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Traction Neurectomy for the Treatment of Painful Residual Limb Neuromas in Lower Extremity Amputees
Mitchell Pet, MD; Janna Friedly, MD; Douglas G. Smith, MD; Jason Ko, MD
University of Washington, Harborview Medical Center, Seattle, WA
Background: Traction neurectomy is a surgical treatment for symptomatic neuroma of the residual limb that entails neuroma excision, with high transection of the nerve while on traction. The nerve stump is thereby proximally relocated into an area more protected by muscle and soft tissue, where it is less likely to become irritated and symptomatic. This technique is favored by many surgeons for its simplicity, and the favorable outcomes documented in the limited available literature. Our group has performed this technique regularly in lower extremity amputees, and in this series we document our experience and outcomes.
Materials and Methods: We retrospectively reviewed all above and below knee amputees with a diagnosis of symptomatic neuroma of the residual limb, treated with traction neurectomy by a single surgeon at a high-volume trauma center between 2006 and 2014. The primary outcome was the presence or absence of neuroma-type pain at the time of last follow-up, and the secondary outcome was performance of revisional surgery for persistent or recurrent symptomatic neuroma(s) of the treated nerve(s). Demographic and clinical variables were investigated as potential predictors for persistent/recurrent disease. Results: 67 patients (108 nerves) met study inclusion criteria. 29 patients were excluded for inadequate follow-up (<10 months) leaving 38 patients (63 nerves) comprising our study group. There were no significant differences between the included and excluded groups with regards to age, gender, amputation level, reason for amputation, prior surgical therapy for symptomatic neuroma, time since amputation, or concomitant surgical procedures. 35/38 (92%) patients experienced initial symptomatic relief, but 16/38 patients (42%) had recurrent or persistent neuroma-type pain at a mean follow-up of 36 months (range, 11-91 months), and 8/38 (21%) underwent subsequent surgical treatment. The mean time to recurrence was 5.3 months (range 0-81 months). Of the demographic and clinical features listed above, only male gender was found to be a statistically significant predictor of persistent or recurrent neuroma-type pain.
Conclusions: In our cohort of lower extremity amputees with symptomatic neuroma of the residual limb, we found a high rate of persistent or recurrent neuroma pain. This is starkly in contrast to other similar series reporting recurrence at or approaching 0%. Most recurrences were early, and male gender was identified as a risk factor for persistent/recurrent symptoms. We conclude that traction neurectomy is not an optimal treatment, and the efforts of many groups who continue to seek better surgical and non-surgical treatments for this problem are justified.
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