Symptomatic Neuroma Formation after Below-knee Amputation Preferentially Occurs in Nerves Unrecognized at Initial Amputation
Christopher M Fleury, MD, Brian L Chang, MD, Patrick W Harbour, MD and Grant M Kleiber, MD, Georgetown University, Washington, DC
Symptomatic Neuroma Formation after Below-knee Amputation Preferentially Occurs in Nerves Unrecognized at Initial Amputation
Christopher Fleury, MD; Brian L. Chang, MD; Patrick Harbour, MD; Grant Kleiber, MD
Introduction
Symptomatic neuromas after below-knee amputation lead to increased pain, decreased ambulation, and decreased quality of life. Neuroma formation is multifactorial; failure to identify and treat major sensory nerves at primary amputation may increase risk of symptomatic neuroma development. This study aims to evaluate failure to recognize major sensory nerves at initial amputation as a risk factor for symptomatic neuroma development.
Materials and Methods
This is a case-control investigation of a single-institution, single-surgeon experience with secondary treatment of symptomatic neuroma after below-knee amputation. Twenty-two legs with symptomatic neuroma after primary amputation were treated with secondary neuroma excision. Operative records from initial amputations were reviewed to determine whether affected nerves were identified at initial amputation. At the secondary procedure, neuromas were identified preoperatively, intraoperatively, and pathologically. These findings were compared to a control group of 22 consecutive below-knee amputees with no evidence of symptomatic neuroma at minimum follow-up of 1 year.
Results
Nerves forming painful neuromas were more likely to be unrecognized at the time of initial amputation, compared with asymptomatic nerves. Of 43 total neuromas treated in the case group, 32 (74%) of the affected nerves were not identified iat initial amputation. Of the 110 non-neuromatous nerves in the control group, only 43 (39%) went unrecognized in the initial amputation, indicating that failure to identify a nerve at initial amputation is a risk factor for symptomatic neuroma development (OR 4.53, p=0.0003). Of the 19 SPN neuromas, 14 were not identified at initial amputation; of the 22 asymptomatic SPN's, only 4 were unrecognized (OR 12.6, p=0.0009). Of the 17 affected saphenous nerves, 14 were unidentified; of the 22 unaffected saphenous nerves, only 7 were unidentified (OR 10.0, p=0.03). The remaining nerve comparisons were not statistically significant.
Conclusion
Failure to identify major sensory nerves of the leg at initial amputation is a risk factor for symptomatic neuroma development. This is especially significant for the SPN and saphenous nerves. Nerves may be treated with several methods at amputation, ranging from simple traction neurectomy to targeted muscle reinnervation. This study suggests that simply recognizing the major sensory nerves of the leg at the time of primary below-knee amputation is an important step toward decreasing symptomatic neuroma formation, thereby improving postoperative pain, ambulation, and quality of life.
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