Neuropathic pain is challenging to treat. End neuromas may cause significant morbidity. Wherever possible I would reconstruct the injured nerve, however in the setting of post-traumatic scar, soft tissue deficiency and the amputated part, a distal nerve stump may not be available. Numerous techniques have been described to mange the painful neuroma with mixed success. The Polyganics Neurocap is a useful tool and provides a bioresorbable chamber to prevent the nerve from becoming tether in scar after resection of the neuroma. I have used it in selective cases for the last 2 years. `the results of the Protect Neuro multicentre study will be available in August 2020 and this should provide some definitive answers in this complex patient group. Until then, what are your preferred methods of management of the end neuroma where there is no distal stump to allow reconstruction?
I’d agree that an end neuroma presents a challenging problem.
I have some experience of submuscular or interosseous implantation with varied results. ALternatives include centro-central neurorrhaphy, an end to side neurorrhaphy or a long to relocate the regenerating stump.
Lately there has been increasing attention upon targeted muscle reinnervation (TMR), particularly in the context of an end neuroma within an amputation stump.
Nerve capping is an old technique which showed some promise before falling out of favour. It seems to be seeing a re-emergence with novel materials that may avoid some of the historical problems with the technique. I’m looking forward to the results of the Protect Neuro trial, having used the device in select cases.