Current Literature

Targeted Muscle Reinnervation Effective, Safe for Postamputation Pain and Phantom Limb Pain

Roubaud MS, Hassan AM, Shin A, et al. Outcomes of Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces for Chronic Pain Control in the Oncologic Amputee Population. J Am Coll Surg. 2023, in press.

Residual extremity pain and phantom limb pain affect 50% to 80% of amputees, according to data cited in this article. Most efforts to deal with the disability and damaged quality of life that result from these morbidities have sought to “mask” the symptoms with pharmacologic treatments, traction neurectomy, muscle implantation, and other interventions.

Recently, microsurgical techniques to achieve pain control using functional nerve restoration have become potentially useful alternatives. The authors reported data from a retrospective cohort study of patients (n = 63) who underwent extremity amputation for treatment of cancer. Each included patient underwent targeted muscle reinnervation (coapting of the amputated nerve to nerve endings within a muscle interface); photographs of the technique are available in the supplemental content supplied online.

The primary outcome of interest was postamputation pain and phantom limb pain measured by standard scales. Median follow up was 11.3 months. Pain was effectively controlled in the treated patients as evidenced by very low pain scores during postoperative follow up. Postoperative narcotic usage was reduced by 50% compared to preoperative measurements. Although average operative time was increased by nearly 1 hour, there was no delay in time to first ambulation (2 days) and no increase in overall complication rates.

The authors concluded that targeted muscle reinnervation was effective and safe as a treatment for postamputation pain and phantom limb pain.

FOLFOX Is Noninferior to Standard Preoperative Chemotherapy and Shows Lower Risk of Toxicity

Schrag D, Shi Q, Weiser MR, et al. Preoperative Treatment of Locally Advanced Rectal Cancer. N Engl J Med 2023 doi: 10.1056/NEJMoa2303269 [published Online First: 20230604]

Preoperative chemoradiotherapy lowers rates of pelvic disease recurrence to 10% in patients with rectal cancer and has been the accepted standard of care in North America since 1990. There is, however, a significant rate of postoperative toxicity symptoms associated with chemoradiotherapy that adversely affect quality of life.

Deborah Schrag, MD, MPH, and coauthors reported a randomized, unblinded, noninferiority trial comparing standard preoperative chemoradiotherapy with neoadjuvant chemotherapy (FOLFOX – fluorouracil, leucovorin, and oxaliplatin). Included patients had “advanced” rectal cancer defined as T2-node positive, T3-node negative, or T3-node positive. All enrolled patients (n = 1,128) were deemed satisfactory candidates for sphincter-sparing surgery. Noninferiority was determined using standard definitions based on rates of disease recurrence and death.

The data analysis showed that 5-year disease-free survival rates were similar in the two comparison groups. Toxicity symptoms were more common in the FOLFOX group preoperatively, but postoperative toxicity symptoms were significantly reduced in patients receiving FOLFOX.

The authors concluded that FOLFOX treatment was noninferior to standard therapy with respect to disease-free survival and was associated with lower risk of postoperative toxicity symptoms. FOLFOX should be considered for preoperative treatment of patients with rectal cancer.

Esmolol Added to Standard Care Significantly Improves Diabetic Foot Ulcer Healing

Rastogi A, Kulkarni SA, Deshpande SK, et al. Novel Topical Esmolol Hydrochloride (Galnobax) for Diabetic Foot Wound: Phase 1/2, Multicenter, Randomized, Double-Blind, Vehicle-Controlled Parallel-Group Study. Adv Wound Care (New Rochelle) 2023;12(8):429-39. doi: 10.1089/wound.2022.0093 [published Online First: 20221116]

Foot ulcers are a source of significant risk for increased morbidity and mortality in patients with diabetes, as these lesions affect up to 25% of diabetic patients. Data cited in this article showed that patients with foot ulcers have a 46% increased risk of 5-year mortality and that only 30% of patients have durable healing with conventional treatments.

The authors reported results of a randomized, double-blind study (n = 120) comparing standard treatment with standard treatment plus topical esmolol. The primary outcome of interest was the rate of wound healing within 12 weeks of beginning treatment. The data showed that complete healing occurred in 77.2% of the esmolol group and 41.7% of the standard care group. The median time for complete ulcer closure was 85 days for the esmolol group. In patients with factors known to impair wound healing such as obesity, arterial disease, renal disease, and anemia, healing rates for patients treated with esmolol were superior to standard care.

The authors concluded that adding esmolol to standard care significantly improved diabetic foot ulcer healing.