Targeted Muscle Reinnervation at the Time of Major Limb Amputation in Traumatic Amputees

Abstract

Background: Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. Methods: Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. Results: At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. Conclusions: The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Prevention is better than cure: Surgical methods for neuropathic pain prevention following amputation – A systematic review

“…Finger amputation happen more often due to trauma (31,32,42,43). In contrast to major limb amputations where oncologic disease, diabetes and vascular disease are responsible for the majority of the indication (33)(34)(35)(36)(37)(38)41). If in major limb amputation a trauma is the cause, the trauma mechanism is more invasive and often more than the affected limb is injured (38).…”

“…Frantz et al reported incidences outcomes after TMR in major amputation of both upper and lower limb. Fourty percent of their patients had RLP at final follow-up (37). The use of opioid medication at final follow up was 16%, of which all patients used opioid medication preoperatively.…”

“…For major limb amputation, the literature reported much higher incidences of neuropathic pain following amputation from 25 to 85% (2,(5)(6)(7)(50)(51)(52)(53)(54)(55)(56). Prevention techniques during amputation reduced the incidence to between 0 and 51% compared to control groups with incidences of between 13 and 81% (33)(34)(35)(36)(37)(38)(39)41). The incidence of phantom limb pain was also lower in the prevention group (0-56%) compared to the control groups (64-91%) (33-35, 38, 39, 41) .…”

“…A part of the 1 major limb amputations reported the use of pain medication during the follow up. At final follow up, the usage of pain medication in the prevention method groups ranged between 16% and 50% (33,(35)(36)(37)39). In literature, the use of pain medication after major limb amputation remains unknown, but a prevalence of 20% has been reported (57).…”

Revision Peripheral Nerve Surgery of the Upper Extremity

“…30 Furthermore, TMR has also served to prevent postoperative pain if performed at the time of limb amputation. [43][44][45] Valerio et al established that preemptive management of postamputation pain with TMR resulted in significantly reduced PLP and residual limb pain compared with the untreated amputee cohort. 44 Recently, TMR in the hand has been studied to examine motor entry points (MEPs) to the intrinsic muscles.…”