Authors: (including presenting author): :
NG HL(1), CHUNG MT Marvin (2), CHING HY Raymond (2), Chui TC (1), Chin YM(1)
Affiliation: :
(1) Occupational Therapy Department, Pamela Youde Nethersole Eastern Hospital, Hong Kong (2) Department of Orthopaedics & Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
Keyword 1: :
Neuropathic Pain
Keyword 2: :
Multimodal Management
Introduction: :
Recurrent Tenosynovial Giant Cell Tumor (TGCT) is a locally aggressive neoplastic condition with a notable risk of recurrence, requiring complex management strategies.
Objectives: :
The report emphasizes a multimodal approach for neuropathic pain management following limb amputation, integrating surgical, pharmacological, and non-pharmacological therapies.
Methodology: :
This case report presents a 66-year-old male with TGCT of the left hand, initially treated by excisions but ultimately progressing to epithelioid sarcoma, necessitating left wrist disarticulation. The patient underwent three excisions between 2019 and 2024, with recurrent epithelioid sarcoma confirmed by MRI and pathology. Given the aggressive nature and infiltration of the tumor, a left wrist disarticulation was performed in January 2025 with the goal of achieving oncologic control and reducing pain-related complications. Surgical pain management included two advanced nerve techniques rarely applied in upper limb surgeries: centro-central nerve anastomosis and regenerative peripheral nerve interface (RPNI). Centro-central anastomosis involves splitting the median and ulnar nerves and suturing each to itself to create a nerve sheath that traps regenerating axons, preventing painful neuroma formation. RPNI was performed on the superficial radial nerve by implanting it into a denervated muscle graft, providing a physiological end organ to promote organized nerve regeneration and reduce phantom limb pain. Pharmacologically, the patient was managed with neuropathic pain agents including gabapentin and tramadol, alongside NSAIDs. Non-pharmacological interventions incorporated comprehensive pain education to enhance understanding and coping strategies, motor visual feedback therapy to engage sensory-motor pathways, gradual desensitization and sensory re-education to reduce allodynia, and meticulous residual limb care. Adaptive tools help to improve patient’s functional independence such as buttoning, hygiene, and food preparation, reinforcing bimanual techniques to prevent overuse injuries.
Result & Outcome: :
Functional independence was supported through adaptive tools for daily activities such as buttoning, hygiene, and food preparation. Over nine months of follow-up, the patient's pain was significantly reduced (VAS 6 to 2), phantom limb pain was minimal, and static mechanical allodynia (SMA) territories shrank progressively. Functional scores of QuickDASH improved from 50 to 25, with independence in activities of daily living (ADL) and instrumental ADLs increasing notably, and the patient was able to confidently use an upper limb prosthesis. This report highlights the efficacy of a multidisciplinary and multimodal strategy combining innovative surgical nerve techniques with tailored pharmacological and rehabilitative care in managing neuropathic pain after amputation for recurrent TGCT. It underscores the importance of individualized treatment plans to optimize pain control and functional outcomes, advocating for ongoing data collection to further validate these approaches.
