs were utilized for this References study. Exclusion criteria included: rigid arthritic ankle deformity, 1. Morton, Thomas G. The Classic, A Peculiar and Painful Affection of the Fourth Metatarso-phalangeal Articulation. Clinical Orthopedics and Related Research. history of forefoot/midfoot/rearfoot arthrodesis, severe pes 1979; 142. cavus deformity, severe pes plano valgus deformity, pedal 2. Gauthier, G. Thomas Morton’s Disease: A Nerve Entrapment Syndrome. Clinical amputations, and knee arthroplasty. Inclusion criteria included Orthopedics and Related Research. 1978. ankle joint range of motion sufficient to reach rectus 3. Nissen, K. I. Plantar Digital Neuritis. The British Journal of Bone and Joint positioning. Each limb was mounted to the MTS 858 Mini Bionix Surgery. 1948;30-B:84-94 biomechanical test system and loaded to 120% of the donor’s 4. Levy, Leonard A, Hetherington, Vincent J. Principles and Practice of Podiatric Medicine 2nd Edition. Data Trace Publishing Company. Brooklandville, Maryland documented body weight at a rate of 15 lbf/second in order to 2006. simulate peak weight-bearing ground reactive forces on the 5. Villas, Carlos, Borja Florez, and Matias Alfonso. "Neurectomy versus neurolysis forefoot. (Figure 1) The limb was held at 120% of body weight for 1 for Morton's neuroma." Foot & Ankle International 29.6 (2008): 578-580. minute and then an anterior-posterior (AP) radiograph was taken 6. Graham, Charles E., and Dorcas M. Graham. "Morton's neuroma: a microscopic using the X-Cel x-ray machine. (Figure 1) The x-ray tube head was Figure 1 – Mounted limb Figure 2 – Incisional approach Figure 3 – Pre-op and immediate post-op films evaluation." Foot & Ankle International 5.3 (1984): 150-153. angled at 15 degrees cephalic and the central ray was directed 7. Kim, J-Young, et al. "An anatomical study of Morton's interdigital neuroma: the relationship between the occurring site and the deep transverse metatarsal at the height of the navicular. The limb was then removed from Discussion ligament (DTML)." Foot & Ankle International 28.9 (2007): 1007-1010. the MTS and dissection of the 3rd intermetatarsal space was The purpose of this study was to evaluate the effect that the transection of the DTML at the 3rd interspace, as seen with a dorsal 8. Southerland, Joe T., et al. McGlamry's Comprehensive Textbook of Foot and performed with a #15 blade until adequate visualization of the incisional approach for Morton’s neuroma, would have on metatarsal alignment. When the DTML was transected in the 3rd Ankle Surgery. Lippincott Williams & Wilkins, 2012. DTML was obtained. The DTML was isolated and completely interspace, it was anticipated that the greatest change in IMA would be between metatarsals 3 and 4, with minimal effect on the 9. Chang, Thomas J (Ed.). Master Techniques in Podiatric Surgery: The Foot and transected using a #15 blade. (Figure 2) [9,17,18] Ankle. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. adjacent intermetatarsal angles. Perhaps the most interesting and unanticipated data showed that there was a statistical 10. Akermark et al. Plantar Versus Dorsal Incision in the Treatment of Primary Each limb was again mounted to the MTS biomechanical test significant difference in the IMA 1-2, which also extended to the IMA 1-4. Intermetatarsal Morton’s Neuroma. Foot and Ankle International 2008; 29:2. system. To simulate peak weight-bearing forces, the limb was The 1st ray range of motion is greater than rays 2-5 and is restricted to motion in the frontal and sagittal planes. The 2nd ray has 11. Bishop J, Kahn A, Turha JE. Surgical correction of the splayfoot: the loaded to 120% of the donor’s weight and an AP radiograph was Giannestras procedure. Clin Orthop 1980;146:234–238. the least amount of motion because of the anatomical mortise formed by the medial and lateral cuneiforms and the base of the 12. Whitney, Alan K. Radiographic Charting Technique. Philadelphia, Pennsylvania taken as described above. After the radiograph was obtained, nd the pre-operative and post-operative IMA 1-2, IMA 2-3, IMA 3-4, 2 metatarsal. Rays 3, 4, and 5 have increasing amounts of motion respectively in the frontal and sagittal planes but still less than College of Podiatric Medicine, 1978. st IMA 4-5, IMA 1-4, IMA 2-5 and IMA 3-5 was measured using the the 1 ray. 13. Root, Merton L, Orien, William P, Weed John H, Normal and Abnormal Function of the Foot, Clinical Biomechanics Vol 2. Clinical Biomechanics Corporation 1977. It would appear that the DTML acts on the metatarsal heads globally to maintain the stability and position of the entire metatarsal Digital Tigerview radiograph viewer to determine the angular 14. Barnes, Debra J. Anatomy of the Lower Extremity. CBLS 2003. st relationship in the specimen. Each IMA was measured via the parabola as a single tethered unit. Because the 1 ray has the most available motion, it also is the most susceptible to abnormal 15. Solomon, Marshall G. Radiographic Biomechanical Evaluation of the Foot. following technique: points were plotted at the medial and transverse plane motion and instability from DTML transection at the 3rd interspace. As these results are cadaveric, it is suspected Cleveland, Jonathan Douglas Inc. 1973. lateral cortex of the distal and proximal extent of the diaphyseal that clinically the intrinsic musculature of the foot would exaggerate this abnormal transverse plane motion of the 1st ray seen 16. Christman, Robert A. Foot and Ankle Radiology. St. Louis, Missouri: Churchill shaft of the metatarsal. A bisection of the line connecting distal with DTML transection. Perhaps similar instability could be appreciated with transection of the DTML at any interspace. Further Livingstone; 2003. 17. Hetherington, Vincent J (Ed.). Hallux Valgus and Forefoot Surgery. New York, and proximal plots was used. (Figure 3) research is necessary to better understand the relationship between motion within the 1st ray and DTML transection. Each limb was then cyclically loaded between 667 N and 2669 N NY: Churchill Livingstone; 1994. 18. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery 4th Edition. (150 lbf and 600 lbf) at 5 Hz. The upper limit, which is in the Although these data demonstrated a statistical significant difference in the IMA 1-2 and IMA 1-4, none of the results showed a radiographically defined splayed foot (IMA 1-2 >12 degrees + IMA 4-5 >8 degrees)[11]. While 2.18 degrees increase in IMA 1-2 or Southerland, Joe T. Lippincott, Williams, and Wilkins 2013. region of 4 times body weight, is a reasonable approximation to 19. Giddings VL, Beaupré GS, Whalen RT, Carter DR.
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