Surgical Treatment of Symptomatic Neuromas After Lower Limb Amputations
ARTICLE PDF

Keywords

pain; residual limb pain; lower limb amputation; surgery.

How to Cite

Liabakh, A., Lazarenko, H., & Piatkovskyi, V. (2020). Surgical Treatment of Symptomatic Neuromas After Lower Limb Amputations. TERRA ORTHOPAEDICA, (2(105), 11-17. https://doi.org/10.37647/0132-2486-2020-105-2-11-17

Abstract

Summary. The pain after amputations is a global problem of modern medicine. There are three distinct clinical entities that can form the postamputation pain: phantom limb pain (PLP), phantom sensations (PSs), and residual limb pain (RLP). PLP and PSs are pathophysiological phenomena, which need complex conservative treatment. RLP is a local condition that arises from neuroma, excessive scarring, osteophites, etc. and can be resolved by surgery. Objective: to analyze the results of surgical treatment of patients with symptomatic neuromas after lower limb amputations (LLA). Materials and Methods. The study included 43 patients with symptomatic neuromas 3–10 years after LLA. There were 40 male and 3 female patients (mean age 33.9±3 years). Amputations were caused by trauma (33 cases), mine-blast injury (7 cases), diabetes (1 case), and oncology (2 cases). The level of amputation was thigh (3 cases), knee (1 case), and ankle (39 cases). The pain intensity was measured by the VAS (Visually Analog Scale) and prosthesis using by the ALAC (Artificial Limb and Appliance Centre, USA) scale. Results. RLP had 43 patients (100%), PLP – 8 (8.6%), and PSs – 35 (81.4%) patients. The average level of pain was 7.4±0.9. Prosthesis was used in 74.4% (32 patients), but 11 of them used prosthesis for cosmetic or transportation reasons (levels I and II by the ALAC scale). Complications after surgery were presented by hematoma (3 cases), marginal skin necrosis (2 cases), and tearing of m. gastrocnemius from the tibia after the fall on the stump (1 case). The results were assessed in 35 patients in terms from 1 to 15 years. The pain severity decreased from 7.4±0.9 to 3.2±0.6 (p˂0.05; two-sample t-test). The number of RLP cases decreased to 11 (31.4%), but the number of PLP and PSs cases did not significantly change (PLP – 5 cases or 14.3%; PSs – 27 cases or 77.1%). The prosthesis using rised to 100% due to functionality (III–VI levels by the ALAC scale). Conclusions. Surgical method is the main treatment of symptomatic neuromas after LLA. The surgery must expect proximal neurotomy and, if need, reamputation and stump reconstruction. This approach helps to reduce pain and improves the functional ability of persons with LLA.

https://doi.org/10.37647/0132-2486-2020-105-2-11-17
ARTICLE PDF

References

Buchheit T, Hsia HJ, Cooter M, Shortell C, Kent M, McDuffie M et al. The impact of surgical amputation and valproic acid on pain and functional trajectory: results from the Veterans Integrated Pain Evaluation Research (VIPER). Randomized, double-blinded placebo-controlled trial. Pain Med. 2019; 20(10):2004-2017. doi: 10.1093 / pm / pnz067.

Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998; (139): 1–119. PMID: 9866429.

Dillingham T, Pezzin L, MacKenzie E. Limb amputation and limb deficiencies: epidemiology and recent trends in the United States. South Med J. 2002; 95:875–883. doi: 10.1097 / 00007611-200208000-00018.

Облитерирующие ангиопатии и расстройства трофики стопы. Под редакцией профессора А.П.Лябаха – К.: Стилос, 2010. – С.137 – 138.

Obliterative angiopathies and disturbances of foot trophic. Edited by professor A.P. Liabakh. Kyiv, Stylos. 2010:137-138. In Russian.

Jensen TS, Krebs B, Nielsen J, Rasmussen P. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain. 1983; 17(3):243–256.

Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000; 81(8):1039–1044. doi: 10.1053 / apmr.2000.7583.

Vernadakis AJ, Koch H, Mackinnon SE. Management of neuromas. Clin Plast Surg. 2003; 30(2):247-68, vii. doi: 10.1016 / s0094-1298 (02) 00104-9.

Lewin-Kovalik J, Marcol W, Kotulska K, Mandera M, Klimczak A. Prevention and management of painful neuroma. Neurol Med Chir (Tokyo). 2006; 46(2):62-68. doi: 10.2176 / nmc.46.62.

Koch H, Haas F, Humber M, Rappl T, Scharnagl E. Treatment of painful neuroma by resection and nerve stump transplantation into a vein. Ann Plast Surg. 2003; 51:45-51. doi: 10.1097 / 01.SAP.0000054187.72439.57.

Sehirlioglu A, Ozturk C, Yazicioglu K, Tugcu I, Yilmaz B, Goktepe AC. Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions. Int Orthop (SICOT). 2009; 33:533-36. Doi: 10.1007 / s00264-007-0466-y.

Campbell WB, Johnston JASt, Kernick VFM, Rutter EA. Lower limb amputation: striking the balance. Ann R Coll Surg Engl. 1994; 76(2):205-209.

Donnal JF, Blinder RA, Coblentz CL, Moylan JA, Fitzpatrick KP. MR imaging of stump neuroma. J Comput Assist Tomogr. 1990; 14(4):656–657. PMID: 2120992.

Subedi N, Parmer V, Beardmore S, Jepson F, Ali SI. Multimodality imaging review of the post-amputation stump pain. Br J Radiol; 89: 20160572. doi: 10.1259 / bjr.20160572.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.