Targeted Muscle Reinnervation for Symptomatic Neuromas Utilizing the Terminal Anterior Interosseous Nerve

Abstract

Summary: Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.

Targeted Muscle Reinnervation

“…Management of the pure sensory nerves in the forearm includes transfer to deep muscular targets, transfer to the distal anterior interosseous nerve (AIN) or PIN, or burying the nerve in bone 2,3,5,7,16,25,26,28,40 . Although not described in the original cases aggregated in Table 5, the superficial radial sensory nerve can be coapted to the conveniently positioned BR muscle or to the PQ 7,28 .…”

“…2,3,5,7,16,25,26,28,40 Although not described in the original cases aggregated in Table 5, the superficial radial sensory nerve can be coapted to the conveniently positioned BR muscle or to the PQ. 7,28 Although the proximal cutaneous nerves (lateral and medial antebrachial cutaneous nerves) are typically treated with traction neurectomies, they can also be transferred to local muscles with redundant functions. 16,[25][26][27] There are also 3 separate reports of cases of TMR performed in the hand after ray amputation.…”

Contemporary Review: Targeted Muscle Reinnervation for Foot and Ankle Applications

“…2 Given its efficacy for the treatment/prevention of neuromas in amputees, TMR is being selectively applied for individually injured nerves in nonamputees as well. 30,48 Nevertheless, the literature is relatively sparse for this indication in both the lower and upper extremities. Specific to the lower extremity, studies are currently limited to case reports and technique articles that describe the management of sural 24 and saphenous 38 neuromas in nonamputees with limited but favorable early results.…”

“Anatomy of the superficial radial nerve and its target nerves for targeted muscle reinnervation: an anatomical cadaver study”

“…7,8 A range of surgical techniques have been described for neuromas of the SRN, including neurectomy, neurolysis, relocation of the nerve stump into deeper tissues such as muscle or bone, and capping of the nerve stump. 6,9–11 However, neuromas of the SRN are notoriously difficult to treat. Recent studies using conventional surgical techniques report success rates between 53% and 68% and high secondary surgery rates of 20%, emphasizing the need for innovation.…”

“…For the SRN in the forearm, motor branches to the pronator quadratus (PQ) and extensor carpi radialis brevis (ECRB) have been described as donor targets. [9][10][11] Other possible targets include the motor branches to the brachioradialis (BR) and extensor carpi radialis longus (ECRL) muscle. However, there is currently no information on the anatomical suitability of these motor nerves as targets for SRN TMR.…”