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03/23/2021    Samuel Cox, DPM

FL Podiatrist Discusses Morton's Neuroma (Peter J. Bregman, DPM)

I read the response from Peter J. Bregman, DPM
and agree I would love to never do another
neurectomy. That said, I have tried first cutting
the deep transverse ligament (DTL) with an #18
needle with poor success. Then I went to an MIS
technique of using a #67 or #64 blade and hugging
the metatarsal and cutting the ligament with only
slightly better success. More recently, I have
been doing about a 1.5 cm incision, then using a
freer elevator to locate the DTL. I then use a
tenotomy scissor to cut the ligament, and use a
hemostat to spread the interspace, with better

With this type of procedure, there is very little
post-op pain and no bleeding. I use a few simple
sutures and it is quickly done, however there
have been some of those procedures that have
failed as well. All the prior listed procedures
were done in the office. If I go to the hospital
or SC for a most open traditional neurectomy, I
often find that there are some very deep binding
fibers well under the level of the DTL. I truly
believe if I released those fibers, the patient’s
issues and pain would be resolved. However,
because a decompression in-office had already
failed and the patient was booked for a
neurectomy, if I leave the nerve in the foot at
that point and they don’t have a good result,
then I could be in a pickle from a medical legal

This is even more so than if the patient
developed a stump neuroma because that is a known
complication. The real issue is figuring out how
to release those deep fibers, saving the nerve,
and not causing a bleeding problem while doing an
in-office procedure. This is because the
reimbursement for the open surgery is so low for
the time commitment to be done in a hospital or
surgery center that I need to either not do them
at all or find a way to do them in-office with
greater success. Now there is an MIS procedure
that can be done in the office where you release
the DTL and do metatarsal osteotomies to both
adjacent metatarsals with some anecdotal success.
I have not attempted this technique as yet.

Samuel Cox, DPM, Goodyear, AZ

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