Regenerative Peripheral Nerve Interfaces For The Management Of Symptomatic Hand And Digital Neuromas
Sarah E. Hart, MD1, Rachel C. Hooper, MD1, Paul S. Cederna, MD1, David L. Brown, MD1, Steven C. Haase, MD1, Jennifer Waljee, MD1, Brent M. Egeland, MD2, Brian P. Kelley, MD2, Theodore A. Kung, MD1.
1University of Michigan, Ann Arbor, MI, USA, 2University of Texas, Austin, TX, USA.
Purpose Painful hand or digital neuromas cause substantial physical disability, reduced ability to work, and psychosocial distress leading to decreased quality of life. As many as 30% of patients with traumatic hand and digital amputations develop symptomatic neuromas. Many patients rely on daily opioids, neuropathic pain meds, and/or antidepressant medications that provide suboptimal pain relief with adverse side effects. Many patients cannot return to work as a result of these neuromas. The Regenerative Peripheral Nerve Interface (RPNI) is a surgical technique that involves implantation of a divided peripheral nerve into a free muscle graft. RPNIs mitigate neuroma formation and treat existing neuroma pain in the setting of major limb amputations. The purpose of this study was to determine if RPNIs effectively treat neuroma pain following partial hand and digital amputations. Methods A retrospective review was performed on seventeen patients who underwent RPNI surgery between November 2014 and July 2019 for the treatment of symptomatic hand and/or digital neuromas following a traumatic injury of the hand. Symptomatic neuromas were diagnosed by history and physical exam. During the operation, the symptomatic neuroma was resected and a free muscle graft for each RPNI was harvested from a donor muscle. The epineurium of the peripheral nerve was secured into the central portion of the muscle graft which was subsequently wrapped around the nerve end entirely. Patient reported postoperative pain, physical exam findings, and complications were reviewed. Results Thirty-four therapeutic RPNIs were performed on seventeen symptomatic neuroma patients in the outpatient setting under regional or general anesthesia by 6 surgeons. In all patients preoperatively, 100% of neuromas had a positive Tinel sign. Postoperatively, 71% of patients had a negative Tinel sign. A total of 88% of patients were pain-free or reported considerably improved pain at their most recent office visit. Two patients required secondary RPNI operations for new neuromas diagnosed after their initial operation. One patient developed cellulitis that was treated with oral antibiotics and another patient developed a surgical site infection requiring surgical exploration and resection of the RPNI. There were no cases of delayed wound healing. The average patient follow-up was 39 weeks (4-128 weeks). Conclusions Symptomatic neuromas resulting from hand or digital trauma decrease an individualís quality of life and extremity function. Our initial retrospective review shows promise that RPNI surgery can provide dramatic improvement in neuroma pain following traumatic hand injury by resecting the painful neuroma and preventing recurrence. This procedure has minimal morbidity to the patient and is easily reproducible by surgeons trained in the technique.
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