Neuroma transposition and intramuscular implantation using the Mitek "soft-tissue anchor": a new technique

Current State of the Surgical Treatment of Terminal Neuromas

Painful terminal neuromas resulting from nerve injury following amputation are common. However, there is currently no universally accepted gold standard of treatment for this condition. A comprehensive literature review is presented on the treatment of terminal neuromas. Four categories of terminal neuroma surgical procedures are assessed: epineurial closure; nerve transposition with implantation; neurorrhaphy, and alternate target reinnervation. Significant patient and case studies are highlighted in each section, focusing on surgical technique and patient outcome metrics. Studies presented consisted of a PubMed search for "terminal neuromas," without year limitation. The current available research supports the use of implantation into muscle for the surgical treatment of terminal neuromas. However, this technique has several fundamental flaws that limit its utility, as it does not address the underlying physiology behind neuroma formation. Regenerative peripheral nerve interfaces and targeted muscle reinnervation are 2 techniques that seem to offer the most promise in preventing and treating terminal neuroma formation. Both techniques are also capable of generating control signals which can be used for both motor and sensory prosthetic control. Such technology has the potential to lead to the future restoration of lost limb function in amputees. Further clinical research employing larger patient groups with high-quality control groups and reproducible outcome measures is needed to determine the most effective and beneficial surgical treatment for terminal neuromas. Primary focus should be placed on investigating techniques that most closely approximate the theoretically ideal neuroma treatment, including targeted muscle reinnervation and regenerative peripheral nerve interfaces.

Implantation of nerve stump inside a vein and a muscle: comparing neuroma formation in rat

Among many techniques independently reported to manage neuroma formation, manipulation of the nerve stump inside muscle and vein is the most advantageous technique. This study aimed to enrich the basic data of macroscopic appearance and histo-pathology regarding which technique generates less neuroma: nerve stump implantation inside vein or inside muscle. An experimental study with posttest-only control-group design was conducted in 24 rats that were randomly arranged into 3 groups. One centimeter of the lateral branch of the right ischiadic nerve was cut. Group A served as the control group, where the proximal nerve stumps were left as they were after the excision; whereas the stumps of groups B and C were implanted inside muscles and veins, respectively. The samples were assessed with histologic examination after 4 weeks to measure the morphometric changes in the nerve endings. The data were statistically analyzed with t test. All rats healed uneventfully. No thrombosis was found within group C, and the stumps were free of neuroma formation. The muscle group formed smaller neuroma than the control group. Statistical analysis showed significant differences between the groups (P < 0.05). The outcome of nerve stump implantation inside the lumen of a vein is superior to the implantation inside a muscle in preventing neuroma formation.

Management of neuromas

After nerve injury and regeneration, significant pain may be associated with the scar and altered sensation observed within the distribution of the injured nerve. A bulbous swelling may form at the severed nerve end, constituting a traumatic neuroma. The development of a painful neuroma may be more disabling to the patient than an area of anesthesia or even loss of motor function. Effective treatment of the painful neuroma remains a difficult problem. Diminished productivity, alterations in patient lifestyle, and possible progression to chronic pain syndromes must be considered within the scope of neuroma management, and treatment must focus on alleviating the pain and restoring the functional loss caused by the nerve injury. Careful patient selection is the cornerstone of successful outcomes. Once the patient has been selected, the surgical management of the painful neuroma throughout the body is based on basic principles that vary only slightly from region to region. Using these tenets, a neuroma management algorithm has been developed based on the pathophysio-logy of the neuroma, the results of experimental studies, review of patient outcomes, and understanding the psychology of pain in the surgical patient.