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Beyond the Surface: Ultrasound as a Diagnostic Tool for Neuromas and TMRpni Success in Osseointegrated Amputees
Anna M. Vaeth
*1, Fiona R. Fragomen
1, Lucy Wei
1, Nancy Qin
1, Makayla Kochheiser
1, Albert Y. Truong
1, Jason S. Hoellwarth
2, Taylor J. Reif
2, S R. Rozbruch
2, Paul Christos
3, Ogonna K. Nwawka
2, David Otterburn
11Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY; 2Hospital for Special Surgery, New York, NY; 3Weill Cornell Medicine, New York, NY
Background: The use of ultrasound in evaluating neuromas is underutilized despite its potential as a noninvasive imaging tool and as an opportunity to visualize nerve reconstruction techniques, which are often performed alongside osseointegrated implant (OI) prosthesis placement. This study aims to evaluate the ability of ultrasound to detect neuromas and nerve reconstruction in lower-limb amputees with OI prostheses.
Methods: This was a prospective observational study of lower-limb amputees with nerve ultrasounds from 2024 to 2025. Nerve reconstruction techniques included targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI) or combined TMRpni. Symptomatic neuromas were assessed with targeted sonopalpation.
Results: A total of 28 nerves were imaged in 11 amputees (2 transfemoral, 9 transtibial) including 19 without nerve reconstruction, 2 with RPNI, and 7 with TMRpni. The median time of imaging was 15.7 months postoperatively. Of the 19 non-reconstructed nerves, ultrasound identified 11 neuromas (58%), while 8 tapered smoothly into musculature. Median neuroma size in nerves without reconstruction was 42.7 mm^2 and 5 were symptomatic (46%). Of the seven nerves with TMRpni, ultrasound detected intact coaptation between the motor nerve branches and sensory branches in 6 nerves (86%) and were observed up to 16 months post-reconstruction without pain to sonopalpation. One 12.4 mm^2 neuroma was identified at one TMRpni coaptation 14 months postoperatively and sonopalpation elicited pain. In the RPNI group, one hypoechoic nodule was observed and nonpainful; however, it could not be distinguished as neuroma versus muscle graft.
Conclusions: Ultrasound was effective in evaluating neuroma formation and assessing nerve reconstruction outcomes in amputees with the added advantage of real-time detection of symptomatic neuromas. Distinguishing neuroma growth with ultrasound following RPNI was more challenging. These findings support the utility of ultrasound as a noninvasive tool for monitoring nerve reconstruction efficacy and neuroma development.
Figure 1: Nerve ultrasounds of the sural nerve (A) with a distinct hypoechoic nodule consistent with a neuroma (yellow arrow) and the deep peroneal nerve (B, white arrows) with intact nerve coaptation to a motor branch of the anterior tibialis (red arrow).
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