Treatment of Painful Neuroma of Amputated Phalanx with Distal Toe Transfer: A Case Report

Distal Finger Reconstruction by Bilateral Lateral Hallux Osteo-onychocutaneous Free Flap

OBJECTIVE

In this report, we present our experience on the use of bilateral lateral hallux osteo-onychocutaneous free flaps for reconstruction of distal finger and the aesthetic and functional results of this technique in a series of cases.

PATIENTS AND METHODS

From February 2005 to May 2015, 7 patients underwent finger reconstruction distal to the distal interphalangeal joint using the bilateral lateral hallux osteo-onychocutaneous free flaps. The mean age was 29.3 years (range, 24-33 years). The lateral hallux osteo-onychocutaneous flaps were harvested from bilateral donor sites. The size of each flap was designed based on the size of half distal finger defect. The lateral hallux osteo-onychocutaneous free flaps from both donor sites were combined to reconstruct the distal finger. More than 50% of hallux nail was preserved in each of donor sites, which was covered with a local flap.

RESULTS

All flaps used for reconstruction survived without complications after surgery. The average length of follow-up was 93.4 months (range, 16-163 months). All reconstructed distal fingers showed good aesthetic appearance, except one that underwent a secondary debulking procedure. The average total active motion of the finger was 215.7 degrees (range, 200-230 degrees). Neither pain nor numbness sensation in the reconstructed fingers was complained by the patients. The donor site morbidity was minimal. All patients had pain-free and good function outcome in both feet.

CONCLUSIONS

The use of the bilateral lateral hallux osteo-onychocutaneous free flaps may provide an option for distal finger reconstruction with satisfactory function and anesthetic outcomes with minimal hallux donor site morbidity.

Outcomes of the surgical treatment of peripheral neuromas of the hand and forearm: a 25-year comparative outcome study

PURPOSE

Peripheral neuromas within the upper extremity result in significant disability. Treatment options vary, and established protocols have yet to be determined. We performed a long-term outcome comparison examining different treatment options for peripheral upper extremity neuromas to determine which method provided superior results using a validated upper extremity outcome measurement system.

METHODS

A retrospective chart review was performed for all patients undergoing surgical intervention from 1980 to 2005 for a symptomatic neuroma of the hand or forearm. Patients' charts were reviewed for medical history, etiology of neuroma, and treatment outcomes. Patients were surveyed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and pain evaluation questionnaires.

RESULTS

We identified 127 eligible patients who had their index procedure performed at our institution. Fifty-six patients completed the questionnaires. In all cases, verification of a neuroma was made on pathologic and surgical examination. Follow-up averaged 240 months from the time of surgery. Mean age at the time of surgery was 40 years (range, 19-72 years). Of all the patients, 11 were treated with muscle or bone transposition, 17 with simple excision, and 28 with nerve repair and neurolysis. Mean DASH score at the final follow-up was 19.75 (range, 0-78.3). Patients who underwent neuroma excision with nerve repair had significantly lower postoperative DASH scores, averaging 11.42, compared with either muscle or bone transposition or simple excision (mean DASH score, 22.4 and 32.0, respectively, P = 0.01). The number of neuroma procedures (P = 0.04), preoperative pain severity (P = 0.03), and postoperative pain severity (P = 0.04) all affected the final DASH score. Fifteen patients (27%) required more than 1 surgery. Simple neuroma excision resulting in the highest incidence of reoperations (47%).

CONCLUSIONS

Treatment of upper extremity neuromas remains a complicated problem. Within this study, nerve repair yielded improved DASH scores compared with nerve transposition or the use of simple resection. Resection alone was associated with an unacceptable recurrence rate and should be discouraged as treatment for upper extremity neuromas. Prior surgical procedures, neuroma size, and the severity of preoperative pain may all adversely impact the success of surgical intervention.

Pulsed radiofrequency ablation under ultrasound guidance for huge neuroma

Amputation neuroma can cause very serious, intractable pain. Many treatment modalities are suggested for painful neuroma. Pharmacologic treatment shows a limited effect on eliminating the pain, and surgical treatment has a high recurrence rate. We applied pulsed radiofrequency treatment at the neuroma stalk under ultrasonography guidance. The long-term outcome was very successful, prompting us to report this case.

Free flap transfer for complex regional pain syndrome type II

A patient with complex regional pain syndrome type II was successfully treated using free anterolateral thigh flap transfer with digital nerve coaptation to the cutaneous nerve of the flap. Release of the scarred tissue and soft tissue coverage with targeted sensory nerve coaptation were useful in relieving severe pain.

The incidence of symptomatic neuroma in amputation and neurorrhaphy patients

PURPOSE

The incidence of symptomatic neuroma in finger nerve injuries varies widely in the literature. In this retrospective study, we evaluated the incidence of symptomatic neuroma after repair of digital nerve injuries (neurorrhaphy) and after amputation of one or more fingers. We also determined the need for re-operation on symptomatic neuroma patients.

METHODS

In a retrospective study, we collected data from medical files. All patients who were treated for a hand trauma in the emergency department during the last 10 years were included. We gathered data on the presence of symptomatic neuroma and re-operation of the patients.

RESULTS

In our database, 583 people had a peripheral nerve injury of whom 177 people had an amputation. The incidence of digital nerve injury without amputation followed by neurorrhaphy was 1%. In digital nerve injuries with amputation the incidence was 7.8%, which is significantly higher than after digital nerve injuries without amputation.

CONCLUSIONS

People with an amputation injury have significantly more symptomatic neuroma than people who undergo neurorrhaphy. People who have a symptomatic neuroma after digital nerve injuries have been operated significantly more than people who have a non-symptomatic neuroma or no neuroma at all. This information can be of help when treating digital nerve injuries. TYPE OF STUDY/LEVEL OF EVIDENCE (LOE): Prognostic.

Neuroma in bilateral upper limb amputation

To evaluate the prevalence of neuroma in bilateral upper limb amputees and investigate the effect of level of amputation on their pain, 86 patients with bilateral upper limb amputation were thoroughly examined by an orthopedic surgeon. Of 172 bilateral amputated upper limbs (86 victims of war) 17.1+/-6.1 years after injury, physical examination revealed that 26.2% had moderate to severe stump pain and clinical signs suggestive of neuroma. Statistical analysis showed no relation between level of amputation, prosthesis usage, and occurrence of neuroma. Although high occurrence of neuroma among traumatic bilateral upper limb amputation had no significant effects on wearing prosthesis, its treatment can deeply influence alleviation of their pain and subsequently their quality of life.