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Pettersen E, Sassu P, Reinholdt C, Dahm P, Rolfson O, Björkman A, Innocenti M, Pedrini FA, Breyer JM, Roche A, Hart A, Harrington L, Ladak A, Power H, Hebert J, Ortiz-Catalan M. Surgical treatments for postamputation pain: study protocol for an international, double-blind, randomised controlled trial. Trials 2023; 24:304. [PMID: 37131180 PMCID: PMC10155377 DOI: 10.1186/s13063-023-07286-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/31/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Painful conditions such as residual limb pain (RLP) and phantom limb pain (PLP) can manifest after amputation. The mechanisms underlying such postamputation pains are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating RLP due to neuroma formation - commonly known as neuroma pain - and to a lesser degree PLP. Two reconstructive surgical interventions, namely targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), are gaining popularity in postamputation pain treatment with promising results. However, these two methods have not been directly compared in a randomised controlled trial (RCT). Here, we present a study protocol for an international, double-blind, RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition (active control) in alleviating RLP, neuroma pain, and PLP. METHODS One hundred ten upper and lower limb amputees suffering from RLP will be recruited and assigned randomly to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations will be performed during a baseline period prior to the surgical intervention, and follow-ups will be conducted in short term (1, 3, 6, and 12 months post-surgery) and in long term (2 and 4 years post-surgery). After the 12-month follow-up, the study will be unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome of the treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator at that site. DISCUSSION A double-blind RCT is necessary for the establishment of evidence-based procedures, hence the motivation for this work. In addition, studies on pain are challenging due to the subjectivity of the experience and the lack of objective evaluation methods. Here, we mitigate this problem by including different pain evaluation methods known to have clinical relevance. We plan to analyse the primary variable, mean change in NRS (0-10) between baseline and the 12-month follow-up, using the intention-to-treat (ITT) approach to minimise bias and keep the advantage of randomisation. The secondary outcomes will be analysed on both ITT and per-protocol (PP). An adherence protocol (PP population) analysis will be used for estimating a more realistic effect of treatment. TRIAL REGISTRATION ClincialTrials.gov NCT05009394.
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Affiliation(s)
- Emily Pettersen
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Paolo Sassu
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Carina Reinholdt
- Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Hand Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Dahm
- Department of Anaesthesia and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Björkman
- Department of Hand Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marco Innocenti
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Francesca Alice Pedrini
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | | | - Aidan Roche
- College of Medicine and Veterinary Medicine, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Andrew Hart
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF UK
- College of Medicine, Veterinary & Life Sciences, The University of Glasgow, University Avenue, Glasgow, G12 8QQ UK
| | - Lorraine Harrington
- Department of Anaesthesia, St John’s Hospital at Howden, NHS Lothian, Livingston, UK
| | - Adil Ladak
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada
| | - Hollie Power
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB Canada
| | | | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- Bionics Institute, Melbourne, Australia
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Erlenwein J, Diers M, Ernst J, Schulz F, Petzke F. Clinical updates on phantom limb pain. Pain Rep 2021; 6:e888. [PMID: 33490849 DOI: 10.1097/PR9.0000000000000888] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/13/2020] [Accepted: 11/12/2020] [Indexed: 12/20/2022] Open
Abstract
Phantom limb pain is highly prevalent after amputation. Treatment results will probably benefit from an interdisciplinary team and individually adapted surgical, prosthetic and pain medicine approaches. Introduction: Most patients with amputation (up to 80%) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility. Methods: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge. Results: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme. Discussion: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed.
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Kadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020; 15:50-53. [PMID: 33363642 PMCID: PMC7744666 DOI: 10.5005/jp-journals-10080-1442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Various surgical treatments have been advocated for stump pain and phantom limb pain after limb amputation but the most effective is unknown. We report a case of intractable stump pain and phantom limb pain of the upper limb, which was successfully treated by end-to-end coaptation of the cutaneous nerves after multimodal treatment failures. Case description A 39-year-old man was referred to our department with a history of severe stump neuroma-related pain and phantom limb pain of his right upper limb. He had undergone multiple treatments over 26 years including medication, nerve blocks, and repeated surgeries. None had been successful for relief of pain. The clinical assessment showed a point of marked tenderness around the medial stump of the upper arm. Ultrasound-guided peripheral infiltration of local anaesthetic around the medial stump produced significant relief of his pain. Exploration around the medial limb stump revealed two stump neuromas of the medial cutaneous nerves of the forearm. Both stump neuromas were resected, and their stumps were coapted to each other. After 4 years, he was completely relieved of his pain and without any sensory deficit. Conclusion Successful nerve coaptations for painful stump neuromas of the upper limb are reported rarely. This case suggests this method can be helpful. The patient burden was minimal because it involved the resection and coaptation of the two neuromas. This method should be encouraged for cases of intractable stump-related pain in the upper limb. How to cite this article Kadota H, Ishida K. Coaptation of Cutaneous Nerves for Intractable Stump Pain and Phantom Limb Pain after Upper Limb Amputation. Strategies Trauma Limb Reconstr 2020;15(1):50-53.
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Affiliation(s)
- Hideki Kadota
- Department of Plastic Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Kunihiro Ishida
- Department of Plastic and Reconstructive Surgery, Okinawa Chubu Hospital, Okinawa, Japan
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Kelle B, Kozanoğlu E, Biçer ÖS, Tan İ. Association between phantom limb complex and the level of amputation in lower limb amputee. Acta Orthop Traumatol Turc 2017; 51:142-145. [PMID: 28242264 PMCID: PMC6197566 DOI: 10.1016/j.aott.2017.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 04/20/2016] [Accepted: 11/17/2016] [Indexed: 12/25/2022]
Abstract
Objective The aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation. Methods The study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files. Results Statistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively). Conclusion VAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation. Level of Evidence Level III Prognostic study.
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