Heterotopic Ossification Is Associated with Painful Neuromas in Transtibial Amputees Undergoing Surgical Treatment of Symptomatic Neuromas
Floris V. Raasveld, MD1, Wen-Chih Liu, MD1, William Renthal, MD, PhD2, Mark E Fleming, DO, FAAOS1, Ian L Valerio, MD, MS, MBA1 and Kyle R. Eberlin, MD1, 1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital/Harvard Medical School, Boston, MA
Introduction:The relation between nerve regeneration and osseous growth has been described. During surgical treatment of neuroma in below-knee amputees, we have noticed that heterotopic ossification (HO) depicted on preoperative X-ray appears to be predictive of the location of symptomatic neuromas in both the peroneal (fibula) and tibial (tibia) nerve distributions.
Methods: Data were collected for transtibial amputees who underwent surgical management of symptomatic neuroma and who were registered in a prospective data repository from 2017 through 2023. Preoperative X-rays were assessed for the presence of HO located at the distal fibula and tibia (Fig. 1). Presence of a peroneal and/or tibial neuroma was based on findings contained within the operative reports. Pain levels were measured on a numeric rating scale from 0 to 10.
Results: Sixty-five limbs of 62 amputees were included in this study. Peroneal neuroma and presence of fibular HO (P=0.001), and tibial neuroma and presence of tibial HO (P=0.038) demonstrated an association. The odds of having a symptomatic peroneal neuroma with fibular HO present are greater than the odds of a symptomatic peroneal neuroma when fibular HO is absent (OR 9.3; 95% CI [1.9-45.6], P=0.006). No significantly higher odds were demonstrated for tibial neuroma and tibial HO (OR, 4.8; 95% CI [0.9-24.7], P=0.061) (Fig. 2). Pre-operative pain scores were significantly higher for all patients with HO (P<0.001), those with fibular HO (P<0.001) and those with tibial HO (P<0.001), compared to patients without distal stump HO (Fig. 3).
Conclusion: Distal HO in transtibial amputees is associated with increased pre-operative pain as well as the presence of a symptomatic neuroma, specifically a peroneal neuroma with fibular distal stump HO and a tibial neuroma with tibial distal stump HO. These findings may assist in intraoperative decision-making on which nerves to address in neuroma surgery, and provide information about the biology of neuroma formation and development.
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