Chronic Knee and Ankle Pain Treatment through Selective Microsurgical Approaches: A Minimally Invasive Option in the Treatment Algorithm for Refractory Lower Limb Pain
Background Injury or compression of a sensory nerve is an under-reported source of disabling pain in the lower limb. It is known that peripheral nerve microsurgeons can reconstruct and rewire injured nerves to relieve chronic pain but this option remains not completely understood and ignored by most orthopaedic surgeons, neurologists, and pain therapists. In this paper, we describe our experience with knee and ankle peripheral nerve surgery to improve the condition of patients suffering from chronic, posttraumatic lower limb pain.
Patients and Methods Between 2015 and 2018, a retrospective investigation was performed including patients who underwent ankle and knee nerve surgery for posttraumatic chronic pain with at least 1 year of follow-up. Previous surgeries or type of trauma, pain location and characteristics, type of operation (reconstruction, decompression, or denervation), and number of nerves operated were listed. Selective neuropathy was confirmed by ultrasound-guided nerve blocks. Outcome was assessed combining the visual analogue scale (VAS) score at rest and during movement, functional indexes, drug use, and ability to work.
Results A total of 34 patients (14 knee and 20 ankle) were included in this study. A statistically significant difference (p < 0.05%) in postoperative pain at rest and during activity was seen in both groups of patients. Good to excellent outcomes were recorded in 92 and 80% of patients treated, respectively, at the knee and the ankle levels. No major complications occurred, while a secondary procedure due to neuroma recurrence was necessary in seven patients (three knees and four ankles).
Conclusion Peripheral nerve microsurgery is a useful and minimally invasive tool to be added in the algorithm of treatment of chronic knee and ankle pain. Physicians should be trained to suspect a neuropathic origin of pain in absence of musculoskeletal signs of pathology, especially following trauma or surgeries.
Received: 13 May 2020
Accepted: 18 August 2020
07 October 2020 (online)
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- 1 Nakagawa R, Yamaguchi S, Kimura S. et al. Association of anxiety and depression with pain and quality of life in patients with chronic foot and ankle diseases. Foot Ankle Int 2017; 38 (11) 1192-1198
- 2 Dellon AL. Partial joint denervation II: knee and ankle. Plast Reconstr Surg 2009; 123 (01) 208-217
- 3 Wilhelm A. [Articular denervation and its anatomical foundation. A new therapeutic principle in hand surgery. On the treatment of the later stages of lunatomalacia and navicular pseudarthrosis]. Hefte Unfallheilkd 1966; 86: 1-109
- 4 Berger RA. Partial denervation of the wrist: a new approach. Tech Hand Up Extrem Surg 1998; 2 (01) 25-35
- 5 Ekerot L, Holmberg J, Eiken O. Denervation of the wrist. Scand J Plast Reconstr Surg 1983; 17 (02) 155-157
- 6 Dellon AL. Partial dorsal wrist denervation: resection of the distal posterior interosseous nerve. J Hand Surg Am 1985; 10 (04) 527-533
- 7 Braga-Silva J, Román JA, Padoin AV. Wrist denervation for painful conditions of the wrist. J Hand Surg Am 2011; 36 (06) 961-966
- 8 Dellon AL. Partial joint denervation I: wrist, shoulder, and elbow. Plast Reconstr Surg 2009; 123 (01) 197-207
- 9 Dellon AL, Mont MA, Mullick T, Hungerford DS. Partial denervation for persistent neuroma pain around the knee. Clin Orthop Relat Res 1996; (329) 216-222
- 10 Dellon AL, Barrett SL. Sinus tarsi denervation: clinical results. J Am Podiatr Med Assoc 2005; 95 (02) 108-113
- 11 Petersen CL, Kjærsgaard JB, Kjærgaard N, Jensen MU, Laursen MB. Thresholds for Oxford Knee Score after total knee replacement surgery: a novel approach to post-operative evaluation. J Orthop Surg Res 2017; 12 (01) 89
- 12 Hale SA, Hertel J. Reliability and sensitivity of the foot and ankle disability index in subjects with chronic ankle instability. J Athl Train 2005; 40 (01) 35-40
- 13 Jones AR, Al-Naseer S, Bodger O, James ETR, Davies AP. Does pre-operative anxiety and/or depression affect patient outcome after primary knee replacement arthroplasty?. Knee 2018; 25 (06) 1238-1246
- 14 Horner G, Dellon AL. Innervation of the human knee joint and implications for surgery. Clin Orthop Relat Res 1994; (301) 221-226
- 15 Shi GG, Williams MA, Whalen JL, Wilke BK, Kraus JC. An anatomic and clinical study of the innervation of the dorsal midfoot capsule. Foot Ankle Int 2019; 40 (10) 1209-1213
- 16 Poppler LH, Parikh RP, Bichanich MJ. et al. Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis. Pain 2018; 159 (02) 214-223
- 17 Garcia-Larrea L, Hagiwara K. Electrophysiology in diagnosis and management of neuropathic pain. Rev Neurol (Paris) 2019; 175 (1-2): 26-37
- 18 Dellon AL, Mont MA, Krackow KA, Hungerford DS. Partial denervation for persistent neuroma pain after total knee arthroplasty. Clin Orthop Relat Res 1995; (316) 145-150
- 19 Gohritz A, Dellon AL, Kalbermatten D, Fulco I, Tremp M, Schaefer DJ. Joint denervation and neuroma surgery as joint-preserving therapy for ankle pain. Foot Ankle Clin 2013; 18 (03) 571-589
- 20 Friberger Pajalic K, Turkiewicz A, Englund M. Update on the risks of complications after knee arthroscopy. BMC Musculoskelet Disord 2018; 19 (01) 179
- 21 Barber FA, Click J, Britt BT. Complications of ankle arthroscopy. Foot Ankle 1990; 10 (05) 263-266
- 22 Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012; 20 (08) 1420-1431
- 23 Yammine K, Assi C. Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies. Surg Radiol Anat 2018; 40 (05) 489-497
- 24 Mochida H, Kikuchi S. Injury to infrapatellar branch of saphenous nerve in arthroscopic knee surgery. Clin Orthop Relat Res 1995; (320) 88-94
- 25 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2 (01) e000435