https://doi.org/10.4081/ltj.2023.318

Management interventions for amputation stump neuromas: evidence based review and cost-benefit analysis

Vol. 30 No. 2 (2023)
Submitted: 30 May 2023
Accepted: 23 August 2023
Published: 12 October 2023
Amputation, neuroma, cost-benefit, laser
Abstract Views: 3980
PDF: 22
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Authors

Ernest A. Azzopardi
info@skinsurgeon.eu
Welsh Laser Service, Neath Port Talbot Hospital, Neath, Wales, United Kingdom; Skinsurgeon@ELms Clinic, Triq il Pirinej, Malta; Consultant Surgeon in Private Practice, The London Welbeck Hospital, Marylebone, London, United Kingdom; Department of Anatomy, Faculty of Medicine and Surgery, University of Malta Medical School, Malta; 5Department of Surgery, Division of Interventional Sciences, University College London, London, United Kingdom.
Philippa Stewart
Rookwood Rehabilitation Hospital Cardiff, Wales, United Kingdom.
Dean Edward Boyce
Welsh Centre for Plastic Surgery, Morriston Hospital, Abertawe, Wales, United Kingdom.
Maxwell Murison
Welsh Laser Service, Neath Port Talbot Hospital, Neath, Wales, United Kingdom.
Hazim Sadideen
Department of Surgery, Imperial College, London, United Kingdom.
Matteo Tretti Clementoni
Laserplast Srl Stp, Milan, Italy.

Amputation is a common military and civilian surgery with high morbidity. Patients without prostheses due to neuroma pain lose productivity and lifelong contributions, which is often underestimated. The surgical and non-surgical treatment of painful stump neuromas is controversial. An evidence-based assessment and cost-benefit analysis of painful stump neuroma management modalities emphasizes institutional awareness and disruptive technologies. An Oxford Centre for Evidence Based Methodology critical appraisal and structured literature review were used in the research. We found 154 records using a reproducible literature search strategy that included electronic databases and references. A full review of 27 manuscripts after exclusion criteria yielded data for analysis. Surgical, injectable, and electromagnetic spectrum methods were used. Surgical interventions had longer follow-up times than injection and radiofrequency treatments, which affected outcomes. CEBM level 4 evidence dominated primary literature, indicating low quality. No therapy was superior, but the risks varied. Injection therapies like sclerosing alcohol had limited success and side effects. Despite limited evidence, electromagnetic spectrum modalities showed potential. Including direct and indirect costs, amputation stump refitting costs millions annually. Compared to outpatient non-surgical interventions, laser therapy could save a lot of money. According to the study, surgical interventions are common but expensive and have limited functional success. Low-risk non-surgical methods like co-ablation, pulsed radiofrequency, and transcutaneous laser therapy have mixed results. The short follow-up of all non-surgical studies seems to limit them. Follow-up duration is crucial to outcome assessment. Long-term, low-risk laser-induced thermotherapy is promising for future research. This study emphasizes the need for more research and the economic benefits of disruptive technologies in treating painful stump neuromas.

Dimensions

Altmetric

PlumX Metrics

Downloads

Download data is not yet available.

Citations

Crossref
Scopus
Google Scholar
Europe PMC
Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 2008;64:S28-37; discussion S37. DOI: https://doi.org/10.1097/TA.0b013e318160937e
Ploeg AJ, Lardenoye JW, Vrancken Peeters MP, Breslau PJ. Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg 2005;29:633-7. DOI: https://doi.org/10.1016/j.ejvs.2005.02.014
Poyntz SA, Hacking NM, Dalal M, Fowler S. Peripheral Interventions for Painful Stump Neuromas of the Lower Limb: A Systematic Review. Clin J Pain 2018;34:285-295. DOI: https://doi.org/10.1097/AJP.0000000000000533
Kay, M. & Marshall, C. Indications and Management of Lower Limb Amputation. Postgraduate Vascular Surgery: A Candidate's Guide to the FRCS and Board Exams. 2018. DOI: https://doi.org/10.1142/9781786344946_0018
Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30. DOI: https://doi.org/10.1016/j.jpain.2008.10.008
Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res 2013;6:121-36. DOI: https://doi.org/10.2147/JPR.S32299
Sackett DL, Rosenberg WM. The need for evidence-based medicine. J R Soc Med 1995;88:620-4. DOI: https://doi.org/10.1177/014107689508801105
Umesh G, Karippacheril JG, Magazine R. Critical appraisal of published literature. Indian J Anaesth 2016;60:670-673. DOI: https://doi.org/10.4103/0019-5049.190624
Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg 2013;70:23-9. DOI: https://doi.org/10.1097/SAP.0b013e31826eab9e
Azzopardi EA, Whitaker IS. Acute pain management during facial injection of botulinum toxin: an evidence-based systematic review. Plast Reconstr Surg 2010;125:162e-164e. DOI: https://doi.org/10.1097/PRS.0b013e3181d45ce0
Harsh S, Clarke D. Advancements in Research Synthesis Methods: From a Methodologically Inclusive Perspective. Rev Educ Res 2009;79:395–430. DOI: https://doi.org/10.3102/0034654308326349
Whittemore R, Chao A, Jang M, et al. Methods for knowledge synthesis: an overview. Heart Lung 2014;43:453-61. DOI: https://doi.org/10.1016/j.hrtlng.2014.05.014
Ducic I, Mesbahi AN, Attinger CE, Graw K. The role of peripheral nerve surgery in the treatment of chronic pain associated with amputation stumps. Plast Reconstr Surg 2008;121:908-914. DOI: https://doi.org/10.1097/01.prs.0000299281.57480.77
Sehirlioglu A, Ozturk C, Yazicioglu K, et al. Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions. Int Orthop 2009;33:533-6. DOI: https://doi.org/10.1007/s00264-007-0466-y
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:e321-5. DOI: https://doi.org/10.1097/BOT.0000000000000337
Lim KB, Kim YS, Kim JA. Sonographically guided alcohol injection in painful stump neuroma. Ann Rehabil Med 2012;36:404-8. DOI: https://doi.org/10.5535/arm.2012.36.3.404
Zhang X, Xu Y, Zhou J, et al. Ultrasound-guided alcohol neurolysis and radiofrequency ablation of painful stump neuroma: effective treatments for post-amputation pain. J Pain Res 2017;10:295-302. DOI: https://doi.org/10.2147/JPR.S127157
Galiano K, Strasak A, Peer S. Practical experience with sonographically guided phenol instillation of stump neuroma: predictors of effects, success, and outcome. AJR Am J Roentgenol 2008;190:1263-9. DOI: https://doi.org/10.2214/AJR.07.2050
Neumann V, O'Connor RJ, Bush D. Cryoprobe treatment: an alternative to phenol injections for painful neuromas after amputation. AJR Am J Roentgenol 2008;191:W313; author reply W314. DOI: https://doi.org/10.2214/AJR.08.1371
Kesikburun S, Yaşar E, Dede I, Göktepe S, Tan AK. Ultrasound-guided steroid injection in the treatment of stump neuroma: pilot study. J Back Musculoskelet Rehabil 2014;27:275-9. DOI: https://doi.org/10.3233/BMR-130444
Kim YK, Jung I, Lee CH, et al. Pulsed radiofrequency ablation under ultrasound guidance for huge neuroma. Korean J Pain 2014;27:290-3. DOI: https://doi.org/10.3344/kjp.2014.27.3.290
Restrepo-Garces CE, Marinov A, McHardy P, et al. Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain. Pain Pract 2011;11:98-102. DOI: https://doi.org/10.1111/j.1533-2500.2010.00398.x
West M, Wu H. Pulsed radiofrequency ablation for residual and phantom limb pain: a case series. Pain Pract 2010;10:485-91. DOI: https://doi.org/10.1111/j.1533-2500.2009.00353.x
Wilkes D, Ganceres N, Solanki D, Hayes M. Pulsed radiofrequency treatment of lower extremity phantom limb pain. Clin J Pain 2008;24:736-9. DOI: https://doi.org/10.1097/AJP.0b013e318170d758
Gimber LH, Melville DM, Bocian DA, et al. Ultrasound Evaluation of Morton Neuroma Before and After Laser Therapy. AJR Am J Roentgenol 2017;208:380-385. DOI: https://doi.org/10.2214/AJR.16.16403
Algermissen B, Philipp CM, Müller U, Urban P, Berlien H-P. Interstitial Thermotherapy (ITT) using Nd: YAG Laser as a new option for the treatment of Neuroma. Medical Laser Application 2001;16:129-134. DOI: https://doi.org/10.1078/1615-1615-00019
Phillips, B. et al. Oxford centre for evidence-based medicine levels of evidence (May 2001). BJU international 2011;107:870. DOI: https://doi.org/10.1111/j.1464-410X.2011.10141.x
Bourke HE, Yelden KC, Robinson KP, Sooriakumaran S, Ward DA. Is revision surgery following lower-limb amputation a worthwhile procedure? A retrospective review of 71 cases. Injury 2011;42:660-6. DOI: https://doi.org/10.1016/j.injury.2010.09.035
Fletcher D, Edwards D, Tolchard S, Baker R, Berstock J. Improving theatre turnaround time. BMJ Qual Improv Rep 2017;6:u219831.w8131. DOI: https://doi.org/10.1136/bmjquality.u219831.w8131
Edwards, N. Reducing outpatient activity does not cut costs. BMJ 2018;361:k1826. DOI: https://doi.org/10.1136/bmj.k1826
Childers CP, Maggard-Gibbons M. Understanding Costs of Care in the Operating Room. JAMA Surg 2018;153:e176233. DOI: https://doi.org/10.1001/jamasurg.2017.6233
Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars. Dermatol Res Pract 2012;2012:243651. DOI: https://doi.org/10.1155/2012/243651
Miletta NR, Donelan MB, Hivnor CM. Management of trauma and burn scars: the dermatologist's role in expanding patient access to care. Cutis 2017;100:18-20.
Azzopardi EA, Duncan RT, Kearns M, et al. Cutaneous laser surgery for secondary burn reconstruction: Cost benefit analysis. Burns 2020;46:561-566. DOI: https://doi.org/10.1016/j.burns.2019.08.021
Azzopardi EA, Abdelrahman W, Azzopardi E, et al. Treatment of cutaneous basal cell carcinoma with combined laser extirpation and methyl aminolevulinic acid: five-year success rates. Ann R Coll Surg Engl 2021;103:263-271. DOI: https://doi.org/10.1308/rcsann.2020.7020
Silva D, Sharma M, Barnett GH. Laser Ablation vs Open Resection for Deep-Seated Tumors: Evidence for Laser Ablation. Neurosurgery 2016;63:15-26. DOI: https://doi.org/10.1227/NEU.0000000000001289
Belykh E, Yagmurlu K, Martirosyan NL, et al. Laser application in neurosurgery. Surg Neurol Int 2017;8:274. DOI: https://doi.org/10.4103/sni.sni_489_16

How to Cite

Azzopardi, E. A., Stewart, P., Boyce, D. E., Murison, M., Sadideen, H., & Tretti Clementoni, M. (2023). Management interventions for amputation stump neuromas: evidence based review and cost-benefit analysis. Laser Therapy, 30(2). https://doi.org/10.4081/ltj.2023.318
Copyright (c) 2023 the Author(s) Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.