Pet MA, Ko JH, Friedly JL, Smith DG. Traction Neurectomy for Treatment of Painful Residual Limb Neuroma in Lower Extremity Amputees. J Orthop Trauma 2015;29:e321-e325.
I applaud the authors for highlighting the troubles with the commonly performed traction neurectomy in patients with lower extremity amputations. As we all know, the problems of those sustaining a lower extremity amputation, especially following trauma, are not always solved once they receive their amputation. Even if there are no post-operative complications such as infection or wound dehiscence, problems such as the development of a painful neuroma can present months, if not, later down the road to recovery. Following their initial amputation, limb swelling improves over the first several weeks followed by limb atrophy which continues for several months post-operatively. As the limb shrinks, once asymptomatic neuromas can become symptomatic.
The authors evaluate outcomes following the most common surgical management of symptomatic neuromas-traction neurectomy. Unfortunately, their results, are not that encouraging. Forty-two percent (16/38) of patients had recurrent or persistent neuroma-type pain following traction neurectomy more than 3 years post procedure. In fact, 21% (8/38) underwent subsequent surgical management of their symptomatic neuromas. The authors noted that 87% of their patients had a bony procedure performed in addition to their traction neurectomy, which they state may have contributed to the higher rate of persistent symptoms post-operatively. Despite this, their data provides good evidence that other options should be considered when surgical management of a painful neuroma is considered.
Our initial surgical management for painful neuromas in our young, active military population was commonly performing a traction neurectomy as described by the authors, but over time, we have transitioned to performing a neuroma excision followed by burying the nerve end within muscle when able because our results seemed very similar to what the authors have presented. In addition, with our typical treatment algorithm consisting of initial medical management followed by prosthetic modification for off-loading if feasible and/or ultrasound guided neuroma injection, fewer and fewer patients seem to be requiring surgical intervention for painful neuromas.
Daniel J. Stinner, MD
Medical Director, The Center for the Intrepid
Department of Orthopaedics and Rehabilitation
Brooke Army Medical Center
Fort Sam Houston, Tx