Challenges and Potential in Targeted Muscle Reinnervation in Pediatric Amputees

Abstract

Targeted muscle reinnervation (TMR) is a powerful new tool in preventing and treating residual limb and phantom limb pain. In the adult population, TMR is rapidly becoming standard of care; however, there is a paucity of literature regarding indications and outcomes of TMR in the pediatric population. We present 2 cases of pediatric patients who sustained amputations and the relevant challenges associated with TMR in their cases. One is a 7-year-old patient who developed severe phantom and residual limb pain after a posttraumatic above-knee amputation. He failed pharmacologic measures and underwent TMR. He obtained complete relief of his symptoms and is continuing to do well 1.5 years postoperatively. The other is a 2-year-old boy with bilateral wrist and below-knee amputations as sequelae of sepsis. TMR was not performed because the patient never demonstrated evidence of phantom limb pain or symptomatic neuroma formation. We use these 2 cases to explore the challenges particular to pediatric patients when considering treatment with TMR, including capacity to report pain, risks of anesthesia, and cortical plasticity. These issues will be critical in determining how TMR will be applied to pediatric patients.

Targeted Muscle Reinnervation in the Setting of Traumatic Bilateral Above-Knee Amputations

“…TMR can be used in transfemoral amputees to safely control these powered prostheses during strenuous exercises. Owing to increasing evidence of beneficial clinical outcomes, several academic centers have considered the use of TMR as the standard of care for all elective and traumatic amputations 19 . To optimize patient outcomes, it is important to consider a multidisciplinary approach.…”

Musculoskeletal Issues in Pediatric Burn Patients

“…22 While well described as beneficial for adult amputees, appropriate use of TMR in the pediatric population has yet to be determined. 23 Transdiaphyseal amputations in children are frequently complicated by stump overgrowth. In extreme cases, the bone may grow out through the skin.…”

“…22 While well described as beneficial for adult amputees, appropriate use of TMR in the pediatric population has yet to be determined. 23…”

Demystifying Targeted Muscle Reinnervation: A Systematic Review of Nerve Transfers for the Lower Extremity

“…Ten original reports described donor nerve dissection and target muscles at the transfemoral level (Table 2; Supplemental Digital Content 1, http://links.lww.com/ PRSGO/C457). 2,3,[12][13][14][15][16][17][18][19] Agnew et al performed the initial anatomic study to advance transfemoral TMR. Landmarks for motor branch clusters to all muscles of the thigh were identified.…”