This is a patient who developed neuroma pain and phantom limb pain following above knee amputation. Via a posterior midline incision, the sciatic nerve is exposed in the interval between the hamstrings. There are many large vascular leashes supplying the muscles in this interval arising from the inferior gluteal vessels and profunda femoris, providing a multitude of options for VDMT creation. Here a vessel loop has been placed around a vascular leash supplying the semitendinosus muscle and a VDMT is being raised on this pedicle. Either bipolar or monopolar cautery can be used to raise the VDMT as long as care is taken to avoid injuring the pedicle. Here a large portion of muscle is being raised given the relatively large caliber of these vessels. This allows for implantation of the entire sciatic nerve into a single muscle target rather than subdividing the nerve into multiple fascicles. We will at times separate the tibial and peroneal nerves from the sciatic nerve for implantation into two VDMTs individually. Importantly, the amount of muscle needed to accept all axons from a given size nerve remains unknown and is therefore subject to the discretion of the surgeon. Following complete elevation, perfusion to the muscle flap is confirmed using handheld Doppler ultrasound. Visual inspection of the flap is also required. At times the margins of the flap must be trimmed until bright red bleeding is encountered. Next, complete denervation of the VDMT is confirmed by stimulating the pedicle and confirming the absence of contractions within the flap. If contractions are observed, the occult motor nerve traveling with the pedicle must be identified, dissected, and divided under loop magnification. Prior to neuroma excision, the sciatic nerve is anesthetized with marcaine. The sciatic nerve is then sectioned proximal to the neuroma. If intraneural scar tissue is initially encountered, bread lobing the nerve with serial sectioning is required until healthy appearing fascicles are encountered. Any number of techniques can be employed to implant the proximal nerve stump within the VDMT. Here, we chose to create a pocket within the VDMT and parachute the proximal nerve into the pocket with two 6-0 proline epineural sutures.

neuroma

phantom limb pain

sciatic nerve

vascularized directed muscle target

above-knee amputation