The Use of Free Flaps as a Surgical Treatment for Chronic Refractory Pain in the Upper Extremity

Abstract

Objective: The objective of this study is to present our experience with free flaps as a treatment for recalcitrant neuropathic pain in the upper extremity. Methods: The first case involved a woman who developed neuropathic pain following carpal tunnel release. After undergoing revision surgery, neurolysis, and Strickland's hypothenar fat pad flap, the patient still experienced persistent pain. Subsequently, after 8 years and 3 surgeries, a free sural flap was proposed. The second case involved a woman with partial amputation of the index finger. Following initial bone regularization and advancement flap, the patient developed refractory neuropathic pain. Three additional surgeries were performed, including resection of the remaining phalanx with denervation, metacarpal osteotomy with neurectomy, and resection of the neuroma followed by burying it into the metacarpal bone. After 3.5 years and 3 surgeries, a perforator artery fibular free flap was offered. The Visual Analog Scale (VAS), and Disabilities of Arm, Shoulder, and Hand (DASH) questionaries were used to evaluate the outcomes. Results: Both patients experienced pain following nerve injury. The sural free flap and the perforator artery peroneal free flap were anastomosed to the radial artery and the volar branch of the radial artery, respectively, using end-to-side and end-to-end techniques. Both patients demonstrated significant clinical improvement, with VAS scores improving by 6 and 8 points, and DASH scores improving to 41 and 36, respectively. The follow-up period was 2.5 years and 1 year, during which no complications were observed. Conclusions: Free flaps represent a viable option for the treatment of recalcitrant neuropathic pain in the upper extremity.