Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol

Alexander, John H.; Jordan, Sumanas W.; West, Julie M.; Compston, Amy; Fugitt, Jennifer; Bowen, Juan; Dumanian, Gregory A.; Pollock, Raphael E.; Mayerson, Joel L.; Scharschmidt, Thomas J.; Valerio, Ian L.

doi:10.1002/jso.25586

Cited by 75 publications

(126 citation statements)

References 95 publications

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“…At the time of the latest follow-up, 85% (17 of 20) of the patients with a lower-extremity amputation and 40% (2 of 5) of the patients with an upper-extremity amputation reported daily prosthetic use. This is comparable with the findings of prior work by the senior author regarding TMR for all indications, which demonstrated an 80% prosthesis wear rate at 3.4 months postoperatively 44 . Furthermore, in the current study, we found a 36% rate of self-reported unemployment due to disability.…”

Section: Discussionsupporting

confidence: 89%

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

et al. 2020

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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.

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Section: Discussionsupporting

confidence: 89%

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

et al. 2020

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“…The efficacy of TMR and RPNI in treating neuropathic pain has been previously reported, with improved pain scores and outcomes compared with those of cohorts undergoing traditional traction neurectomies and cohorts undergoing “burying nerves in the surrounding muscle.” 12 , 16 , 17 We believe that TMRpni may have advantages compared with TMR or RPNI alone. RPNI is limited by the size of the free muscle graft.…”

Section: Discussionmentioning

confidence: 91%

“…Any patient who is a candidate for TMR is eligible for TMRpni, including adult and pediatric patients requiring amputation for traumatic, oncologic, infectious, or dysvascular indications. 17 , 18 TMRpni can be performed at the time of amputation for neuropathic pain prevention and improved intuitive prosthetic control, or as a delayed treatment. TMR has been described for below and above knee, transradial and transhumeral, and forequarter and hindquarter amputations, as well as for treatment of neuroma without any associated amputation.…”

Section: Indicationsmentioning

confidence: 99%

TMRpni: Combining Two Peripheral Nerve Management Techniques

Kurlander

Wee

Chepla

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Summary: Amputee patients suffer high rates of chronic neuropathic pain, residual limb dysfunction, and disability. Recently, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are 2 techniques that have been advocated for such patients, given their ability to maximize intuitive prosthetic function while also minimizing neuropathic pain, such as residual and phantom limb pain. However, there remains room to further improve outcomes for our residual limb patients and patients suffering from symptomatic end neuromas. “TMRpni” is a nerve management technique that leverages beneficial elements described for both TMR and RPNI. TMRpni involves coaptation of a sensory or mixed sensory/motor nerve to a nearby motor nerve branch (ie, a nerve transfer), as performed in traditional TMR surgeries. Additionally, the typically mismatched nerve coaptation is wrapped with an autologous free muscle graft that is akin to an RPNI. The authors herein describe the “TMRpni” technique and illustrate a case where this technique was employed.

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“…5 Targeted muscle reinnervation (TMR) is a nerve transfer technique where proximal stumps of the transected major peripheral nerves are transferred to recipient redundant motor nerves within adjacent muscles of the amputated limb. [1][2][3][6][7][8] TMR purposefully redirects the major peripheral nerve into an intact nerve and accompanying freshly de-innervated neuromuscular junction, thus providing a target into which the regenerating major peripheral nerve may grow rather than forming a painful neuroma. [1][2][3][6][7][8] This technique provides viable end-organs (Golgi apparatus) for the transected nerves to reinnervate, mitigating the mechanism for symptomatic neuroma complications seen in traditional traction neurectomy by limiting the nerve-scar interface and sequelae.…”

Section: Introductionmentioning

confidence: 99%

“…TMR confers a functional destination for regenerating axons via trophic stimulation, satisfying the nerve ending to lessen and/or prevent the development of neuropathic pain. 1,4,[6][7][8] As such, the concept of TMR is analogous to grounding a live electrical wire. 1 Historically, TMR has provided additional benefits by increasing electromyography (EMG) signal generators for advanced myoelectric prostheses.…”

Section: Introductionmentioning

confidence: 99%

Targeted muscle reinnervation following external hemipelvectomy or hip disarticulation: An anatomic description of technique and clinical case correlates

Anderson

Wimalawansa

Roubaud

et al. 2020

Journal of Surgical Oncology

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Background: Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. Methods: Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. Results: A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. Conclusions: This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.

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Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol

Cited by 75 publications

References 95 publications

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

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

TMRpni: Combining Two Peripheral Nerve Management Techniques

Targeted muscle reinnervation following external hemipelvectomy or hip disarticulation: An anatomic description of technique and clinical case correlates

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