Ultrasound-guided Injection Treatments versus Surgical Neurectomy for Morton Neuroma: A Cost-effectiveness Analysis.

Background: Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. Objective: The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas that have failed conservative management. Methods: An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three injection selective strategies in which one or more ultrasound-guided injection therapies was tried first prior to surgery for non-responders. The three injection selective strategies included: (1) steroid selective (2) alcohol selective, and (3) steroid/alcohol selective in which both steroid injections and alcohol sclerosing injections were trialed successively prior to surgical neurectomy. The direct to surgery approach was compared with the three different injection selective strategies, and with a no-treatment strategy, in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuromas that had failed conservative management. Model parameters including treatment costs, effectiveness, complication rates, and health utility states were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality adjusted life year (QALY) with a time horizon of three years. A societal cost perspective was adopted with a willingness to pay threshold of $100,000 per QALY. Sensitivity analyses for key model parameters were performed. Results: For the base input values, the steroid/alcohol selective strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401/QALY compared to no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective strategy became most cost-effective. Conclusion: A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared to proceeding directly to surgical neurectomy. Clinical Impact: Ultrasound-guided injection therapies are indicated as a first line treatment for patients with symptomatic Morton neuromas that have failed conservative management.