Abstract
This study evaluated pain scores and maximal incisal opening (MIO) in patients with total alloplastic temporomandibular joints found to have post-surgical neuromas following revision arthroplasty, compared with patients who underwent revision arthroplasty without neuromas. 19 cases were reviewed of which 11 had neuromas excised. Data were available for 8 cases in the immediate postoperative period and 7 cases had follow-up data. 8 patients had revision arthoplasty with excision of scar tissue (7 with postoperative, 4 with long-term data). Follow-up ranged from 2 months to 5.9 years (mean 1.2 years). 6 of 8 patients obtained clinically significant pain reduction in the immediate postoperative period when their neuromas were excised, compared with 3 of 7 patients without neuromas. On long-term follow-up, 3 of 7 patients in the neuroma group had clinically significant pain reduction, 3 reported lower pain scores, 1 had no pain change. No patients had increased pain. 1 of 4 patients in the scar revision group had clinically significant pain reduction, 2 had no change, 1 reported increased pain. Mean MIO was 23 mm preoperative and 28 mm postoperative in patients with neuromas, compared with 27.75 mm and 31.25 mm, respectively, in patients without neuromas.
Alloplastic total joint reconstruction is a safe and effective option for the treatment of end-stage degenerative joint disease, ankylosis and tumor reconstruction. Some patients with temporomandibular joint (TMJ) disease following total joint replacement suffer from chronic refractory pain with limited response to narcotics. The orthopedic, neurosurgical and plastic surgery literature contain numerous reports, case series and reviews concerning post-surgical neuroma formation and treatment options . These reviews and case series deal primarily with large, named nerves . The treatment options discussed include simple excision, nerve capping, nerve relocation, neurolysis or medical management . Although there are some case series concerned with small sensory nerves in mastectomy scars, neuromas involving incisions of the knee, and amputation neuromas described in post-cholecystectomy syndrome, the authors are unaware of any study specifically addressing neuroma formation in the TMJ .
Recently, in the authors’ institution, some patients have been identified who develop chronic refractory pain several months after otherwise successful joint reconstruction. In this case series, subjective pain scores and maximal incisal opening (MIO) are evaluated prior to and following revision arthroplasty in which post-surgical neuromas were found in patients with total alloplastic reconstruction of the TMJ, this is contrasted to patients with revision arthroplasty in which no neuromas were found ( Figs. 1–3 ).
Materials and methods
In this retrospective case series, the surgical log at one institution was reviewed for patients with a history of previous alloplastic TMJ reconstruction with refractory neuropathic pain requiring revision arthoplasty. 11 cases of post-surgical amputation neuromas were identified for review from September 2002 to August 2008. 19 revision arthroplasties occurred during this period. Of the 11 cases, 3 patients had a second procedure for additional excision of new neuromas. The pathologic reports for these patients were reviewed. Patients with confirmed neuromas by histopathology were compared with the patients with revision arthroplasty and excision of fibrous connective tissue or scar ( Fig. 4 ).
One surgeon performed all procedures. The records of these patients were reviewed for reported preoperative pain reports using a 0 out of 10 scale, with 0 being the lowest possible score and 10 the worst. Reported postoperative pain was reviewed for the initial postoperative visit and the last follow-up visit. Preoperative MIO and postoperative MIO at the last visit were also reviewed. The time from the last surgical procedure, until the excision of neuroma was documented. The location of the neuroma was noted by reviewing the operative note ( Fig. 5 ).
Results
Figure 6 shows individual pain reports in patients who had neuromas, preoperatively and immediately postoperatively. The follow-up time ranged from 2 months to 5.9 years, with a mean follow-up of 1.2 years. Figure 7 compares individual patient pain reports at last follow-up for patients with neuromas. The mean preoperative MIO was 23 mm and the postoperative MIO 28 mm, showing a mean increase of 5 mm for patients with neuromas. Figure 8 gives the MIO scores of individual patients. Neuromas were located in the incisional scar and the peri-prosthetic scar. Several patients had neuromas in both locations, others had neuromas either in the incisional scar or around the peri-prosthetic scar. The time from the last surgical intervention until the excision of neuroma ranged from 9 months to 6.5 years, with a mean of 2.8 years. The preoperative and immediate postoperative pain scores for patients with revision arthroplasty with scar excised are given in Fig. 9 . Figure 10 shows preoperative and long-term postoperative pain scores for revision arthoplasties with scar. Figure 11 shows the preoperative and postoperative MIO scores for patients with revision arthroplasty with scar excision ( Fig. 12 ).
