Introduction Morton’s neuroma is a frequent cause of metatarsalgia and represents a common diagnostic challenge in clinical practice. Although ultrasound (US) and magnetic resonance imaging (MRI) are the most widely used imaging techniques, their reported diagnostic accuracy is highly variable and a standardized diagnostic pathway is still lacking. This variability is largely related to differences in imaging protocols, operator experience, technological factors, and diagnostic criteria, limiting a truly evidence-based choice between imaging modalities Purpose of the study Purpose of this study was to prospectively compare the diagnostic accuracy of dynamic ultrasound and magnetic resonance imaging in the diagnosis of Morton’s neuroma, based on the hypothesis that ultrasound, when performed according to standardized criteria and by experienced operators, may be superior, particularly in distinguishing Morton’s neuroma from intermetatarsal bursitis. The study also aimed to identify the main imaging parameters predictive of disease and to contribute to the definition of a standardized and reproducible diagnostic pathway, with the goal of improving clinical appropriateness and surgical indication. Materials and Methods This prospective observational study was conducted between January 2022 and December 2024 and included 53 patients (76 feet) with clinical suspicion of Morton’s neuroma. All subjects underwent dynamic ultrasound and forefoot MRI, interpreted independently and in a blinded fashion by different radiologists. When at least one imaging modality suggested the presence of a neuroma, patients underwent surgical excision with histopathological confirmation. Cases with concordant imaging diagnosis of intermetatarsal bursitis were managed conservatively and were not operated on. Sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) curves were calculated for both imaging techniques. Multivariate logistic regression analysis was performed to identify imaging features predictive of Morton’s neuroma. Results A total of 53 patients (47 women, 6 men; median age 58 years) were included. Ultrasound demonstrated a sensitivity of 100%, specificity of 95.83%, and diagnostic accuracy of 98.68%, with an area under the ROC curve (AUC) of 0.991. MRI showed a sensitivity of 84.91%, specificity of 100%, and accuracy of 89.47%, with an AUC of 0.925. The difference between the AUCs was statistically significant (p = 0.0147), in favor of ultrasound. The most predictive ultrasound features for Morton’s neuroma were a positive Mulder’s sign (p = 0.0015) and lesion non-compressibility (p = 0.0027), whereas for MRI the most predictive parameters were maximum lesion diameter and lesion shape. Conclusions Dynamic ultrasound proved to be significantly more accurate than MRI in the diagnosis of Morton’s neuroma and in distinguishing it from intermetatarsal bursitis. When performed by experienced operators, ultrasound should be considered the first-line imaging modality in the diagnostic pathway of Morton’s neuroma, reserving MRI for equivocal or complex cases. This approach may optimize surgical indication and reduce the risk of inappropriate diagnoses.
Introduzione Il neuroma di Morton rappresenta una delle cause più frequenti di metatarsalgia. Sebbene l’ecografia e la risonanza magnetica costituiscano le principali metodiche di imaging utilizzate nel percorso diagnostico, la letteratura riporta risultati di accuratezza diagnostica ampiamente variabili e manca, ad oggi, un iter diagnostico standardizzato e condiviso. In questo contesto, risulta ancora controverso il ruolo relativo delle due metodiche, in particolare nella distinzione tra neuroma di Morton e borsite intermetatarsale. Scopo dello studio Scopo dello studio è confrontare prospetticamente l’accuratezza diagnostica dell’ecografia dinamica e della risonanza magnetica nella diagnosi del neuroma di Morton, partendo dall’ipotesi che l’ecografia, se eseguita secondo criteri standardizzati e da operatori esperti, possa risultare superiore, in particolare nella distinzione dalla borsite intermetatarsale. Lo studio mira, inoltre, a identificare i principali parametri di imaging predittivi di malattia e a contribuire alla definizione di un percorso diagnostico standardizzato e riproducibile, volto a migliorare l’appropriatezza clinica e l’indicazione al trattamento chirurgico. Materiali e metodi Studio prospettico osservazionale condotto tra gennaio 2022 e dicembre 2024 su 53 pazienti (76 piedi) con sospetto clinico di neuroma di Morton. Tutti i soggetti sono stati sottoposti a US dinamica e RM dell’avampiede, refertate in cieco da radiologi differenti. Qualora almeno una metodica suggerisse la presenza di neuroma, il paziente veniva sottoposto a escissione chirurgica con conferma istologica. I casi con diagnosi concordante di borsite intermetatarsale non venivano trattati chirurgicamente. Sono state calcolate sensibilità, specificità, accuratezza, PPV, NPV e curve ROC per entrambe le metodiche. È stata inoltre eseguita regressione logistica multivariata per identificare i parametri predittivi di neuroma. Risultati Sono stati arruolati 53 pazienti (47 donne, 6 uomini; età mediana 58 anni). L’US ha mostrato sensibilità del 100%, specificità del 95,83% e accuratezza del 98,68%, con AUC pari a 0,991. La RM ha ottenuto sensibilità dell’84,91%, specificità del 100% e accuratezza dell’89,47%, con AUC di 0,925. La differenza tra le AUC è risultata statisticamente significativa (p = 0,0147) a favore dell’ecografia. I parametri ecografici maggiormente predittivi di neuroma sono risultati la positività del segno di Mulder (p = 0,0015) e la non comprimibilità della lesione (p = 0,0027), mentre per la RM sono risultati predittivi il diametro massimo e la forma della lesione. Conclusioni L’ecografia dinamica si è dimostrata significativamente più accurata della RM nella diagnosi di neuroma di Morton e nella distinzione dalla borsite intermetatarsale. In presenza di operatori esperti, l’US dovrebbe essere considerata metodica di prima linea nel percorso diagnostico del neuroma di Morton, riservando la RM ai casi dubbi o complessi. Questo approccio consente di ottimizzare l’indicazione al trattamento chirurgico e di ridurre il rischio di diagnosi inappropriate.
Ecografia dinamica vs risonanza magnetica per il neuroma di Morton: qual è il gold standard diagnostico?
SCIARRETTA, GIOVANNI
2023/2024
Abstract
Introduction Morton’s neuroma is a frequent cause of metatarsalgia and represents a common diagnostic challenge in clinical practice. Although ultrasound (US) and magnetic resonance imaging (MRI) are the most widely used imaging techniques, their reported diagnostic accuracy is highly variable and a standardized diagnostic pathway is still lacking. This variability is largely related to differences in imaging protocols, operator experience, technological factors, and diagnostic criteria, limiting a truly evidence-based choice between imaging modalities Purpose of the study Purpose of this study was to prospectively compare the diagnostic accuracy of dynamic ultrasound and magnetic resonance imaging in the diagnosis of Morton’s neuroma, based on the hypothesis that ultrasound, when performed according to standardized criteria and by experienced operators, may be superior, particularly in distinguishing Morton’s neuroma from intermetatarsal bursitis. The study also aimed to identify the main imaging parameters predictive of disease and to contribute to the definition of a standardized and reproducible diagnostic pathway, with the goal of improving clinical appropriateness and surgical indication. Materials and Methods This prospective observational study was conducted between January 2022 and December 2024 and included 53 patients (76 feet) with clinical suspicion of Morton’s neuroma. All subjects underwent dynamic ultrasound and forefoot MRI, interpreted independently and in a blinded fashion by different radiologists. When at least one imaging modality suggested the presence of a neuroma, patients underwent surgical excision with histopathological confirmation. Cases with concordant imaging diagnosis of intermetatarsal bursitis were managed conservatively and were not operated on. Sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) curves were calculated for both imaging techniques. Multivariate logistic regression analysis was performed to identify imaging features predictive of Morton’s neuroma. Results A total of 53 patients (47 women, 6 men; median age 58 years) were included. Ultrasound demonstrated a sensitivity of 100%, specificity of 95.83%, and diagnostic accuracy of 98.68%, with an area under the ROC curve (AUC) of 0.991. MRI showed a sensitivity of 84.91%, specificity of 100%, and accuracy of 89.47%, with an AUC of 0.925. The difference between the AUCs was statistically significant (p = 0.0147), in favor of ultrasound. The most predictive ultrasound features for Morton’s neuroma were a positive Mulder’s sign (p = 0.0015) and lesion non-compressibility (p = 0.0027), whereas for MRI the most predictive parameters were maximum lesion diameter and lesion shape. Conclusions Dynamic ultrasound proved to be significantly more accurate than MRI in the diagnosis of Morton’s neuroma and in distinguishing it from intermetatarsal bursitis. When performed by experienced operators, ultrasound should be considered the first-line imaging modality in the diagnostic pathway of Morton’s neuroma, reserving MRI for equivocal or complex cases. This approach may optimize surgical indication and reduce the risk of inappropriate diagnoses.| File | Dimensione | Formato | |
|---|---|---|---|
|
tesi_GSciarretta.pdf
Accesso riservato
Dimensione
1.19 MB
Formato
Adobe PDF
|
1.19 MB | Adobe PDF |
The text of this website © Università degli studi di Padova. Full Text are published under a non-exclusive license. Metadata are under a CC0 License
https://hdl.handle.net/20.500.12608/103438