Traumatic Hip Disarticulation with Sciatic Nerve Capping for Neuroma Prevention
Desirae McKee, MD, Samir Sherali, BA, Cameron Cox, BA and Brendan J MacKay, MD, Texas Tech University Health Sciences Center, Lubbock, TX
Introduction
Traumatic hip disarticulations are not only uncommon, but also carry a high rate of morbidity and mortality. In these patients, amputations are often accompanied by phantom or stump pain, which for a subset of lower limb amputees is disabling. These amputees are at particular risk for developing neuromas. Successful treatment of these neuromas can provide significant improvements in pain, quality of life, and ambulation status.
Recently nerve caps have been developed by Axogen as a modality for treatment of neuromas. The placement of nerve caps may function in part by inducing increased expression of RhoA, a Ras GTPase protein, which inhibits axonal regrowth thereby preventing neuroma formation. The use of Axogen nerve caps has shown positive outcomes in animal models.
In this rare case, a 25 year old male survived a motorcycle accident resulting in traumatic amputation of his right leg with hip disarticulation. At 1 month post-op, the patient underwent a novel procedure in which nerve caps were placed on the sciatic nerve to prevent neuroma.
Materials & Methods
The sciatic nerve and epineurium bundle was separated into seven separate 7mm fascicles. Each fascicle was fit into an individual nerve cap and secured with an 8.0 epineurial stitch, leaving 5 mm between the end of each split and the end of the cap. A muscular trough was created in the posterior pelvic muscular wall into which the capped nerve bundle was laid and covered with muscle.
Results
In the month following the initial procedure, the patient continued to have procedures for incision and drainage, irrigation, and debridement to eliminate infection. Prior to the capping procedure, the patient reported both phantom pain and stump pain. Two months postoperatively, the patient's pain frequency decreased from every 5 minutes to 2 times daily. At this time the patient had both phantom pain and incision pain.
Five months postoperatively the patient's phantom pain reduced to 3 times a week with no signs of infection. The patient was also able to hop on a walker and was making progress toward prosthetic fitting.
Conclusions
In this case, the nerve caps have thus far been successful for the prevention of neuroma of the sciatic nerve. Usage of nerve caps following amputation surgery or neurectomy may serve as an effective method to prevent neuromas, reduce the need for future follow-up surgeries, and minimize chronic debilitating pain following surgery.
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