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J Reconstr Microsurg 2024; 40(02): 109-117
DOI: 10.1055/a-2086-0395
Original Article

Primary Targeted Muscle Reinnervation in Above-Knee Amputations in Patients with Unsalvageable Limbs from Limb-Threatening Ischemia or Infection

Brian L. Chang
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Alison L. Hill 
2   Georgetown University School of Medicine, Washington, District of Columbia
,
Joshua Mondshine
2   Georgetown University School of Medicine, Washington, District of Columbia
,
Patrick W. Harbour
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Nicole C. Episalla
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Christopher E. Attinger
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Grant M. Kleiber
1   Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
› Author Affiliations Funding None.
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Abstract

Background Amputees frequently suffer from chronic pain in both their residual limbs (RLP) and phantom limbs (PLP) following their amputation. Targeted muscle reinnervation (TMR) is a nerve transfer technique that has been demonstrated to improve pain secondarily and at time of amputation. The goal of this study is to report on the efficacy of primary TMR at time of above-knee level amputations in the setting of limb-threatening ischemia or infection.

Methods This is a retrospective review of a single-surgeon experience with TMR in patients undergoing through- or above-knee level amputations from January 2018 to June 2021. Patient charts were reviewed for the comorbidities in the Charlson Comorbidity Index. Postoperative notes were assayed for presence and absence of RLP and PLP, overall pain severity, chronic narcotic use, ambulatory status, and complications. A control group of patients undergoing lower limb amputation who did not receive TMR from January 2014 to December 2017 was used for comparison.

Results Forty-one patients with through- or above-knee level amputations and primary TMR were included in this study. The tibial and common peroneal nerves were transferred in all cases to motor branches to the gastrocnemius, semimembranosus, semitendinosus, and biceps femoris. Fifty-eight patients with through- or above-knee level amputations without TMR were included for comparison. The TMR group had significantly less overall pain (41.5 vs. 67.2%, p = 0.01), RLP (26.8 vs. 44.8%, p = 0.04), and PLP (19.5 vs. 43.1%, p = 0.02). There were no significant differences in complication rates.

Conclusion TMR can safely and effectively be performed at time of a through- and above-knee level amputation and improves pain outcomes.

Keywords

TMR - neuropathic pain - phantom limb pain


Publication History

Received: 10 January 2023

Accepted: 02 May 2023

Accepted Manuscript online:
04 May 2023

Article published online:
22 June 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Alexander JH, Jordan SW, West JM. et al. Targeted muscle reinnervation in oncologic amputees: early experience of a novel institutional protocol. J Surg Oncol 2019; 120 (03) 348-358
    CrossrefPubMedGoogle Scholar
  • 2 Valerio IL, Dumanian GA, Jordan SW. et al. Preemptive treatment of phantom and residual limb pain with targeted muscle reinnervation at the time of major limb amputation. J Am Coll Surg 2019; 228 (03) 217-226
    CrossrefPubMedGoogle Scholar
  • 3 Smith DG, Ehde DM, Legro MW, Reiber GE, del Aguila M, Boone DA. Phantom limb, residual limb, and back pain after lower extremity amputations. Clin Orthop Relat Res 1999; ; (361): 29-38
    CrossrefPubMedGoogle Scholar
  • 4 Ehde DM, Czerniecki JM, Smith DG. et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil 2000; 81 (08) 1039-1044
    CrossrefPubMedGoogle Scholar
  • 5 Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005; 86 (10) 1910-1919
    CrossrefPubMedGoogle Scholar
  • 6 Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res 2013; 6: 121-136
    PubMedGoogle Scholar
  • 7 Buchheit T, Van de Ven T, Hsia HL. et al. Pain phenotypes and associated clinical risk factors following traumatic amputation: results from veterans integrated pain evaluation research (VIPER). Pain Med 2016; 17 (01) 149-161
    PubMedGoogle Scholar
  • 8 Flor H, Elbert T, Knecht S. et al. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature 1995; 375 (6531): 482-484
    CrossrefPubMedGoogle Scholar
  • 9 Flor H, Nikolajsen L, Staehelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity?. Nat Rev Neurosci 2006; 7 (11) 873-881
    CrossrefPubMedGoogle Scholar
  • 10 Montoya P, Ritter K, Huse E. et al. The cortical somatotopic map and phantom phenomena in subjects with congenital limb atrophy and traumatic amputees with phantom limb pain. Eur J Neurosci 1998; 10 (03) 1095-1102
    CrossrefPubMedGoogle Scholar
  • 11 Preissler S, Feiler J, Dietrich C, Hofmann GO, Miltner WH, Weiss T. Gray matter changes following limb amputation with high and low intensities of phantom limb pain. Cereb Cortex 2013; 23 (05) 1038-1048
    CrossrefPubMedGoogle Scholar
  • 12 Vaso A, Adahan HM, Gjika A. et al. Peripheral nervous system origin of phantom limb pain. Pain 2014; 155 (07) 1384-1391
    CrossrefPubMedGoogle Scholar
  • 13 Jensen TS, Krebs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain 1985; 21 (03) 267-278
    CrossrefPubMedGoogle Scholar
  • 14 Jensen TS, Krebs B, Nielsen J, Rasmussen P. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain 1983; 17 (03) 243-256
    CrossrefPubMedGoogle Scholar
  • 15 Pierce Jr RO, Kernek CB, Ambrose II TA. The plight of the traumatic amputee. Orthopedics 1993; 16 (07) 793-797
    CrossrefPubMedGoogle Scholar
  • 16 Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma 1996; 10 (04) 223-229
    CrossrefPubMedGoogle Scholar
  • 17 Nikolajsen L, Ilkjaer S, Krøner K, Christensen JH, Jensen TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain 1997; 72 (03) 393-405
    CrossrefPubMedGoogle Scholar
  • 18 Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain among American veterans: results of a survey. Pain 1984; 18 (01) 83-95
    CrossrefPubMedGoogle Scholar
  • 19 Sherman RA, Sherman CJ. Prevalence and characteristics of chronic phantom limb pain among American veterans. Results of a trial survey. Am J Phys Med 1983; 62 (05) 227-238
    PubMedGoogle Scholar
  • 20 Elbert T, Rockstroh B. Reorganization of human cerebral cortex: the range of changes following use and injury. Neuroscientist 2004; 10 (02) 129-141
    CrossrefPubMedGoogle Scholar
  • 21 Giummarra MJ, Moseley GL. Phantom limb pain and bodily awareness: current concepts and future directions. Curr Opin Anaesthesiol 2011; 24 (05) 524-531
    CrossrefPubMedGoogle Scholar
  • 22 Chang BL, Mondshine J, Fleury CM, Attinger CE, Kleiber GM. Incidence and nerve distribution of symptomatic neuromas and phantom limb pain after below-knee amputation. Plast Reconstr Surg 2022; 149 (04) 976-985
    CrossrefPubMedGoogle Scholar
  • 23 Pet MA, Ko JH, Friedly JL, Smith DG. Traction neurectomy for treatment of painful residual limb neuroma in lower extremity amputees. J Orthop Trauma 2015; 29 (09) e321-e325
    CrossrefPubMedGoogle Scholar
  • 24 Pet MA, Ko JH, Friedly JL, Mourad PD, Smith DG. Does targeted nerve implantation reduce neuroma pain in amputees?. Clin Orthop Relat Res 2014; 472 (10) 2991-3001
    CrossrefPubMedGoogle Scholar
  • 25 Economides JM, DeFazio MV, Attinger CE, Barbour JR. Prevention of painful neuroma and phantom limb pain after transfemoral amputations through concomitant nerve coaptation and collagen nerve wrapping. Neurosurgery 2016; 79 (03) 508-513
    CrossrefPubMedGoogle Scholar
  • 26 Barberá J, Albert-Pampló R. Centrocentral anastomosis of the proximal nerve stump in the treatment of painful amputation neuromas of major nerves. J Neurosurg 1993; 79 (03) 331-334
    CrossrefPubMedGoogle Scholar
  • 27 Boroumand MR, Schulz D, Uhl E, Krishnan KG. Tibioperoneal short circuiting for stump neuroma pain in amputees: revival of an old technique. World Neurosurg 2015; 84 (03) 681-687
    CrossrefPubMedGoogle Scholar
  • 28 Dellon AL, Mackinnon SE, Pestronk A. Implantation of sensory nerve into muscle: preliminary clinical and experimental observations on neuroma formation. Ann Plast Surg 1984; 12 (01) 30-40
    CrossrefPubMedGoogle Scholar
  • 29 Mobbs RJ, Vonau M, Blum P. Treatment of painful peripheral neuroma by vein implantation. J Clin Neurosci 2003; 10 (03) 338-339
    CrossrefPubMedGoogle Scholar
  • 30 Hemmy DC. Intramedullary nerve implantation in amputation and other traumatic neuromas. J Neurosurg 1981; 54 (06) 842-843
    CrossrefPubMedGoogle Scholar
  • 31 Dumanian GA, Potter BK, Mioton LM. et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: a randomized clinical trial. Ann Surg 2019; 270 (02) 238-246
    CrossrefPubMedGoogle Scholar
  • 32 Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted muscle reinnervation technique in below-knee amputation. Plast Reconstr Surg 2019; 143 (01) 309-312
    CrossrefPubMedGoogle Scholar
  • 33 Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, challenges, and pitfalls after targeted muscle reinnervation in high-level amputees: is it worth the effort?. Plast Reconstr Surg 2019; 144 (06) 1037e-1043e
    CrossrefPubMedGoogle Scholar
  • 34 Michno DA, Woollard ACS, Kang NV. Clinical outcomes of delayed targeted muscle reinnervation for neuroma pain reduction in longstanding amputees. J Plast Reconstr Aesthet Surg 2019; 72 (09) 1576-1606
    CrossrefPubMedGoogle Scholar
  • 35 Eberlin KR. Invited commentary targeted muscle reinnervation: a significant advance in the prevention and treatment of post-amputation neuropathic pain. J Am Coll Surg 2019; 228 (03) 226-227
    CrossrefPubMedGoogle Scholar
  • 36 Mioton LM, Dumanian GA. Targeted muscle reinnervation and prosthetic rehabilitation after limb loss. J Surg Oncol 2018; 118 (05) 807-814
    CrossrefPubMedGoogle Scholar
  • 37 Bowen JB, Wee CE, Kalik J, Valerio IL. Targeted muscle reinnervation to improve pain, prosthetic tolerance, and bioprosthetic outcomes in the amputee. Adv Wound Care (New Rochelle) 2017; 6 (08) 261-267
    CrossrefPubMedGoogle Scholar
  • 38 Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res 2014; 472 (10) 2984-2990
    CrossrefPubMedGoogle Scholar
  • 39 McNamara CT, Iorio ML. Targeted muscle reinnervation: outcomes in treating chronic pain secondary to extremity amputation and phantom limb syndrome. J Reconstr Microsurg 2019
    PubMedGoogle Scholar
  • 40 Kubiak CA, Kemp SWP, Cederna PS, Kung TA. Prophylactic regenerative peripheral nerve interfaces to prevent postamputation pain. Plast Reconstr Surg 2019; 144 (03) 421e-430e
    CrossrefPubMedGoogle Scholar
  • 41 Santosa KB, Oliver JD, Cederna PS, Kung TA. Regenerative peripheral nerve interfaces for prevention and management of neuromas. Clin Plast Surg 2020; 47 (02) 311-321
    CrossrefPubMedGoogle Scholar
  • 42 Walsh AR, Lu J, Rodriguez E, Diamond S, Sultan SM. The current state of targeted muscle reinnervation: a systematic review. J Reconstr Microsurg 2023; 39 (03) 238-244
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Chang BL, Mondshine J, Attinger CE, Kleiber GM. Targeted Muscle Reinnervation Improves Pain and Ambulation Outcomes in Highly Comorbid Amputees. Plast Reconstr Surg 2021; 148 (02) 376-386
    CrossrefPubMedGoogle Scholar
  • 44 Kurlander DE, Wee C, Chepla KJ. et al. TMRpni: combining two peripheral nerve management techniques. Plast Reconstr Surg Glob Open 2020; 8 (10) e3132
    CrossrefPubMedGoogle Scholar