Neuromas are a substantial cause of morbidity and reduction in quality of life. This is not only caused by a disruption in motor and sensory function from the underlying nerve injury but also by the debilitating effects of neuropathic pain resulting from symptomatic neuromas. A wide range of surgical and therapeutic modalities have been introduced to mitigate this pain. Nevertheless, no single treatment option has been successful in completely resolving the associated constellation of symptoms. While certain novel surgical techniques have shown promising results in reducing neuroma-derived and phantom limb pain, their effectiveness and the exact mechanism behind their pain-relieving capacities have not yet been defined. Furthermore, surgery has inherent risks, may not be suitable for many patients, and may yet still fail to relieve pain. Therefore, there remains a great clinical need for additional therapeutic modalities to further improve treatment for patients with devastating injuries that lead to symptomatic neuromas. However, the molecular mechanisms and genetic contributions behind the regulatory programs that drive neuroma formation—as well as the resulting neuropathic pain—remain incompletely understood. Here, we review the histopathological features of symptomatic neuromas, our current understanding of the mechanisms that favor neuroma formation, and the putative contributory signals and regulatory programs that facilitate somatic pain, including neurotrophic factors, neuroinflammatory peptides, cytokines, along with transient receptor potential, and ionotropic channels that suggest possible approaches and innovations to identify novel clinical therapeutics.

Summary: Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.

Background: Numeric scales are validated methods to report pain outcomes after targeted muscle reinnervation (TMR) but do not include the assessment of qualitative pain components. This study evaluates the application of pain sketches within a cohort of patients undergoing primary TMR and describes differences in pain progression according to early postoperative sketches. Methods: This study included 30 patients with major limb amputation and primary TMR. Patients’ drawings were categorized into four categories of pain distribution [focal pain (FP), radiating pain (RP), diffuse pain (DP), or no pain (NP)] and interrater reliability was calculated. Second, pain outcomes were analyzed for each category. Pain scores were the primary outcome, and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments were the secondary outcome. Results: The interrater reliability for the sketch categories was good (overall kappa coefficient of 0.8). The NP category reported a mean decrease in pain of 4.8 points, followed by the DP (2.5 points) and FP categories (2.0 points). The RP category reported a mean increase in pain of 0.5 points. For PROMIS Pain Interference and Pain Intensity, the DP category reported a mean decrease of 7.2 and 6.5 points, respectively, followed by the FP category (5.3 and 3.6 points). The RP category reported a mean increase of 2.0 points in PROMIS Pain Interference and a mean decrease of 1.4 points in PROMIS Pain Intensity. Secondary outcomes for the NP category were not reported. Conclusion: Pain sketches demonstrated reliability in pain morphology assessment and might be an adjunctive tool for pain interpretation in this setting.

Background: A relationship between nerve and osseous regeneration has been described. During the surgical treatment of symptomatic neuroma in transtibial amputees, the authors have found that heterotopic ossification (HO) depicted on preoperative radiographs appeared to be associated with the location of symptomatic neuromas in both the peroneal and tibial nerve distributions. Methods: Data were collected for transtibial amputees who underwent surgical management of symptomatic neuroma and were prospectively enrolled from 2018 through 2023. Preoperative radiographs were assessed for the presence of HO located at the distal fibula and tibia. The presence of a peroneal or tibial neuroma was based on findings contained within the operative reports. Pain levels were measured on a numeric rating scale (0 to 10). Results: Sixty-five limbs of 62 amputees were included. Peroneal neuroma and presence of fibular HO (P = 0.001) and tibial neuroma and presence of tibial HO (P = 0.038) demonstrated an association. The odds of having a symptomatic peroneal neuroma with fibular HO present were greater than the odds of a symptomatic peroneal neuroma when fibular HO was absent (OR, 9.3 [95% CI, 1.9 to −45.6]; P = 0.006). Preoperative pain scores were significantly higher for all patients with HO (P < 0.001), those with fibular HO (P < 0.001), and those with tibial HO (P < 0.001), compared with patients without HO. Conclusions: In patients with symptomatic neuromas, preoperative pain was worse when HO was present in the transtibial amputee’s residual limb. Further research on the neuroma–HO complex in symptomatic amputees is required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Summary: Disposable handheld nerve stimulators are widely used in peripheral nerve surgery. Such devices stimulate a motor nerve or the motor component of a mixed nerve by applying electrical current to the proximal region, targeting the main nerve trunk. This stimulation then travels along the motor nerve, reaching the distal end to control the corresponding muscle(s). In this study, the authors demonstrate three useful tips and tricks for handheld nerve stimulation during targeted muscle reinnervation and peripheral nerve surgery. The three tips are (1) identification of proximal muscle contraction by retrograde electrical stimulation of a distal sensory nerve; (2) graded stimulation for identifying motor nerves within fibrotic scarred tissue beds or parallel to the major motor/mixed nerve of interest; and (3) proximal stimulation for validation of adequate post-targeted muscle reinnervation coaptation(s).

Introduction: Limb salvage centers have increased in number over time, but lack standardized defining criteria. This systematic review aimed to assess organizational features of limb salvage centers and determine whether orthoplastic centers, in comparison to vascular limb salvage centers, represent a distinct care model that may benefit from standardization. Methods: We conducted a systematic review of publications related to limb salvage centers by searching MEDLINE, Embase, Web of Science, and Cochrane databases from their inception through 2024. We quantified binary data extraction as a reporting score of 26 organizational features across six structural care domains for limb salvage centers, based on a validated quality measurement framework. Organizational features differentiating distinct center types were identified to establish a quality framework for orthoplastic centers. Statistical comparisons between center types were performed using appropriate tests ( p < 0.05). Results: Of 118 included studies, orthoplastic ( n = 43) and vascular ( n = 48) centers represented 77% of all studies. Recent increases in orthoplastic publications show substantial variability in organizational features. Orthoplastic center literature more frequently reported plastic surgery consultation criteria ( p < 0.001), surgical outcomes ( p < 0.001), and centralized network integration ( p ≤ 0.006), highlighting acute reconstructive approaches. Vascular center studies documented significantly more organizational team features ( p < 0.001) and quality systems ( p = 0.033), reflecting established care frameworks for chronic disease management. Six organizational features characterized orthoplastic centers with > 70% prevalence, providing a benchmark framework with standardization priorities. Conclusion: Orthoplastic limb salvage centers demonstrate distinct care paradigms that benefit from standardization. Our findings suggest structural benchmarks to support the need for standardized development of orthoplastic limb salvage centers.