Morton neuroma: effect of MR imaging findings on diagnostic thinking and therapeutic decisions.

PURPOSE: To determine the effect of magnetic resonance (MR) imaging results on diagnostic thinking and therapeutic decisions by orthopedic surgeons in cases of a possible Morton neuroma. MATERIAL AND METHODS: Orthopedic surgeons completed a questionnaire before and after MR imaging for 54 feet in 49 patients thought to have Morton neuroma. Clinical diagnosis (Morton neuroma, differential diagnosis), location, diagnostic confidence, and therapeutic decisions were noted before and after MR imaging. The influence of the size of the neuroma on therapeutic decisions was analyzed. MR imaging diagnoses were compared with surgical results for 23 revised intermetatarsal spaces. RESULTS: After MR imaging, the clinical diagnosis of Morton neuroma was withdrawn in 15 of 54 (28%) feet. In 14 of 39 maintained diagnoses, the location or number of neuromas was changed after MR imaging. Confidence levels for Morton neuroma increased substantially after MR imaging. In 31 (57%) feet, a change in treatment plan resulted after MR imaging. Diameters of neuromas on MR images were significantly larger (P = .003) in surgically treated feet than in conservatively treated feet. MR imaging diagnoses were correct in all 23 revised intermetatarsal spaces. CONCLUSION: MR imaging has a major effect on diagnostic thinking and therapeutic decisions by orthopedic surgeons when Morton neuroma is suspected, especially because MR imaging helps in localization and size assessment of Morton neuromas.

Outcomes after partial neurectomy of Morton's neuroma related to preoperative case histories, clinical findings, and findings on magnetic resonance imaging scans.

Our purpose was to evaluate the reliability of preoperative case histories, clinical findings, and magnetic resonance imaging (MRI) scans in substantiating the diagnosis of Morton's neuroma and in predicting clinical outcomes after surgical intermetatarsal neurectomy. We studied 19 consecutive patients with histologically proved Morton's neuroma. All had preoperative MRI of the forefoot. Partial neurectomy was performed when there was forefoot pain with transmetatarsal compression and positive findings on MRI scans. Case histories, clinical findings, and findings on MRI scans were correlated with clinical outcomes. Preoperative clinical findings including localization correlated with intraoperative findings in 11 of 19 patients (58%), and MRI scans correlated in 16 of 19 patients (84%). Of the 19 patients, 74% achieved satisfactory outcomes. Neither reliable clinical findings or findings on MRI scans nor confirmation of clinical findings by MRI correlated with a superior result, but 77% of patients with neuromas measuring more than 5 mm in transverse measurement on MRI scans had good outcomes; only 17% with neuromas measuring 5 mm or less had good outcomes. Preoperative localization and diagnosis of Morton's neuroma is better achieved with MRI than through clinical findings. A more favorable clinical outcome can be expected after surgical intermetatarsal neurectomy when a Morton's neuroma has a transverse measurement larger than 5 mm on MRI scans.

MRI of the foot and ankle: diagnostic performance and patient acceptance of a dedicated low field MR scanner.

The objective of this study was to compare image quality and patient acceptance of a dedicated .2-T MR system and a 1.0-T whole body system. Forty-one consecutive patients referred for MRI of the foot or ankle were prospectively examined with a dedicated .2-T low field system and a 1.0-T whole body system. Images were evaluated qualitatively by two observers and quantitatively using signal-difference-to-noise ratios. The patients were interviewed with respect to positioning, examination time, noise, claustrophobia, confidence in the diagnosis, and willingness to repeat the examination, using a questionnaire. The qualitative score was significantly higher for the 1.0-T system (2.6 vs 2.2 for reader 1 [P = .008] and 2.6 vs 1.7 for reader 2 [P < .0001]), respectively). The signal-difference-to-noise ratios were also superior for the 1.0-T MR system (2.96 vs .88, P < .0001). However, 96% of the lesions visualized at 1.0 T were also detected with the low field system. Patient acceptance was significantly better for the 1.0-T MR scanner (48.6 vs 43.9, P = .007). Image quality of the dedicated low field system was inferior to the 1.0-T system using objective parameters, and patients did not prefer the low field system. Although only 4% of lesions were missed in this series, the low field MR system can only be recommended when funding is limited and the available space is limited.

[Long-term results of single stem silastic implants in the metatarsophalangeal joint]. / Langzeitresultate bei einstieligen Silastic-Implantaten im Grosszehengrundgelenk.

AIM OF THE STUDY: Long-term results of single stemmed silicone prostheses. METHOD: 61 feet were reviewed after a mean follow-up time of 13 years. RESULTS: 18 implants (29.5%) have been removed, 7 of them in the first year after operation. The often impressive radiologic changes showed no correlation to the subjective results but a correlation to time. 1/3 of the patients were not satisfied with the outcome. An average of 75% of the prosthesis was destroyed after 10 years, 93.5% were loosened. CONCLUSION: By reason of the high rate of failure of the implant, we have abandoned this procedure.

[Subtalar arthrodesis--minimal resection technique]. / Subtalare Arthrodese--Minimale Resektionstechnik.

INTRODUCTION: This is a prospective clinical and radiological study of the treatment of talocalcaneal deformity or degeneration by a modified technique of isolated talocalcaneal fusion. METHODS: Thirty-six patients were evaluated with clinical examination, plain dorso-plantar and oblique x-rays and CT-scan or magnetic resonance imaging in a follow-up of 32.5 months (range: 20-62). In 12 cases a posterior tibial tendon rupture with secondary osteoarthritis and in 24 cases a posttraumatic secondary osteoarthritis (18 calcaneal fractures, 3 talar fractures, 2 axial traumas with secondary talar necrosis and 1 rheumatoid arthritis with calcanear and talar fracture) were the indications for arthodesis. RESULTS: On a visual analog pain scale the patients graded their pain preoperatively at 4.4 and postoperatively at 1.1. The subjective results showed in 12 cases (33.3%) complete satisfaction, in 10 cases (27.7%) satisfaction with minor reservation, in 11 cases (30.5%) satisfaction with major reservation and in 3 cases (8.5%) dissatisfaction. The overall objective results were excellent in 17 (47.2%), good in 11 (30.5%), fair in 6 (16.8%) and poor in 2 (5.5%) cases. A further advantage of this type of talocalcaneal fusion is the remaining range of motion in the neighbouring joints, at the ankle (in 75.7% the same or better ROM than preoperatively) and at Chopart joint (in 69.4% the same or better ROM than preoperatively). The fusion rate was high with 94.5%. CONCLUSION: The modified isolated talocalcaneal fusion without disruption at the Chopart joint is a simple surgical technique in the hand of the experienced surgeon. The subjective and objective mid-term results of this prospective follow-up study are comparable to other technique described in literature.

Isolated talocalcaneal interposition fusion: a prospective follow-up study.

This is a prospective clinical and radiological study of the treatment of talocalcaneal deformity or degeneration by a modified technique of isolated talocalcaneal fusion. Thirty-six patients were evaluated with clinical examination, plain dorsoplantar and oblique radiographs, and computed tomography scanning or magnetic resonance imaging in a follow-up of 32.5 months (range, 20-62 months). Indications for arthrodesis were posterior tibial tendon rupture with secondary osteoarthritis (12 cases) and secondary posttraumatic osteoarthritis (24 cases). On a visual analog pain scale, the patients graded their pain at 4.4 before surgery and at 1.1 after surgery. The subjective results were 33% complete satisfaction, 28% satisfaction with minor reservation, 31% satisfaction with major reservation, and 9% dissatisfaction. The overall objective results were excellent in 47%, good in 31%, fair in 17%, and poor in 6% of cases. A further advantage of this type of talocalcaneal fusion is a large remaining range of motion in the neighboring joints, at the ankle (in 76% the same or better ROM than before surgery), and at Chopart's joint (in 69% the same or better ROM than before surgery). The fusion rate was high (95%).

Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers.

PURPOSE: To determine the prevalence and size of presumed Morton neuromas and fluid in the intermetatarsal bursae on magnetic resonance (MR) images. MATERIALS AND METHODS: In 70 asymptomatic subjects, transaxial T1-weighted spin-echo and T2-weighted turbo spin-echo images were obtained of the right forefoot. The prevalence and size of presumed Morton neuromas (diagnosed with MR imaging criteria) were evaluated, and the sizes were compared with those of 16 symptomatic, surgically proved Morton neuromas. The prevalence and diameter of fluid collections in the intermetatarsal bursae were evaluated on the T2-weighted images. RESULTS: Twenty-four Morton neuromas were diagnosed in 21 subjects (prevalence, 30%). The transverse diameter of the neuromas was 3-7 mm (mean, 4.5 mm) versus 4-8 mm (mean, 5.6 mm) in symptomatic subjects; this difference was significant (P = .0075). The prevalence of fluid in the intermetatarsal bursa was 20%, 47%, 49%, and 0% for the first through fourth intermetatarsal spaces. The transverse diameter of the fluid collection was 1-4 mm. CONCLUSION: The diagnosis of Morton neuroma at MR imaging may be relevant only when the transverse diameter is 5 mm or more and can be correlated to clinical findings. Fluid collections in the first three intermetatarsal bursae with a transverse diameter of 3 mm or less can be considered physiologic.

Efficacy of MR imaging in patients suspected of having Morton's neuroma.

OBJECTIVE: The purpose of our study was to evaluate the role of MR imaging in patients with suspected Morton's neuroma and to assess the value of various MR sequences in this diagnosis. MATERIALS AND METHODS: Thirty-two consecutive patients with suspected Morton's neuroma were studied using a 1.0-T MR scanner. Axial T1- and T2-weighted spin-echo, short inversion time inversion recovery, and enhanced T1-weighted fat-suppressed spin-echo images were obtained on each patient. Eighteen intermetatarsal spaces in 16 of the 32 patients were evaluated surgically. Contrast-to-noise ratios for Morton's neuroma versus surrounding fat were calculated and standardized for imaging times. RESULTS: In 15 of 18 intermetatarsal spaces, a Morton's neuroma was surgically proven. Thirteen true-positive, two false-negative, three true-negative, and no false-positive MR diagnoses were given. In six of 15 proven neuromas, the clinical examiner was not able to identify the correct intermetatarsal space. The MR diagnoses in the 16 remaining patients who did not undergo surgery were Morton's neuroma (n = 8), stress fracture (n = 1), foreign body reaction (n = 1), tendon sheath ganglion (n = 1), postoperative changes (n = 2), and no abnormality (n = 3). Standardized contrast-to-noise ratios (+/- SD) were 2.42 +/- 0.72 for T1-weighted images; 1.43 +/- 1.13 for T2-weighted images; 1.26 +/- 1.47 for short inversion time inversion recovery images; and 0.83 +/- 0.59 gadolinium-enhanced fat-suppressed images. The differences were statistically significant for the T1-weighted spin-echo images versus the three other sequences (p = .001-.018), but not among the other sequences (p = .209-.710). CONCLUSION: MR imaging is accurate in diagnosing Morton's neuroma and may be important for correct localization. A limited examination employing axial T1-weighted spin-echo images is adequate; additional sequences should be employed only for differential diagnosis.

Magnetic resonance imaging of injuries to the ankle joint: can it predict clinical outcome?

OBJECTIVE: To predict clinical outcome after ankle sprains on the basis of magnetic resonance (MR) findings. DESIGN AND PATIENTS: Twenty-nine consecutive patients (mean age 32.9 years, range 13-60 years) were examined clinically and with MR imaging both after trauma and following standardized conservative therapy. Various MR abnormalities were related to a clinical outcome score. RESULTS: There was a tendency for a better clinical outcome in partial, rather than complete, tears of the anterior talofibular ligament and when there was no fluid within the peroneal tendon sheath at the initial MR examination (P = 0.092 for either abnormality). A number of other MR features did not significantly influence clinical outcome, including the presence of a calcaneofibular ligament lesion and a bone bruise of the talar dome. CONCLUSION: Clinical outcome after ankle sprain cannot consistently be predicted by MR imaging, although MR imaging may be more accurate when the anterior talofibular ligament is only partially torn and there are no signs of injury to the peroneal tendon sheath.

[Juvenile hallux valgus]. / Der kindliche Hallux valgus.

Juvenile bunions have different etiologies and require specific operative approaches. Any operative procedure to correct a juvenile hallux valgus deformity should correct all the components of the deformity, i.e. pronation of the hallux, the increased hallux valgus angle, the enlarged medial eminence, the increased intermetatarsal angle, and hypermobility or obliquity of the first metatarso-cuneiform joint with the intention of decreasing the rate of recurrence.

[Surgical fusion of the subtalar joint--changing concepts in changing times]. / Versteifungseingriffe am unteren Sprunggelenk--wechselnde Konzepte im Wandel der Zeit.

Triple arthrodesis respects the functional unit of the subtalar joint, but shows several intraoperative difficulties such as surfaces of resection that are too large or wrong positions between the hind and the middle foot. Furthermore postoperative problems like walking on uneven pavements, a reduced range of motion in the adjacent joints and the development of osteoarthritis of the ankle are not easy to deal with. Therefore isolated fusions of the talocalcaneal, talonavicular and calcaneo-cuboidal joint with a minimal resection technique seem to present several advantages. Among them we would mention a minimal reduction of the range of motion, the preservation of a physiological position of the adjacent joints and the prevention of osteoarthritis in the adjacent joint which rarely appears and when it does only in an asymptomatic form. The subtalar implants and the astragaloplasty as possibilities to treat disorders of the subtalar joint complex are also discussed.

Clinical examination and magnetic resonance imaging in the assessment of ankle sprains treated with an orthosis.

This is a prospective clinical study of treatment of ankle sprains with an ankle brace that permits ankle dorsiflexion and plantarflexion of 20 degrees, but limits inversion and eversion for 6 weeks. The ankle brace is followed by physiotherapy for another 6 weeks. Thirty patients were evaluated with clinical examination and magnetic resonance (MR) imaging before treatment and after 12 weeks of treatment. MR imaging revealed acute tears in the anterior talofibular ligament in all 30 ankles (100%) and tears in the calcaneofibular ligament in 25 of 30 ankles (83%). At 12 weeks after injury, MR evidence of healing was present for the anterior talofibular ligament in 22 of 30 ankles (73%) and for the calcaneofibular ligament in 23 of 25 ankles (92%). Postural sway analysis after therapy was used to quantify functional stability of the ankle. There was no correlation with MR findings, but there was a correlation with the subjective impression of functional instability. Twenty-eight of 30 patients (93%) had a functionally stable ankle after 12 weeks of treatment. MR findings after ankle sprain could not predict clinical outcome.

[The lax juvenile flexible flatfoot--disease or normal variant?]. / Der lockere kindliche Knickplattfuss--Krankheit oder Normvariante?

The spectrum of normal variations of children's feet is extremely broad and often difficult to separate from pathological conditions. Especially the flexible flatfoot normally disappears during growth, and even if it persists up to adult life, it hardly has any pathological significance. The natural course taken even by severe flexible flatfoot in children leads to results that are as good, if not even better than when surgery had been performed; therefore, more reticence with surgical treatment in such cases is advocated.

Analyses of 94 consecutive spinal cord injury patients using ASIA definition and modified Frankel score classification.

Serial neurological examinations were analysed on 94 consecutive spinal cord injury (SCI) patients admitted for rehabilitation to the Swiss Paraplegic Center at the Clinic Balgrist Zurich, Switzerland between 1987 and 1992. Patients' data were examined adopting ASIA and modified Frankel definitions in order to compare the two classifications in terms of consistency and prognostic value. The modified Frankel definition was subdivided into five categories (A, B, C, D and E). On admission (discharge) 43 (37) patients were classified as Frankel A, 23 (11) patients in group B, 26 (42) patients in group C, 2 (2) patients as Frankel D and 0 (2) patients in group E. A qualitative analysis of the results on the base of a maximal score of 100 points (A = 0, B = 25, C = 50, D = 75 and E = 100 points) suggested a mean score improvement from 21.5 (+/- 22.5) to 29.0 (+/- 26.3) or 7.5 (+/- 7.1), regarding all 94 patients during follow up (admission/discharge). The median improvement was one modified Frankel grade (A/B to B/C). No detailed assessments were yielded concerning motor and sensory functions. Using ASIA definition, a continuous numerical score of motor and sensory function was observed. Recovery during follow up was determined by detailed motor and sensory function. For all 94 patients (quadriplegics and tetraplegics), the average motor recovery according to the ASIA definition was 9.4 (+/- 9.6). The mean ASIA motor score improved from 52.2 (+/- 17.3) on admission to 61.6 (+/- 17.9) on discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Natural course of juvenile foot deformities]. / Spontanverlauf kindlicher Fussdeformitäten.

The spectrum of normal variations of children's feet is extremely broad and often difficult to separate from pathological conditions. Especially the flexible flatfoot and the pes adductus normally disappear during growth, and even if they do persist up to adult life, they hardly have any pathological significance. It therefore appears proper to see foot deformities of children from the prognosis point of view, that is, to differentiate between a benign, pain-free course of development with no functional restriction even under load, and pathological deformities which systematically require conservative or surgical therapy. However, definite pathological conditions like pes equinovarus, talus verticalis, or foot deformities due to development of defects, without therapy lead in most cases to well-known deformations and often to painful functional disorders. Early detection and treatment can contribute to a favorable prognosis in many cases.

[Injuries in snowboarding--a prospective study]. / Verletzungen beim Snowboardsport--eine prospektive Studie.

180 patients with injuries effected through snowboarding were evaluated during a period of 2 1/2 months in both the hospitals and private surgeries of Oberwallis. This was done to determine the nature of the injuries and the risk factors that led to them. Snowboarders are on the average 21 years of age and only rarely over 40. One-third are women, and two-third are men. More than half are beginners with less than one week's training experience; one-fifth of the beginners met with the accident on the first "snowboard day". Over 80% of the injured said that riding mistakes and insufficient training and instruction were the cause; rarely were the conditions of the runway blamed. The accidents happened irrespective of snow and runway conditions. Accidents due to tearing of the fastenings always injured the lower extremity. Injuries of the upper and lower extremities take place in the same proportions. Injuries of the trunk and head are rare. Beginners usually injure the upper, while good snowboarders the lower extremities. The most common injuries are radius fractures, followed by ankle and knee distorsions. In the case of injuries to the lower extremities, the forward leg which is the "skating leg" or "standing leg", is affected more than 80% of the cases.

[Foot problems in the elderly]. / Fussprobleme beim älteren Menschen.

Foot problems in the geriatric patient are multiple and sometimes complex. The choices in treatment are frequently restricted because of contraindications for surgery. Common foot problems are common in the elderly patient, too, but in addition there is a specific pathology of this group of patients. Inexpensive, but institutionalized routine foot care is an essential medical need of the elderly to improve the quality of life.