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J Reconstr Microsurg 2021; 37(03): 234-241
DOI: 10.1055/s-0040-1717100
Original Article

Chronic Knee and Ankle Pain Treatment through Selective Microsurgical Approaches: A Minimally Invasive Option in the Treatment Algorithm for Refractory Lower Limb Pain

Giorgio Pietramaggiori
1   Department of Plastic, Reconstructive and Aesthetic Surgery, Global Plastic Surgery, Lausanne, Switzerland
2   Department of Plastic and Reconstructive Surgery, University Hospital of Padova, Padova, Italy
,
Gianluca Sapino
3   Department of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
,
Giorgio De Santis
3   Department of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, Italy
,
Franco Bassetto
2   Department of Plastic and Reconstructive Surgery, University Hospital of Padova, Padova, Italy
,
Saja Scherer
1   Department of Plastic, Reconstructive and Aesthetic Surgery, Global Plastic Surgery, Lausanne, Switzerland
2   Department of Plastic and Reconstructive Surgery, University Hospital of Padova, Padova, Italy
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Abstract

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.

Keywords

chronic pain - partial joint denervation - knee pain - ankle pain


Publication History

Received: 13 May 2020

Accepted: 18 August 2020

Article published online:
07 October 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 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
    CrossrefPubMedGoogle Scholar
  • 2 Dellon AL. Partial joint denervation II: knee and ankle. Plast Reconstr Surg 2009; 123 (01) 208-217
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 4 Berger RA. Partial denervation of the wrist: a new approach. Tech Hand Up Extrem Surg 1998; 2 (01) 25-35
    CrossrefPubMedGoogle Scholar
  • 5 Ekerot L, Holmberg J, Eiken O. Denervation of the wrist. Scand J Plast Reconstr Surg 1983; 17 (02) 155-157
    CrossrefPubMedGoogle Scholar
  • 6 Dellon AL. Partial dorsal wrist denervation: resection of the distal posterior interosseous nerve. J Hand Surg Am 1985; 10 (04) 527-533
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 8 Dellon AL. Partial joint denervation I: wrist, shoulder, and elbow. Plast Reconstr Surg 2009; 123 (01) 197-207
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 10 Dellon AL, Barrett SL. Sinus tarsi denervation: clinical results. J Am Podiatr Med Assoc 2005; 95 (02) 108-113
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 14 Horner G, Dellon AL. Innervation of the human knee joint and implications for surgery. Clin Orthop Relat Res 1994; (301) 221-226
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 17 Garcia-Larrea L, Hagiwara K. Electrophysiology in diagnosis and management of neuropathic pain. Rev Neurol (Paris) 2019; 175 (1-2): 26-37
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 20 Friberger Pajalic K, Turkiewicz A, Englund M. Update on the risks of complications after knee arthroscopy. BMC Musculoskelet Disord 2018; 19 (01) 179
    CrossrefPubMedGoogle Scholar
  • 21 Barber FA, Click J, Britt BT. Complications of ankle arthroscopy. Foot Ankle 1990; 10 (05) 263-266
    CrossrefPubMedGoogle Scholar
  • 22 Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012; 20 (08) 1420-1431
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 24 Mochida H, Kikuchi S. Injury to infrapatellar branch of saphenous nerve in arthroscopic knee surgery. Clin Orthop Relat Res 1995; (320) 88-94
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar