Targeted muscle reinnervation for a recurrent traumatic neuroma of the sural nerve: illustrative case

Abstract

BACKGROUND Traumatic neuromata often recur after resection. Recently, targeted muscle reinnervation (TMR) has been shown to be a promising alternative for the treatment of traumatic neuroma, also in nonamputees. This case shows that TMR can also be applied for this indication in recurrent traumatic neuroma. OBSERVATIONS A 55-year-old patient with a history of cerebral palsy presented with a painful swelling in his right knee, 40 years after multiple Achilles tendon surgeries for contractures. On imaging, the lesion was suspect for a traumatic neuroma of the posterior sural nerve. After two failed resections, TMR was performed by connecting the proximal end of the sural nerve to the motor branch of the lateral gastrocnemius muscle. During outpatient visits at 3, 6, and 12 months, the patient reported significantly less pain compared to before the TMR. He had no weakness of plantar flexion. Postoperative imaging, however, showed atrophy of the lateral gastrocnemius muscle. LESSONS This case shows that TMR can be a successful strategy to treat recurrent traumatic neuroma after previous failed transection of single neuromata in nonamputee cases. In the authors’ patient, TMR did not result in motor deficit, but more research is needed to investigate this consequence of TMR for this indication.

Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide

“…The proximal end of the lost motor nerve could form a symptomatic terminal end neuroma. 80 In theory, either could contribute to peripheral or central sensitization, thereby contributing to and worsening chronic pain experienced by these patients. 81–85…”

“…The proximal end of the lost motor nerve could form a symptomatic terminal end neuroma. 80 In theory, either could contribute to peripheral or central sensitization, thereby contributing to and worsening chronic pain experienced by these patients. [81][82][83][84][85] One proposed solution to address this nerve-size mismatch and corresponding axonal escape is to place a denervated piece of muscle around the TMR coaptation site.…”

Biology and pathophysiology of symptomatic neuromas

“…In instances of neuroma recurrence despite nerve-capping, more contemporary strategies such as TMR have demonstrated stable improvements to pain. 131 Targeted muscle reinnervation has been documented as yielding complete analgesia even in patients with high comorbidity: 71% of TMR patients were “pain-free” compared with 36% of their controls with similar trends across metrics for residual phantom pain and ambulatory status. 25 Regenerative peripheral nerve interfaces saw similar effects with patient reported 71% reduction in neuroma pain and 53% reduction in phantom pain.…”