Original Article

Vascular and Endovascular Surgery

2024, Vol. 58(2) 142–150
Phantom Limb Pain and Painful Neuroma © The Author(s) 2023

After Dysvascular Lower-Extremity Article reuse guidelines:

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Amputation: A Systematic Review and DOI: 10.1177/15385744231197097
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Meta-Analysis

Mirte Langeveld, MD, MPH1,2 , Romy Bosman, BSc1,2, Caroline A. Hundepool, MD, PhD1,
Liron S. Duraku, MD, PhD3, Christopher McGhee, BNurs2, J. Michiel Zuidam, MD, PhD1,
Tom Barker, MD, FRCS4, Maciej Juszczak, PhD, FRCS4, and
Dominic M. Power, MA, MB BChir (Cantab), FRCS (Tr & Orth)2

Abstract
Background: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life
of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb
amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and
incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. Methods: Four databases (Embase,
MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective
observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/
or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening,
data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb
pain, a meta-analysis using a random effects model was performed. Results: Twelve articles were included in the quantitative
analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience
phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4
and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. Conclusions: This
meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and
disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to
prevent it at the time of amputation.

Keywords
lower limb amputation, dysvascular amputation, neuropathic pain, phantom limb pain, neuroma

Introduction
Amputation of the lower extremity is one of the most frequently
performed surgical interventions worldwide,1 with national in-
cidences ranging from 5.8 to 31 per 100,000.2 With the rapid rise
in the prevalence of diabetes mellitus, particularly in low- and
middle-income countries, the rates of associated peripheral ar-
terial occlusive disease (PAD), diabetic neuropathy, and soft
tissue sepsis have increased as well.3,4 Together, PAD and
complications from diabetes mellitus have become the leading
cause of lower extremity amputation (LLA), with dysvascularity
responsible for 82% of limb loss in the United States.5
Over 70% of amputees experience pain in the residual
limb.6 Residual limb pain can have many causes, including
bone spurs, pressure points, or deep tissue infections, but can
1
Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus
Medical Center, Rotterdam, The Netherlands
2
Hand and Peripheral Nerve Injury Service, Queen Elizabeth Hospital,
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
3
Department of Plastic, Reconstructive Surgery and Hand Surgery,
Amsterdam UMC, Amsterdam, the Netherlands
4
Department of Vascular Surgery, Birmingham Heartlands Hospital,
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Corresponding Author:
Dominic M. Power, MA, MB BChir (Cantab), FRCS (Tr & Orth), The HaPPeN
research group, NIHR Surgical Reconstruction and Microbiology Research
Centre, North Block, 4th Floor, Heritage Building (Queen Elizabeth
Hospital), Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK.
Email: dominicpower1@gmail.com
Langeveld et al.
also be the consequence of neuroma formation. Furthermore,
many patients experience phantom limb pain (PLP) following
lower extremity amputation. PLP is the sensation of burning,
tingling, or electrical shooting pain originating from an area of
body tissue that is not physically present.7 PLP and neuro-
pathic pain from a symptomatic neuroma can be debilitating
and significantly impact the quality of life of amputees and be
difficult to manage. The pain decreases the patient’s ability
and desire to wear prosthetics, impairing mobility status and
function of the limb.8
The prevalence of PLP and symptomatic neuromas in
patients following dysvascular LLA has not been reliably
established. The traditional rationale was that dysvascular
amputees were thought to experience less neuropathic pain
and PLP due to longstanding peripheral neuropathy as a
consequence of diabetes mellitus, leading to loss of sensation
and pain.7 However, research by Clark et al7 reported no
significant difference in PLP between dysvascular and non-
dysvascular amputees. The impact of PLP and symptomatic
neuromas on the patient’s mobility status and quality of life
make it essential to gain an understanding of the magnitude of
the problem in this patient population that already experiences
higher complication and mortality rates than non-vascular
amputees.9,10 This systematic review examines the preva-
lence and incidence of phantom limb pain and symptomatic
neuroma after dysvascular LLA.
Methods
Literature Search
A systematic review was conducted to study the prevalence and/
or incidence of phantom limb pain and symptomatic neuroma
following dysvascular LLA. The study was performed in ac-
cordance with the Preferred Reporting Items for Systematic
Reviews and Meta-analyses statement (PRISMA guidelines,
Appendix, Supplemental Digital Content 1).11 Databases Em-
base, MEDLINE, Web of Science Core Collection, and Co-
chrane Central were searched from inception to 5th October 2022
(Appendix, Supplemental Digital Content 2).
Study Selection
Two authors (R.B. and M.L.) independently identified rele-
vant studies meeting the eligibility criteria based on title and
abstract. All articles were screened for the following inclusion
criteria: prospective or retrospective observational cohort
studies or cross-sectional studies reporting the prevalence (for
cross-sectional studies) or incidence (for prospective cohort
studies) of PLP and/or symptomatic neuromas following
dysvascular LLA, where LLA included transtibial amputation,
transfemoral amputation, foot amputation, knee disarticula-
tion and hip disarticulation (Table 1). Dysvascular LLA was
defined as amputation of the lower extremity that is dys-
vascular in etiology due to complications from peripheral
143
arterial disease (PAD), embolism, or diabetes mellitus (DM).
If studies reported the outcomes of LLA for multiple etiologies
(e.g., traumatic, dysvascular, and oncological), outcomes for
patients with dysvascular LLA had to be individually dis-
cernable. Studies with less than 30 patients were excluded.
Experimental studies, case reports, animal studies, reviews,
conference abstracts, and poster presentations were excluded,
as well as non-English articles and articles without full-text
available. Disagreements between the authors were discussed
in consensus meetings.
Data Extraction and Quality Scoring
Two authors (R.B. and M.L.) extracted data from the selected
articles. Collected variables included the year of publication,
country, number of patients, age of patients, level of ampu-
tation, time to follow-up, and reported outcome measure.
The primary outcome was the proportion of patients that
experienced PLP after LLA. PLP was defined as pain that is
felt in the portion of the limb that has been amputated.
Secondary outcomes were the proportion of patients with a
symptomatic neuroma in the amputation stump of the affected
lower limb following LLA, and pain score measured with the
Visual Analog Scale (VAS)/Numerical Rating Scale (NRS).
The Jovell and Narvarro-Rubio classification was used to
classify eligible articles by strength of evidence (Appendix,
Supplemental Digital Content 3). A quality assessment was
performed using the Study Quality Assessment Tools of the
National Institutes of Health (NIH) (Appendix, Supplemental
Digital Content 4) (2).
Statistical Analysis
Descriptive data was summarized in tables. For each study, the
absolute number and proportion of patients reporting PLP was
determined. Those numbers were statistically combined in a
meta-analysis to generate an overall pooled proportion with a
95% confidence interval. This proportional meta-analysis was
performed in R (version 4.0.5.) using a random-effects model
with logit transformation. The random-effects model was
selected because of the expected heterogeneity between the
included studies. In this model, studies are equally weighted.
A back-transformation from logit was performed to provide
the pooled proportion of PLP. Heterogeneity testing was
performed with a generalized/weighted least-squares exten-
sion of Cochran’s Q-test. The results of the analysis are
graphically presented in a forest plot. A funnel plot was used
to analyze publication bias.
Results
The literature search yielded 5668 publications (Figure 1).
After duplicates were removed and abstracts were screened,
5610 articles were excluded. Fifty-eight studies were read in
full text and assessed for eligibility. In twenty-six studies the
144 Vascular and Endovascular Surgery 58(2)

Table 1. Baseline Characteristics of Included Studies.

Patients Amputation level Mean follow-up months

Author, year Country Study type LoE (n) Age (yr) (n) (range)

AlMehmam et al, Saudi Arabia Cross-sectional VIII 78 57.5 ± 12.0 NRS NR

2022 study
Borsje et al, 2004 The Cross-sectional VIII 127 NRS NRS NR
Netherlands study
Clark et al, 2013 United Cross-sectional VIII 50 70.5 ± 1.45 Above knee: 11 1.5 y ± 0.2 y
Kingdom study Below knee: 39
Dijkstra et al, 2002 The Cross-sectional VIII 216 NRS Above knee: 167 18.8 y ± 18.1 y
Netherlands study Below knee: 266
Durovic et al, 2007 Servia Prospective cohort VI 38 NRS Above knee: 11 2m
Below knee: 24
Foot: 3
Ephraim et al, 2005 United States Cross-sectional VIII 335a 55.6 ± 10.9 Above knee: 93 3 y (1 y-48 y)b
study Below knee: 178
Bilateral: 64
Lans et al, 2022 United States Retrospective VI 643 60.5 ± 16.2 NRS NRS
cohort
Mayo et al, 2022 Canada Cross-sectional VIII 231 63.4 (31-95)b Above knee: 24 40.3 m(6 m - 20 y)b
study Below knee: 171
Bilateral: 36
Penna et al, 2017 Australia Retrospective VI 40 NRS NRS 12 m
cohort
Richardson et al, United Prospective cohort VI 52 63.8 ± 10.4 Above knee: 25 6m
2006 Kingdom Below knee: 24
Bilateral: 3
Richardson et al, United Cross-sectional VIII 89 65.5 ± 11.4 Above knee: 57 2.9 m ± 4.6 m
2015 Kingdom study Below knee: 32
Weiss and lindell, United States Retrospective VI 45 NRS NRS NR
1996 cohort
Values are presented as mean ± Standard Deviation.
LoE: Level of Evidence assessed with the classification of strength of evidence by Jovell and Navarro-Rubio.
NR: not reported; NRS: not reported specifically for dysvascular MLA patients; NA: not applicable.
a
The patient population includes 5 patients (1.5%) with upper limb amputation.
b
Value is presented as mean (range).

outcome of interest in dysvascular patients was non-
distinguishable from other causes for major limb amputa-
tion. Other reasons for exclusion were no outcome of interest
(n = 2), sample size below 30 patients (n = 1), article not
available in the English language (n = 3) and previously
unidentified duplicative articles (n = 3). Eleven articles were
not available in full text. A total of 12 articles were included
in qualitative analysis and 11 in quantitative analysis
(Table 2).1,7,12-21
Seven of the 12 included articles were cross-sectional
studies (Table 2),7,12-14,16,18,20 two prospective cohort
studies,15,19 and three retrospective cohort studies.1,15,17,19,21
The studies were conducted in seven different countries and
published between 1996 and 2022. The number of patients in
each study ranged between 38 and 643, with a median of 70.5
(Table 2). Seven studies included both above and below-knee
amputations,7,14-16,18-20,22 while five studies did not report
amputation levels specifically for dysvascular MLA patients
(Table 2).1,12,13,17,21 Three studies included bilateral
amputations.16,18,19 The mean age of included patients in each
study ranged between 57.7 and 70.5 years (Table 2).
Articles used various outcome measures to assess the
presence of PLP and symptomatic neuroma. Ten studies used
questionnaires including the Kooijman Phantom Pain Ques-
tionnaire, the Groningen Questionnaire of Problems after Leg
Amputation, the Dysvascular Conditions Scale Questionnaire,
the Phantom phenomena questionnaire and Haber’s Phantom
Limb Questionnaire (Table 2).7,12-16,18-21 One study by Lans
et al17 retrospectively based the prevalence of PLP on re-
porting in medical charts. A single study by Penna et al1
evaluated symptomatic neuroma’s presence by combining
clinical signs with radiological or histological confirmation.
Five studies used numerical pain scores to assess the severity
of the PLP. Four studies used the 0-10 VAS scale or 0-10 NRS
scale.7,15,19,20 Weiss and Lindell21 used a 0-6 verbal pain
scale.
Langeveld et al.
Figure 1. Flowchart regarding the selection of included articles according to the PRISMA standards.
Quality Assessment of Included Studies
Five cohort studies scored a level of evidence of six according
to the classification of strength of evidence according to the
Jovell and Navarro-Rubio classification.1,15,17,19,21 The re-
maining seven cross-sectional studies scored a level of evi-
dence of eight.7,12-14,16,18,20 When scored with the NIH Risk
of Bias tool, all studies had an average risk of bias (Appendix,
Supplemental Digital Content 4). No studies were excluded
based on the quality assessment or risk of bias tool.
Proportion of Patients with PLP Following
Dysvascular LLA
Eleven studies reported phantom limb pain for a total of 1924
LLA (Table 3).7,12-21 A meta-analysis of these studies dem-
onstrated that 69% of the patients experience phantom limb
pain (95% CI 53-86%) (Figure 2).
Pain Intensity of PLP
Reported pain intensity scores of PLP on the 0-10 VAS/NRS
scale ranged between 2.3 ± 1.4 and 5.5 ± .7 (Table 3). Weis and
145
Lindell evaluated pain intensity on a 0-6 pain scale and re-
ported a score of 2.6 ± 1.8.21
Proportion of Patients with Symptomatic Neuroma
Following Dysvascular LLA
A single study reported the number of patients that developed
a symptomatic neuroma following dysvascular LLA.1 In a
study population of 40, Penna et al1 reported that two patients
(5%) developed a symptomatic neuroma (Table 3).
Discussion
PLP and symptomatic neuromas can significantly impact an
amputee’s quality of life and mobility status, and insight into the
magnitude of the problem is necessary. This systematic review
aimed to examine the prevalence of PLP and symptomatic
neuroma after dysvascular LLA. Overall, 69% of patients report
experiencing PLP following LLA (95% CI 53-86%). In current
literature and this review, evidence for the percentage of
symptomatic neuroma following dysvascular LLA is lacking.
However, a single study reported an incidence of 5%.1
146 Vascular and Endovascular Surgery 58(2)

Table 2. The Reported Presence of Phantom Limb Pain and Symptomatic Neuroma.

Number of patients with Number of patients with Pain

Author, year Method of outcome measurement phantom limb pain (%) symptomatic neuroma (%) score

Almehmam et al, Kooijman phantom pain questionnaire 47 (60.3%) NR NR

2022
Borsje et al, 2004 The Groningen questionnaire of problems 90 (71%) NR NR
after leg amputation
Clark et al, 2013 Questionnaire 41 (82%) NR 3.9 ± 0.4
Dijkstra et al, Questionnaire 169 (78.2%) NR NR
2002
Durovic et al, Questionnaire 22 (57.9%) NR 2.3 ± 1.4
2007
Ephraim et al, Questionnaire 281 (83.9%)a NR NR
2005
Lans et al, 2022 Phantom limb pain reported in medical 227 (35%) NRS NR
chart
Mayo et al, 2022 Dysvascular conditions scale questionnaire 162 (70.1%) NR NR
Penna et al, 2017 Clinical signs in combination with NR 2 (5%) NR
radiological or histological confirmation.
Richardson et al, Phantom phenomena questionnaire 41 (78.8%) NR 2.7 ± 1.6
2006
Richardson et al, Phantom phenomena questionnaire 56 (63%) NR 5.5 ± .7b
2015
Weiss and lindell, Haber’s phantom limb questionnaire 33 (73.3%) NR 2.6 ± 1.8c
1996
Values are presented as mean ± Standard Deviation.
NR: not reported; NRS: not reported specifically for dysvascular MLA patients.
a
The patient population includes 5 patients (1.5%) with upper limb amputation.
b
The pain score was only recorded for outpatient patients (n = 25).
c
Pain was recorded on a 0-6 verbal pain scale.

Figure 2. Meta-analysis of proportions of PLP in LLA.

In this systematic review, we report a similar prevalence of in surgical and traumatic amputations and reported a pooled
PLP in dysvascular amputees as has been established in lit- prevalence estimate of PLP of 64% (95% CI 60.01-68.05).
erature for the total population of all-cause amputees. Li- Additionally, Schwingler et al24 reported a pooled prevalence
makatso et al23 systematically reviewed the prevalence of PLP of PLP of 53% (95% CI 40%-66%) following all-cause LLA.
Langeveld et al.
Stankevicius et al25 conducted a rapid systematic review
without a meta-analysis and reported a wide range in point
prevalences of PLP in included studies between 6.7%-88.1%
and lifetime prevalences between 76%-87% in all-cause upper
and lower limb amputations. Individual studies also corrob-
orate our findings that the prevalence of PLP in dysvascular
LLA patients is not lower than that in non-dysvascular am-
putees. Clark et al7 compared the prevalence of PLP between
dysvascular LLA and non-dysvascular amputations and found
no difference between the groups.
Conflicting theories have been previously proposed for
dysvascular amputees experiencing either less or more neu-
ropathic pain than non-dysvascular amputees. Traditionally,
patients with dysvascular LLA were hypothesized to experi-
ence less PLP and neuropathic pain than non-dysvascular
amputees.7,26 The rationale is that the high prevalence of
diabetes mellitus in this population and the associated long-
standing peripheral diabetic neuropathy leads to a loss of
sensation in the limb and, as a result, less pain. In their ret-
rospective cohort study, Lans et al17 reported diabetes mellitus
as a protective factor for developing PLP and symptomatic
neuroma, with the hypothesis that nerve regeneration potential
is inhibited in patients with diabetes mellitus, making them
less prone to develop neuropathic pain. Our meta-analysis
disputes this theory, and we found a similar prevalence of PLP
in dysvascular amputees as has been reported for all-cause
amputees. Alternatively, dysvascularity may be associated
with identified risk factors of PLP, like pre-amputation pain
and depression, making dysvascular patients more likely to
develop neuropathic pain.23 While a significant portion of
dysvascular amputees have a diagnosis of diabetic neuropathy
that pre-dates the amputation, a pathophysiological associa-
tion between diabetic neuropathy and the development of
post-amputation neuropathic pain has not been sufficiently
studied.27 The mechanisms that lead to diabetic neuropathic
pain are not yet fully understood either, although it is thought
that the toxic effects of hyperglycemia play an important
role.28 Other theories proposed by Schreiber et al28 include
changes in blood vessels that supply the peripheral nerves,
changes in sodium and calcium channels, metabolic and
autoimmune disorders accompanied by glial cell activation,
and central pain mechanisms. However, whether these factors
also influence phantom limb pain development or symp-
tomatic neuroma formation is not currently known.
Due to the potentially debilitating nature of PLP and
symptomatic neuromas, various surgical strategies have been
proposed to inhibit the development of neuropathic pain.
Targeted Muscle Reinnervation (TMR) and Regenerative
Peripheral Nerve Interfaces (RPNI) have been proposed as
preventive procedures performed during major limb ampu-
tation. TMR is a procedure where the peripheral nerves are
coapted to motor branches supplying functionally expendable
portions of muscle in the vicinity of the nerve.29 Originally
developed to provide intuitive control of upper limb pros-
theses, Dumanian et al first noted the improvement in PLP and
147
decrease in neuropathic pain in patients who underwent TMR
at the time of amputation.30 The rationale is that providing the
transected nerves with a physiological target for reinnervation
prevents hypersensitivity and the formation of symptomatic
neuromas. Alternatively, during RPNI, the transected pe-
ripheral nerves are implanted into autologous free, denervated,
and devascularized muscle grafts.31,32 Multiple studies have
reported that performing prophylactic TMR during limb
amputation significantly reduces the development of phantom
limb pain, residual limb pain, and symptomatic neuroma.33-35
For example, Valerio et al33 demonstrated an incidence of
phantom limb pain in 55.8% of the patients treated with
prophylactic TMR compared to 78.6% of the controls. In one
study it was reported that prophylactic RPNI significantly
reduced the incidence of painful neuroma and PLP, following
LLA from 91% in the control group to 51% in the RPNI
group.36 Most studies have excluded dysvascular amputations
focusing instead on amputation of trauma or oncological
aetiology.
In dysvascular patients, there are several factors that could
dissuade the surgeon from using TMR or RPNI preventively,
including higher re-amputation rates, higher complication and
wound infection rates, and a peri-operative mortality of 10-
15%.37-39 Furthermore, TMR and RPNI lengthen the opera-
tive time and often necessitate making additional surgical
wounds. However, a recent study by Chang et al40 used
prophylactic TMR in 100 patients at the time of below-knee
amputation in a highly comorbid cohort and compared the
outcomes with 100 patients treated with amputation with
standard traction neurectomy in a non-randomized study. Of
this cohort, 76% of patients underwent amputation for a di-
abetic wound or arterial or venous ulcer, 15% for a failed
Charcot reconstruction and 10% for ischemic pain. Chang
et al40 reported significantly less pain and PLP in the TMR
cohort, with 71% of TMR patients being pain-free at 9.6 ±
5.7 months follow-up compared to 36% of non-TMR patients
(P < .01), and PLP occurring in 19% of the TMR patients vs
47% in the non-TMR patients (P < .01). Additionally, the
TMR cohort’s ambulation rate was significantly higher, while
complications requiring revision or debridement occurred less
than in the cohort treated with standard traction neurectomy.
On average, preventive TMR added an additional 34.8 ±
75 minutes to the operative time.40 These demonstrate that use
of PLP preventive strategies at the time of dysvascular LLA in
selected patients may significantly reduce pain and improve
quality of life and overall health.
There are several limitations to this study. The most sig-
nificant limitation is the varying methods of outcome mea-
surements used to assess PLP. As no universally accepted
criteria exist for PLP, studies used varying definitions to
evaluate its presence, such as ‘pain in the missing part of the
limb’ or ‘an unpleasant sensation in the nerve distribution of
the missing body part’. Furthermore, no validated method of
outcome measurement exists for PLP. Most included articles
used unvalidated questionnaires, while others reported PLP
148
based on clinical signs or retrospectively assessed medical
records. This may explain why the study by Lans et al reported
a particularly low prevalence of PLP, as it was the only study
to use retrospective chart review to evaluate the presence of
phantom limb pain, which may have led to underreporting.
Additionally, the varying criteria for PLP and the variability in
methods of outcome measurement may have caused the re-
ported heterogeneity between the included studies in our meta-
analysis. Furthermore, while the I-squared statistic supposedly
indicates significant heterogeneity between included studies in
the conducted analysis, this statistic should be interpreted
cautiously. Due to the nature of proportional data, the I-
squared statistic tends to yield high values in proportional
meta-analyses, primarily due to the fact that even small studies
with limited sample sizes often exhibit small variances in their
outcomes, leading to high I-squared values.41 Consequently,
the high I-square value in such cases does not automatically
indicate data inconsistency, and a conservative interpretation
is recommended.41 Therefore, a pooled proportion for PLP
across the included studies was presented in this analysis
despite the high I-squared value. Lastly, it was impossible to
perform subgroup analyses to evaluate whether the prevalence
of PLP and symptomatic neuroma differ between levels of
amputation and/or amputation techniques. Previous studies
have reported higher rates of neuropathic pain and PLP in
proximal amputations compared to distal amputations.17,42,43
There is a scarcity of literature addressing the prevalence of
symptomatic neuromas resulting from dysvascular conditions. A
single retrospective study by Penna et al1 reported a prevalence of
5%. The formation of a neuroma is expected in every severed
nerve without a distal nerve end, due to disorganized axial re-
generation. However, it remains unclear which mechanisms
determine whether a neuroma will cause symptomatic neuro-
pathic pain in patients. Further research is necessary to inves-
tigate the influence of dysvascularity on the development of
symptomatic neuromas. The diagnosis of symptomatic neuroma
development is further complicated by the absence of universally
accepted diagnostic criteria. To address this issue and facilitate
consistent diagnosis, diagnostic criteria proposed by Arnold
et al44 have been suggested for adoption in clinical practice and
future research. To receive a diagnosis of symptomatic neuroma,
patients must exhibit pain with at least three “neuropathic”
characteristics, symptoms in a specific neural anatomical dis-
tribution, and a history of or suspected nerve injury. Furthermore,
patients must meet at least one of the following criteria: (1) a
positive Tinel sign upon examination at or along the suspected
nerve injury site of a cutaneous nerve, (2) a positive response to a
diagnostic local anaesthetic injection, or (3) confirmation of
neuroma through ultrasound or magnetic resonance imaging.
Incorporating these diagnostic criteria into future research will
enable the evaluation of the prevalence of symptomatic neuro-
mas following dysvascular amputation in a universally com-
parable manner.44
Vascular and Endovascular Surgery 58(2)
Conclusions
This systematic review and meta-analysis demonstrates a high
prevalence of PLP after dysvascular LLA. Evidence on the
prevalence of symptomatic neuromas after dysvascular am-
putation is still lacking, and further research is needed. There
is good evidence in non-dysvascular amputations, and a single
study in dysvascular amputation, that use of surgical strategies
such as TMR and RNPI at the time of amputation may sig-
nificantly reduce subsequent PLP. Knowledge of the preva-
lence of PLP and symptomatic neuroma in patients
undergoing dysvascular amputation may encourage wider
adoption of techniques in this patient group.
Acknowledgments
The authors like to thank Elise Krabbendam, biomedical information
specialist at the Erasmus Medical Center, for her assistance with the
literature search.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, au-
thorship, and/or publication of this article.
Ethical Board and Informed Consent
This manuscript is a systematic review and meta-analysis. As such,
the article is not subject to ethical approval or informed consent
procedures in the Netherlands or the United Kingdom, where the
authors are located.
ORCID iD
Mirte Langeveld  https://orcid.org/0000-0001-6849-5036
Supplemental Material
Supplemental material for this article is available online.
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