Symptomatic Neuromas in Lower Extremity Amputees: Implications for Pre-emptive–targeted Muscle Reinnervation

Nigam, Manas; Webb, Alex; Harbour, Patrick; Devulapalli, Chris; Kleiber, Grant M.

doi:10.1097/01.gox.0000584672.39249.cf

Cited by 8 publications

(10 citation statements)

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“…No peer-reviewed literature specifically reports using ultrasound to detect neuromas in purely sensory nerves (e.g., sural and saphenous), despite knowledge that these nerves can also develop painful terminal neuromas after limb loss. 25,26 Furthermore, although several studies have reported findings of inflammation or soft tissue abnormalities, descriptions on how to distinguish among the different causes are sparse. No publications have reported on the sonographic appearance of a normal or abnormal myodesis.…”

Section: Discussionmentioning

confidence: 99%

“…No data describe normative CSAs of these nerves in individuals with limb loss, or the timeline for any changes in nerve CSAs to occur following amputation. No peer‐reviewed literature specifically reports using ultrasound to detect neuromas in purely sensory nerves (e.g., sural and saphenous), despite knowledge that these nerves can also develop painful terminal neuromas after limb loss 25,26 …”

Section: Discussionmentioning

confidence: 99%

“…To this end, we present an ultrasound imaging example of a sural neuroma in an individual with a transtibial amputation (Figure 2B). 25,26…”

Section: Neuromamentioning

confidence: 99%

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Diagnostic ultrasound of the residual limb: A narrative review

Powell

Sparling

Yuan

2022

PM&R

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Globally, 57.7 million people lived with traumatic limb loss in 2017, with the prevalence of amputation in the United States alone expected to reach 3.6 million by 2050. Pain is a common complication after limb loss, with up to 59% of patients experiencing residual limb pain (RLP). Although RLP is often due to a structural etiology, it is difficult to treat because the exact structure involved is frequently not apparent on history and physical examination alone. This narrative review aims to summarize the available literature on diagnostic ultrasound of the residual limb and examine the utility of ultrasound in identifying specific pathology. A total of 31 peer‐reviewed manuscripts published between 1989 and 2021 were included, grouped by pathology. Although ultrasound presents a promising and cost‐effective approach to identifying pathology within the residual limb, many gaps remain in the current knowledge, and no specific protocol for a sonographic assessment of the residual limb has ever been proposed. Future studies of diagnostic ultrasound of the residual limb should focus on replicable sonographic techniques and standardized exam protocols.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Diagnostic ultrasound of the residual limb: A narrative review

Powell

Sparling

Yuan

2022

PM&R

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“…These standardized sites were available among all participants with LLL and were selected to avoid the inherent variability of the distal end of the residual limb, as well as common locations of residual limb neuromas. 22 Unilateral testing order was consistently presented in the abovementioned order, but testing side was randomized (ie, residual vs. intact or right vs. left for participants with LLL and controls, respectively). Each site was tested 3 times, with ∼10 seconds of rest between trials.…”

Section: Ppt Testingmentioning

confidence: 99%

Mechanical Pain Sensitivity in Postamputation Pain

Beisheim‐Ryan

Pohlig

Hicks

et al. 2021

The Clinical Journal of Pain

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Objectives: Postamputation, clinical markers of pain-related peripheral and central nervous system hypersensitivity remain understudied. This study aimed to identify whether adults with postamputation pain demonstrate greater pain sensitivity in primary (ie, amputated region) and secondary (ie, nonamputated region) sites, as compared with painfree peers and controls with intact limbs.Methods: Ninety-four participants postunilateral, transtibial amputation (59 with pain, 35 pain-free) and 39 controls underwent pain-pressure threshold (PPT) testing at 10 sites. Pain-pressure thresholds were normalized to sex-specific control data using Z score conversions. Normalized primary-site and secondary-site PPTs were compared between groups using multivariate analysis of variance (P < 0.050).Results: Compared with pain-free peers, adults with postamputation pain demonstrated reduced normalized PPTs across primary and secondary sites (mean difference = 0.61-0.74, P = 0.001 to 0.007). Compared with controls, adults with postamputation pain demonstrated reduced normalized PPTs (mean difference = 0.52, P = 0.026) only at primary sites.Discussion: Adults with postamputation pain demonstrate greater amputated region pain sensitivity as compared with pain-free peers or controls with intact limbs, indicating peripheral sensitization persists even after limb healing. Secondary-site pain sensitivity was similar between controls and adults with postamputation pain, suggesting central nervous system hypersensitivity may not be ubiquitous with postamputation pain. Studies are needed to investigate mechanisms underlying pain sensitivity differences between adults with and without postamputation pain.

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“…Whereas the benefits of targeted muscle reinnervation on pain after amputation continue to be reported, 3,5,7,8 the addition of a separate procedure increases operative time and often introduces a second surgical team, both of which may increase the risk for postoperative complications such as surgical site infection and delayed wound healing. 9 To date, no studies have evaluated the potential effect of this additional procedure on perioperative complications when performed at the time of below-knee amputation.…”

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confidence: 99%

Primary Targeted Muscle Reinnervation after Below Knee Amputation is Not Associated with An Increased Risk of Major or Minor Surgical Complications: A Multi-Institutional, Propensity Score-Matched Analysis

Shammas

Azoury

Sergesketter

et al. 2022

Plastic &Amp; Reconstructive Surgery

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Background: Targeted muscle reinnervation has emerged as a technique to reduce neuroma and phantom limb pain after below-knee amputation; however, the incidence of postoperative complications remains unknown. This multi-institutional study assessed the risk of postoperative complications among patients who underwent targeted muscle reinnervation at the time of below-knee amputation. Methods: Patients who underwent below-knee amputation with targeted muscle reinnervation were propensity score–matched 1:3 to patients who underwent below-knee amputation alone. Study outcomes included the incidence of major or minor complications within 60 days. Regression models were used to estimate the relative risk of major and minor complications. Results: Overall, 96 patients were matched, including 31 patients who had below-knee amputation with targeted muscle reinnervation and 65 who had below-knee amputation alone. In the matched sample, a higher incidence of major complications (29 percent versus 24.6 percent), readmission (25.8 percent versus 18.5 percent), and reoperation (19.4 percent versus 10.8 percent) was seen after both procedures compared with below-knee amputation alone. Patients who underwent both procedures displayed a higher incidence of minor complications (25.8 percent versus 20.0 percent), blood transfusion (22.6 percent versus 18.5 percent), and wound healing complications (45.2 percent versus 33.8 percent) and longer operative time (mean ± SD, 188.5 ± 63.6 minutes versus 88 ± 28.2 minutes). There was no statistically significant difference in the risk of major (relative risk, 1.20; 90 percent CI, 0.68, 2.11) or minor (relative risk, 1.21; 90 percent CI, 0.61, 2.41) complications between the two cohorts. Conclusions: Despite an increased incidence of postoperative complications, undergoing below-knee amputation with targeted muscle reinnervation does not confer a statistically significant increased risk of major or minor complications. Future studies are needed to delineate patient selection criteria when assessing the suitability of targeted muscle reinnervation at the time of major limb amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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Symptomatic Neuromas in Lower Extremity Amputees: Implications for Pre-emptive–targeted Muscle Reinnervation

Cited by 8 publications

References 0 publications

Diagnostic ultrasound of the residual limb: A narrative review

Diagnostic ultrasound of the residual limb: A narrative review

Mechanical Pain Sensitivity in Postamputation Pain

Primary Targeted Muscle Reinnervation after Below Knee Amputation is Not Associated with An Increased Risk of Major or Minor Surgical Complications: A Multi-Institutional, Propensity Score-Matched Analysis

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