Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study

Fracol, Megan; Janes, Lindsay E.; Ko, Jason H.; Dumanian, Gregory A.

doi:10.1097/prs.0000000000004773

Cited by 46 publications

(47 citation statements)

References 8 publications

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“…For both above-and below-knee amputations, the anatomical basis for lower extremity TMR has been well described with motor points and their locations mapped. 1,38,39 The main donor nerves include the posterior tibial nerve, sural nerve, and common peroneal nerve. Based on the site of pain, these nerves are isolated, and available intact motor nerves are used as recipient sites for reinnervation.…”

Section: Surgical Techniquementioning

confidence: 99%

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

McNamara

Iorio

2019

J Reconstr Microsurg

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Background Secondary to vascular disease, oncological resection, or devastating trauma, lower extremity amputations are performed globally at a yearly rate exceeding 1 million patients. Three-quarters of these patients will develop chronic pain or phantom pain, which presents a functional limitation for prosthetic use and contributes to deconditioning and increased mortality. Targeted muscle reinnervation (TMR) presents a surgical solution to this problem as either a primary or secondary intervention. Methods A review of the existing literature was conducted using a combination of the terms “phantom pain” “chronic pain,” “neuroma,” and “targeted muscle reinnervation” in Medline and PubMed. Results Five articles were found which addressed TMR for pain syndromes, four of which involved lower extremity amputation. Four of the articles were retrospective reviews, and one was a randomized control trial. A total of 149 patients were included, of which 82 underwent lower extremity amputation. Ninety-two of the patients underwent prophylactic TMR, of which 57 were secondary procedures.In patients who underwent TMR at the time of amputation, all studies reported a minimal development of symptomatic neuromas (27%). For secondary TMR, near-complete resolution of previous pain was found (90%). Phantom pain was noted to be similar to other studies in the literature but noted to improve over time with both primary (average drop of 3.5 out of 10 points on the numerical rating scale) and secondary (diminishing from 72% of patients to 13% over 6 months) operations. Conclusion Although much of the current literature is limited to retrospective studies with few patients, these data point toward near-complete resolution of neuroma pain after treatment as well as complete prevention of chronic pain if TMR is used as a prophylactic measure during the index amputation. This study was a level of evidence IV.

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Section: Surgical Techniquementioning

confidence: 99%

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

McNamara

Iorio

2019

J Reconstr Microsurg

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“…Hash marks are made at 10% intervals, and marks are made for the anticipated locations of the MEPs. 8 The anterior transverse incision is designed 10–15 cm distal to the tibial tuberosity with length 2/3 the circumference of the leg. The posterior skin flap is designed extending from the lateral extent of the anterior marking; this junction can be curved proximally to prevent dog ears and gain access to the more proximally located MEPs, if necessary (Fig.…”

Section: Introductionmentioning

confidence: 99%

“…MEPs to TA are located at 10%–40% leg length, PL at 20%–40%, Sol at 20%–60%, and FDL at 30%–60%. 8 FDL indicates flexor digitorum longus; PL, peroneus longus; Sol, soleus; TA, tibialis anterior.…”

Section: Introductionmentioning

confidence: 99%

“…Some surgeons do not routinely perform TMR for this nerve as subcutaneous dissection at the end of the flap has potential to compromise vascularity. 8 To avoid vascular compromise, the nerve is delivered to the deep plane by creation of a window through the deep surface of the posterior myocutaneous flap at a distance approximately 50% of the leg length. The window is created with blunt dissection in the midline raphe of the soleus, continuing down between the heads of the gastrocnemius into the subcutaneous tissue.…”

Section: Introductionmentioning

confidence: 99%

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Surgical Technique for Below-knee Amputation with Concurrent Targeted Muscle Reinnervation

Daugherty

Parikh

Mailey

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Summary: Targeted muscle reinnervation (TMR) is beneficial for decreasing pain following below-knee amputation (BKA). While most current literature describes the principles behind primary TMR, they provide few principles key to the amputation, as the BKA is usually performed by another surgeon. When the BKA and TMR are performed by the same surgeon, it can be performed through the same surgical access as needed for both procedures. The purpose of this article is to describe our anatomically based BKA technique in the setting of planned primary TMR as performed by 3, single, peripheral nerve plastic surgeons at 2 institutions. Advantages of the single-surgeon technique include efficiency in dissection, preservation of donor nerve length, limited proximal dissection, early identification of recipient motor nerves for coaptation, ability to stimulate these while still under tourniquet, and decreased tourniquet and operative time. This technique is quick, reliable, and reproducible to help promote widespread adoption of TMR at the time of BKA.

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“…This nerve begins near the fibular head and runs through the fibularis muscles. After supplying the motor component, the nerve provides cutaneous innervations to the lower one third on the lateral side of the leg (Rainoldi et al, ; Lee et al, ; Fracol et al, ).…”

Section: Introductionmentioning

confidence: 99%

Guideline for Botulinum Toxin Injections in the Effective Treatment of Fibular Spasticity

et al. 2019

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This study used a modified Sihler's staining method to analyze the nerve distributions of the fibularis muscle to identify the most effective sites for botulinum toxin injection for fibular spasticity treatment. Ten specimens of the fibularis longus and brevis were obtained bilaterally from five fixed cadavers. The applied method of modified Sihler's staining was designed to reveal the intramuscular nerve distribution of the fibularis muscles. We divided the fibularis muscles into four quarters, which were defined as Sections 1–4 starting from the proximal part of the leg. There were one, two, and three nerve entry points in one (10%), six (60%), and three (30%) of the fibularis longus specimens, respectively, and in four (40%), five (50%), and one (10%) of the fibularis brevis specimens, respectively. We counted the number of nerve endings in each section: 321 and 195 points were identified in the fibularis longus and brevis, respectively. The densities of nerve endings were highest in Section 2 of the fibularis longus (147 of 321, 46%) and in Section 3 of the fibularis brevis (78 of 195, 40%). The landmarks used in this study (the fibular head and lateral malleolus) are easily palpable on the skin's surface, allowing clinicians to target the effective injection site (Section 2) without requiring ultrasound guidance, especially for the fibularis longus. Clin. Anat. 33:365–369, 2020. © 2019 Wiley Periodicals, Inc.

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Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study

Abstract: Targeted muscle reinnervation is technically feasible in the lower leg. This cadaveric study provides a roadmap for incision placement and identification of motor nerve targets.

Cited by 46 publications

References 8 publications

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

Surgical Technique for Below-knee Amputation with Concurrent Targeted Muscle Reinnervation

Guideline for Botulinum Toxin Injections in the Effective Treatment of Fibular Spasticity

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