targeted-muscle-reinnervation-surgical-protocol-for-randomized

Targeted Muscle Reinnervation: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the ...

regenerative-peripheral-nerve-interface-surgical-protocol-for

Regenerative Peripheral Nerve Interface: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain

Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past ...

Northwestern Feinberg School of Medicine

Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied.

Targeted muscle reinnervation: a novel approach to postamputation neuroma pain.

High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.

Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury.

The hand is extremely susceptible to burn injuries, and hand burns can occur in up to 90% of all major burns. A thorough neurovascular examination of the hand should be performed in the acute setting. Escharotomies are required in patients with full-thickness or circumferential burns, when perfusion of the upper extremity is compromised. The decision for excision and grafting is based on whether the wound will heal in the first 2 to 3 weeks after the burn injury. Acute care and resuscitation are always importance in this patient population; subsequent care leads to optimal hand functionality and cosmetic long-term outcomes.

Acute Management of Hand Burns.

Optimizing the Treatment of Burn Injuries of the Upper Extremity.

Targeted muscle reinnervation reroutes the ends of cut nerves to reinnervate small motor nerves of nearby muscles, with the goal of reducing neuroma pain and/or improving prosthesis function. Anatomical roadmaps for targeted muscle reinnervation have been established in the upper extremity and thigh, but not for the lower leg.

Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study.

To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain.

Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.

A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain.

Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation.

Conventional suture repairs, when stressed, fail by suture rupture, knot slippage, or suture pull-through, when the suture cuts through the intervening tissue. The purpose of this study was to compare the biomechanical properties of flexor tendon repairs using a novel mesh suture with traditional suture repairs.

Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model.

Neuromas are a debilitating peripheral nerve problem due to aberrant axon sprouting and inflammation after nerve injury. The surgical management of neuromas has for a long time been up for debate, largely due to lack of consistent, reliable outcomes with any one technique. We have found success utilizing targeted muscle reinnervation, a technique originally described in amputees that re-routes the proximal ends of cut sensory nerve stumps into the distal ends of motor nerves to nearby muscles. In doing so, the sensory nerve ending can regenerate along the length of the motor nerve, giving it a place to go and something to do. In this report, we describe our technique specifically for targeted muscle reinnervation of sural nerve neuromas that is applicable to both amputees and to patients with intact limbs. Sural nerve neuromas can occur after sural nerve harvest for reconstructive procedures and particularly after lateral malleolar incisions for orthopedic access to the calcaneus. By re-routing the sural nerve into a motor nerve of the lateral gastrocnemius muscle, we are able to manage a variety of sural nerve neuromas presenting anywhere along the course of the sural nerve and in a variety of clinical settings.

Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation.

More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain.

Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey.

Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene.

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis.

Obturator nerve injury can occur as a complication of gynecologic surgeries, occurring most frequently in patients with endometriosis and genitourinary malignancies. The resulting injury causes paresthesia and major weakness in adduction and atrophy of the adductor group of lower extremity muscles. The objective of this study was to conduct a systematic review and meta-analysis of the effectiveness of end-to-end repair, nerve grafting, and nerve transfer in improving motor function in patients with obturator nerve injury.

A systematic review of nerve grafting, end-to-end repair, and nerve transfer for obturator nerve injuries.

In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower limb. This results in residual limb pain in up to 85% of cases. Targeted muscle reinnervation (TMR) is a technique that has been shown to prevent symptomatic neuroma formation. In this video, the authors demonstrate their technique utilizing TMR at the time of above-the-knee amputation. Coaptations are made to provide motor targets for branches of the saphenous, tibial, and peroneal sensory nerves. At the featured patient's most recent follow-up visit 3 months postoperatively, she reported no stump pain or phantom limb pain. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2293.

ArticleTotal : 2	Year
Publication title Cited by 5	2024
Publication title Cited by 5	2024

Article	Year
Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clinical orthopaedics and related research\| PubMed ID: 24562875	2014
Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury. Hand clinics\| PubMed ID: 27094891	2016
Acute Management of Hand Burns. Hand clinics\| PubMed ID: 28363290	2017
Optimizing the Treatment of Burn Injuries of the Upper Extremity. Hand clinics\| PubMed ID: 28363305	2017
Targeted Muscle Reinnervation in the Lower Leg: An Anatomical Study. Plastic and reconstructive surgery\| PubMed ID: 30020229	2018
Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Annals of surgery\| PubMed ID: 30371518	2019
Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation. Journal of the American College of Surgeons\| PubMed ID: 30634038	2019
Biomechanical Properties of a Novel Mesh Suture in a Cadaveric Flexor Tendon Repair Model. The Journal of hand surgery\| PubMed ID: 30660397	2019
Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation. Plastic and reconstructive surgery. Global open\| PubMed ID: 32095388	2020
Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey. Plastic and reconstructive surgery. Global open\| PubMed ID: 32802669	2020
Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene. Plastic and reconstructive surgery. Global open\| PubMed ID: 34036024	2021
Targeted Muscle Reinnervation for the Treatment of Neuroma. Hand clinics\| PubMed ID: 34253308	2021
Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons\| PubMed ID: 34366221	2021
A systematic review of nerve grafting, end-to-end repair, and nerve transfer for obturator nerve injuries. International journal of gynecological cancer : official journal of the International Gynecological Cancer Society\| PubMed ID: 35948366	2022
Targeted muscle reinnervation in above knee amputation: surgical technique. Neurosurgical focus: Video\| PubMed ID: 36628094	2023

Jason Ko

Biography

JoVE Journal Publications

Other Publications