Abstract
Background
Today’s foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.
Materials and Methods
A review of the literature was conducted using the PubMed search engine, with key terms including, “mallet toe,” “hammertoe,” “neuroma,” “metatarsophalangeal joint instability,” “plantar plate,” and “forefoot surgery.” Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.
Conclusions
There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.
Level of Evidence
Level V, meta-synthesis.
Similar content being viewed by others
References
DuVries, H. L. (1959). Surgery of the foot. St. Louis: Mosby.
Coughlin, M. J. (2014). Chapter 7. In M. Coughlin, C. Saltzman, R. Anderson (Eds.), Mann’s surgery of the foot and ankle, 9th edn (pp. 357–361). Philadelphia, PA: Elsevier Saunders.
Jones, S., Ali, F., Genever, A., Flowers, M. J., & Bostock, S. H. (2003). Distal interphalangeal joint arthrodesis of the lesser toes using the Barouk screw. The Foot.,13(1), 10–13. https://doi.org/10.1016/s0958-2592(02)00113-x.
Coughlin, M. J., Dorris, J., & Polk, E. (2000). Operative repair of the fixed hammertoe deformity. Foot and Ankle International,21(2), 94–104.
Kramer, W. C., Parman, M., & Marks, R. M. (2015). Hammertoe correction with k-wire fixation. Foot and Ankle International,36(5), 494–502.
Holinka, J., Schuh, R., Hofstaetter, J. G., & Wanivenhaus, A. H. (2013). Temporary Kirschner wire transfixation versus strapping dressing after second MTP joint realignment surgery: a comparative study with ten-year follow-up. Foot and Ankle International,34(7), 984–989.
Canales, M. B., Razzante, M. C., Ehredt, D. J., Jr., & Clougherty, C. O. (2014). A simple method of intramedullary fixation for proximal interphalangeal arthrodesis. Journal of Foot and Ankle Surgery,53(6), 817–824.
Boffeli, T. J., Thompson, J. C., & Tabatt, J. A. (2016). Two-pin fixation of proximal interphalangeal joint fusion for hammertoe correction. Journal of Foot and Ankle Surgery,55(3), 480–487.
Rothermel, S. D., Aydogan, U., Roush, E. P., & Lewis, G. S. (2019). Proximal interphalangeal arthrodesis of lesser toes utilizing k-wires versus expanding implants: comparative biomechanical cadaveric study. Foot and Ankle International,40(2), 231–236.
Guelfi, M., Pantalone, A., Cambiaso Daniel, J., Vanni, D., Guelfi, M. G. B., & Salini, V. (2015). Arthrodesis of proximal inter-phalangeal joint for hammertoe: intramedullary device options. J Orthop Traumatol.,16(4), 269–273.
Obrador, C., Losa-Iglesias, M., Becerro-de-Bengoa-Vallejo, R., & Kabbash, C. A. (2018). Comparative study of intramedullary hammertoe fixation. Foot and Ankle International,39(4), 415–425.
Richman, S. H., Siqueira, M. B. P., McCullough, K. A., & Berkowitz, M. J. (2017). Correction of hammertoe deformity with novel intramedullary PIP fusion device versus k-wire fixation. Foot and Ankle International,38(2), 174–180.
Catena, F., Doty, J. F., Jastifer, J., Coughlin, M. J., & Stevens, F. (2014). Prospective study of hammertoe correction with an intramedullary implant. Foot and Ankle International,35(4), 319–325.
Sandhu, J. S., DeCarbo, W. T., & Hofbauer, M. H. (2013). Digital arthrodesis with a one-piece memory nitinol intramedullary fixation device: a retrospective review. Foot and Ankle Specialist,6(5), 364–366.
Scholl, A., McCarty, J., Scholl, D., & Mar, A. (2013). Smart toe® implant versus buried Kirschner wire for proximal interphalangeal joint arthrodesis: a comparative study. Journal of Foot and Ankle Surgery,52(5), 580–583.
Payo-Ollero, J., Casajús-Ortega, A., Llombart-Blanco, R., Villas, C., & Alfonso, M. (2019). The efficacy of an intramedullary nitinol implant in the correction of claw toe or hammertoe deformities. Archives of Orthopaedic and Trauma Surgery. https://doi.org/10.1007/s00402-019-03203-w.
Jay, R. M., Malay, D. S., Landsman, A. S., Jennato, N., Huish, J., & Younger, M. (2016). Dual-component intramedullary implant versus Kirschner wire for proximal interphalangeal joint fusion: a randomized controlled clinical trial. Journal of Foot and Ankle Surgery,55(4), 697–708.
Basile, A., Albo, F., & Via, A. G. (2015). Intramedullary fixation system for the treatment of hammertoe deformity. Journal of Foot and Ankle Surgery,54(5), 910–916.
Konkel, K. F., Sover, E. R., Menger, A. G., & Halberg, J. M. (2011). Hammer toe correction using an absorbable pin. Foot and Ankle International,32(10), 973–978.
Konkel, K. F., Menger, A. G., & Retzlaff, S. A. (2007). Hammer toe correction using an absorbable intramedullary pin. Foot and Ankle International,28(8), 916–920.
Albright, R. H., Waverly, B. J., Klein, E., Weil, L., Jr., Weil, L. S., Sr., & Fleischer, A. E. (2018). Percutaneous Kirschner wire versus commercial implant for hammertoe repair: a cost-effectiveness analysis. Journal of Foot and Ankle Surgery,57(2), 332–338.
Dieterle, J. O., & Kuzma, J. F. (1946). A case of Morton’s metatarsalgia (Morton’s toe) treated by operation. Wisconsin Medical Journal,45, 967.
Graham, C. E., & Graham, D. M. (1984). Morton’s neuroma: a microscopic evaluation. Foot Ankle.,5(3), 150–153.
Graham, C. E., Johnson, K. A., & Ilstrup, D. M. (1981). The intermetatarsal nerve: a microscopic evaluation. Foot Ankle.,2(3), 150–152.
Ha’Eri, G.B., Fornasier, V.L., Schatzker, J. (1979). Morton’s neuroma—pathogenesis and ultrastructure. Clinical Orthopaedics and Related Research, (141), 256–259.
Mann, R. A., & Reynolds, J. C. (1983). Interdigital neuroma–a critical clinical analysis. Foot Ankle.,3(4), 238–243.
Addante, J. B., Peicott, P. S., Wong, K. Y., & Brooks, D. L. (1986). Interdigital neuromas. Results of surgical excision of 152 neuromas. Journal of the American Podiatric Medical Association,76(9), 493–495.
Karges, D. E. (1988). Plantar excision of primary interdigital neuromas. Foot Ankle.,9(3), 120–124.
Friscia, D. A., Strom, D. E., Parr, J. W., Saltzman, C. L., & Johnson, K. A. (1991). Surgical treatment for primary interdigital neuroma. Orthopedics.,14(6), 669–672.
Coughlin, M. J., & Pinsonneault, T. (2001). Operative treatment of interdigital neuroma. A long-term follow-up study. Journal of Bone and Joint Surgery,83(9), 1321–1328.
Levitsky, K. A., Alman, B. A., Jevsevar, D. S., & Morehead, J. (1993). Digital nerves of the foot: anatomic variations and implications regarding the pathogenesis of interdigital neuroma. Foot Ankle.,14(4), 208–214.
Valero, J., Gallart, J., González, D., Deus, J., & Lahoz, M. (2015). Multiple interdigital neuromas: a retrospective study of 279 feet with 462 neuromas. Journal of Foot and Ankle Surgery,54(3), 320–322.
Bucknall, V., Rutherford, D., MacDonald, D., Shalaby, H., McKinley, J., & Breusch, S. J. (2016). Outcomes following excision of Morton’s interdigital neuroma: a prospective study. The Bone and Joint Journal,98-B(10), 1376–1381.
Reichert, P., Zimmer, K., Witkowski, J., Wnukiewicz, W., Kuliński, S., & Gosk, J. (2016). Long-term results of neurectomy through a dorsal approach in the treatment of Morton’s Neuroma. Advances in Clinical and Experimental Medicine,25(2), 295–302.
Kasparek, M., & Schneider, W. (2013). Surgical treatment of Morton’s neuroma: clinical results after open excision. International Orthopaedics,37(9), 1857–1861.
Lee, K. T., Kim, J. B., Young, K. W., Park, Y. U., Kim, J. S., & Jegal, H. (2011). Long-term results of neurectomy in the treatment of Morton’s neuroma: more than 10 years’ follow-up. Foot and Ankle Specialist,4(6), 349–353.
Pace, A., Scammell, B., & Dhar, S. (2010). The outcome of Morton’s neurectomy in the treatment of metatarsalgia. International Orthopaedics,34(4), 511–515.
Nery, C., Raduan, F., Del Buono, A., Asaumi, I. D., & Maffulli, N. (2012). Plantar approach for excision of a Morton neuroma: a long-term follow-up study. Journal of Bone and Joint Surgery,94(7), 654–658.
Kundert, H.-P., Plaass, C., Stukenborg-Colsman, C., & Waizy, H. (2016). Excision of Morton’s neuroma using a longitudinal plantar approach: A midterm follow-up study. Foot and Ankle Specialist,9(1), 37–42.
Faraj, A. A., & Hosur, A. (2010). The outcome after using two different approaches for excision of Morton’s neuroma. Chinese Medical Journal,123(16), 2195–2198.
Valisena, S., Petri, G. J., & Ferrero, A. (2018). Treatment of Morton’s neuroma: A systematic review. Foot and Ankle Surgery,24(4), 271–281.
Lee, J., Kim, J., Lee, M., Chu, I., Lee, S., & Gwak, H. (2017). Morton’s neuroma (interdigital neuralgia) treated with metatarsal sliding osteotomy. Indian Journal of Orthopaedics,51(6), 692–696.
Kubota, M., Ohno, R., Ishijima, M., et al. (2015). Minimally invasive endoscopic decompression of the intermatatarsal nerve for Morton’s neuroma. Journal of Orthopaedics,12(Suppl 1), S101–S104.
Zelent, M. E., Kane, R. M., Neese, D. J., & Lockner, W. B. (2007). Minimally invasive Morton’s intermetatarsal neuroma decompression. Foot and Ankle International,28(2), 263–265.
Naraghi, R., Slack-Smith, L., & Bryant, A. (2018). Plantar pressure measurements and geometric analysis of patients with and without Morton’s neuroma. Foot and Ankle International,39(7), 829–835.
Kim, J.-Y., Choi, J. H., Park, J., Wang, J., & Lee, I. (2007). An anatomical study of Morton’s interdigital neuroma: the relationship between the occurring site and the deep transverse metatarsal ligament (DTML). Foot and Ankle International,28(9), 1007–1010.
Brodsky, J. W., Passmore, R. N., & Shabat, S. (2004). Transection of the plantar plate and the flexor digitorum longus tendon of the fourth toe as a complication of endoscopic treatment of interdigital neuroma. A case report. Journal of Bone and Joint Surgery American.,86(10), 2299–2301.
Ratanshi, I., Hayakawa, T. E. J., & Giuffre, J. L. (2016). Excision with interpositional nerve grafting: An alternative technique for the treatment of Morton Neuroma. Annals of Plastic Surgery,76(4), 428–433.
Rungprai, C., Cychosz, C. C., Phruetthiphat, O., Femino, J. E., Amendola, A., & Phisitkul, P. (2015). Simple neurectomy versus neurectomy with intramuscular implantation for interdigital neuroma: A comparative study. Foot and Ankle International,36(12), 1412–1424.
Vito, G. R., & Talarico, L. M. (2003). A modified technique for Morton’s neuroma. Decompression with relocation. Journal of the American Podiatric Medical Association,93(3), 190–194.
Wolfort, S. F., & Dellon, A. L. (2001). Treatment of recurrent neuroma of the interdigital nerve by implantation of the proximal nerve into muscle in the arch of the foot. Journal of Foot and Ankle Surgery,40(6), 404–410.
Perini, L., Perini, C., Tagliapietra, M., et al. (2016). Percutaneous alcohol injection under sonographic guidance in Morton’s neuroma: follow-up in 220 treated lesions. La Radiologia Medica,121(7), 597–604.
Pasquali, C., Vulcano, E., Novario, R., Varotto, D., Montoli, C., & Volpe, A. (2015). Ultrasound-guided alcohol injection for Morton’s neuroma. Foot and Ankle International,36(1), 55–59.
Magnan, B., Marangon, A., Frigo, A., & Bartolozzi, P. (2005). Local phenol injection in the treatment of interdigital neuritis of the foot (Morton’s neuroma). Chirurgia Degli Organi di Movimento,90(4), 371–377.
Santos, D., Morrison, G., & Coda, A. (2018). Sclerosing alcohol injections for the management of intermetatarsal neuromas: A systematic review. Foot.,35, 36–47.
Gurdezi, S., White, T., & Ramesh, P. (2013). Alcohol injection for Morton’s neuroma: a five-year follow-up. Foot and Ankle International,34(8), 1064–1067.
Espinosa, N., Seybold, J. D., Jankauskas, L., & Erschbamer, M. (2011). Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma. Foot and Ankle International,32(6), 576–580.
Lee, K., Hwang, I.-Y., Ryu, C. H., Lee, J. W., & Kang, S. W. (2018). Ultrasound-guided hyaluronic acid injection for the management of Morton’s Neuroma. Foot and Ankle International,39(2), 201–204.
Campbell, C. M., Diamond, E., Schmidt, W. K., et al. (2016). A randomized, double-blind, placebo-controlled trial of injected capsaicin for pain in Morton’s neuroma. Pain,157(6), 1297–1304.
Lizano-Díez, X., Ginés-Cespedosa, A., Alentorn-Geli, E., et al. (2017). corticosteroid injection for the treatment of Morton’s neuroma: a prospective, double-blinded, randomized. Placebo-Controlled Trial. Foot and Ankle International,38(9), 944–951.
Masala, S., Cuzzolino, A., Morini, M., Raguso, M., & Fiori, R. (2018). Ultrasound-guided percutaneous radiofrequency for the treatment of Morton’s neuroma. Cardiovascular and Interventional Radiology,41(1), 137–144.
Brooks, D., Parr, A., & Bryceson, W. (2018). Three cycles of radiofrequency ablation are more efficacious than two in the management of Morton’s Neuroma. Foot and Ankle Specialist,11(2), 107–111.
Seok, H., Kim, S.-H., Lee, S. Y., & Park, S. W. (2016). Extracorporeal shockwave therapy in patients with Morton’s Neuroma a randomized, placebo-controlled trial. Journal of the American Podiatric Medical Association,106(2), 93–99.
Deniz, S., Purtuloglu, T., Tekindur, S., et al. (2015). Ultrasound-guided pulsed radio frequency treatment in Morton’s neuroma. Journal of the American Podiatric Medical Association,105(4), 302–306.
Fridman, R., Cain, J. D., & Weil, L., Jr. (2009). Extracorporeal shockwave therapy for interdigital neuroma: a randomized, placebo-controlled, double-blind trial. Journal of the American Podiatric Medical Association,99(3), 191–193.
Park, Y. H., Choi, W. S., Choi, G. W., & Kim, H. J. (2019). Intra- and interobserver reliability of size measurement of morton neuromas on sonography. Journal of Ultrasound in Medicine. https://doi.org/10.1002/jum.14928.
Cohen, S. L., Miller, T. T., Ellis, S. J., Roberts, M. M., & DiCarlo, E. F. (2016). Sonography of Morton Neuromas: What are we really looking at? Journal of Ultrasound in Medicine,35(10), 2191–2195.
Bignotti, B., Signori, A., Sormani, M. P., Molfetta, L., Martinoli, C., & Tagliafico, A. (2015). Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. European Radiology,25(8), 2254–2262.
Torres-Claramunt, R., Ginés, A., Pidemunt, G., Puig, L., & de Zabala, S. (2012). MRI and ultrasonography in Morton’s neuroma: Diagnostic accuracy and correlation. Indian J Orthopaedics,46(3), 321–325.
Park, H.-J., Kim, S. S., Rho, M.-H., Hong, H.-P., & Lee, S.-Y. (2011). Sonographic appearances of Morton’s neuroma: differences from other interdigital soft tissue masses. Ultrasound in Medicine and Biology,37(8), 1204–1209.
Weishaupt, D., Treiber, K., Kundert, H.-P., et al. (2003). Morton neuroma: MR imaging in prone, supine, and upright weight-bearing body positions. Radiology,226(3), 849–856.
Hidalgo-Ovejero, A. M., Martinez-Grande, M., Sanchez-Villares, J. J., Garcia-Mata, S., & Lasanta, P. (2002). Clinical examination and imaging studies in the diagnosis of interdigital neuroma. Journal of Bone and Joint Surgery American.,84(7), 1276–1277.
Aydinlar, E. I., Uzun, M., Beksac, B., Ozden, V. E., Karaarslan, E., & Oge, A. E. (2014). Simple electrodiagnostic method for Morton neuroma. Muscle and Nerve,49(2), 193–197.
Ruiz Santiago, F., Prados Olleta, N., Tomás Muñoz, P., Guzmán Álvarez, L., & Martínez, Martínez A. (2019). Short term comparison between blind and ultrasound guided injection in morton neuroma. European Radiology,29(2), 620–627.
Tagliafico, A., Bignotti, B., & Martinoli, C. (2016). Update on ultrasound-guided interventional procedures on peripheral nerves. Semin Musculoskelet Radiol.,20(5), 453–460.
Coughlin, M., Saltzman, C., & Anderson R. (2014). Mann’s surgery of the foot and ankle, 9th edn. Philadelphia, PA: Elsevier Sanders.
Coughlin, M. J. (1999). Chapter 12. In M. Coughlin, R. Mann (Eds.), Mann’s surgery of the foot and ankle, 7th edn. Philadelphia, PA: Elsevier Saunders.
Coughlin, M. J. (1999). Chapter 7. In M. Coughlin, R. Mann, C. Saltzman (Eds.), Mann’s surgery of the foot and ankle, 8th edn. Philadelphia, PA: Elsevier Saunders.
Coughlin, M. J. (1987). Crossover second toe deformity. Foot Ankle.,8(1), 29–39.
Deland, J. T., & Sung, I. H. (2000). The medial crossover toe: a cadaveric dissection. Foot and Ankle International,21(5), 375–378.
Coughlin, M. J., Schutt, S. A., Hirose, C. B., et al. (2012). Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot and Ankle International,33(2), 133–140.
Coughlin, M. J., Baumfeld, D. S., & Nery, C. (2011). Second MTP joint instability: grading of the deformity and description of surgical repair of capsular insufficiency. The Physician and Sportsmedicine,39(3), 132–141.
Bouché, R. T., & Heit, E. J. (2008). Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. Journal of Foot and Ankle Surgery,47(2), 125–137.
Blitz, N. M., Ford, L. A., & Christensen, J. C. (2004). Plantar plate repair of the second metatarsophalangeal joint: technique and tips. Journal of Foot and Ankle Surgery,43(4), 266–270.
Powless, S. H., & Elze, M. E. (2001). Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management. Journal of Foot and Ankle Surgery,40(6), 374–389.
Gregg, J., Silberstein, M., Clark, C., & Schneider, T. (2007). Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot and Ankle Surgery.,13(3), 116–121. https://doi.org/10.1016/j.fas.2007.01.001.
Weil, L., Jr., Sung, W., Weil, L. S., Sr., & Malinoski, K. (2011). Anatomic plantar plate repair using the Weil metatarsal osteotomy approach. Foot and Ankle Specialist,4(3), 145–150.
Hsu, R. Y., Barg, A., & Nickisch, F. (2018). Lesser metatarsophalangeal joint instability: Advancements in plantar plate reconstruction. Foot and Ankle Clinics,23(1), 127–143.
Watson, T. S., Reid, D. Y., & Frerichs, T. L. (2014). Dorsal approach for plantar plate repair with weil osteotomy: Operative technique. Foot and Ankle International,35(7), 730–739.
Cooper, M. T., & Coughlin, M. J. (2011). Sequential dissection for exposure of the second metatarsophalangeal joint. Foot and Ankle International,32(3), 294–299.
Nery, C., Coughlin, M. J., Baumfeld, D., & Mann, T. S. (2012). Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot and Ankle International,33(4), 301–311.
Flint, W. W., Macias, D. M., Jastifer, J. R., Doty, J. F., Hirose, C. B., & Coughlin, M. J. (2017). Plantar plate repair for lesser metatarsophalangeal joint instability. Foot and Ankle International,38(3), 234–242.
Cook, J. J., Cook, E. A., Hansen, D. D., et al. (2019). One-year outcome study of anatomic reconstruction of lesser metatarsophalangeal joints. Foot and Ankle Specialist. https://doi.org/10.1177/1938640019846974.
McCartan, B. L., Juels, C. A., & Shih, J. A. (2019). Technique and tips for multiplanar correction of plantar plate repairs in lesser metatarsophalangeal joints. Journal of the American Podiatric Medical Association,109(1), 80–86.
Clements, J. R., & Ghai, A. K. (2019). An innovative method for plantar plate repair: Technique guide and case report. Journal of Foot and Ankle Surgery,58(3), 555–561.
Prissel, M. A., Hyer, C. F., Donovan, J. K., & Quisno, A. L. (2017). Plantar plate repair using a direct plantar approach: An outcomes analysis. Journal of Foot and Ankle Surgery,56(3), 434–439.
Funding
None.
Author information
Authors and Affiliations
Contributions
This manuscript has been read and approved by all authors and represents honest work. Both authors contributed to the writing of this manuscript.
Corresponding author
Ethics declarations
Conflict of Interest
The senior author, MC, has consulting relationships with Stryker & Arthrex, whose implants are referenced in this paper. The lead author, DD has no conflicts of interest.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Dang, D.Y., Coughlin, M.J. Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery. JOIO 54, 3–13 (2020). https://doi.org/10.1007/s43465-019-00015-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43465-019-00015-3