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Chang BL, Hill AL, Mondshine J, Harbour PW, Episalla NC, Attinger CE, Kleiber GM. Primary Targeted Muscle Reinnervation in Above-Knee Amputations in Patients with Unsalvageable Limbs from Limb-Threatening Ischemia or Infection. J Reconstr Microsurg 2024; 40:109-117. [PMID: 37142250 DOI: 10.1055/a-2086-0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
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.
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Affiliation(s)
- Brian L Chang
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Alison L Hill
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Joshua Mondshine
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Patrick W Harbour
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Nicole C Episalla
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Grant M Kleiber
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Shamoun F, Shamoun V, Akhavan A, Tuffaha SH. Target Receptors of Regenerating Nerves: Neuroma Formation and Current Treatment Options. Front Mol Neurosci 2022; 15:859221. [PMID: 35866159 PMCID: PMC9295905 DOI: 10.3389/fnmol.2022.859221] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022] Open
Abstract
Neuromas form as a result of disorganized sensory axonal regeneration following nerve injury. Painful neuromas lead to poor quality of life for patients and place a burden on healthcare systems. Modern surgical interventions for neuromas entail guided regeneration of sensory nerve fibers into muscle tissue leading to muscle innervation and neuroma treatment or prevention. However, it is unclear how innervating denervated muscle targets prevents painful neuroma formation, as little is known about the fate of sensory fibers, and more specifically pain fiber, as they regenerate into muscle. Golgi tendon organs and muscle spindles have been proposed as possible receptor targets for the regenerating sensory fibers; however, these receptors are not typically innervated by pain fibers, as these free nerve endings do not synapse on receptors. The mechanisms by which pain fibers are signaled to cease regeneration therefore remain unknown. In this article, we review the physiology underlying nerve regeneration, the guiding molecular signals, and the target receptor specificity of regenerating sensory axons as it pertains to the development and prevention of painful neuroma formation while highlighting gaps in literature. We discuss management options for painful neuromas and the current supporting evidence for the various interventions.
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Affiliation(s)
- Feras Shamoun
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
| | - Valentina Shamoun
- Department of Biological Sciences, University of Toronto at Scarborough, Scarborough, ON, Canada
| | - Arya Akhavan
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
| | - Sami H. Tuffaha
- Peripheral Nerve Lab, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Sami H. Tuffaha,
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Fatma Ö, Tekin E, Uran Şan A, Demir Y, Aydemir K, Kesikburun S. The Efficacy of Acupuncture on Pain and Functional Status in Patients with Lower Extremity Amputation with Stump Neuroma: A prospective randomised controlled pilot study. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Targeted Muscle Reinnervation Improves Pain and Ambulation Outcomes in Highly Comorbid Amputees. Plast Reconstr Surg 2021; 148:376-386. [PMID: 34398088 DOI: 10.1097/prs.0000000000008153] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 200,000 people undergo a lower extremity amputation each year. Following amputation, patients suffer from chronic pain, inability to ambulate, and high mortality rates. Targeted muscle reinnervation is a nerve transfer procedure that redirects transected sensory and mixed nerves into motor nerves to treat neuroma and phantom limb pain. This study evaluates outcomes with prophylactic targeted muscle reinnervation at the time of below-knee amputation. METHODS This is a cohort study comparing 100 patients undergoing below-knee amputation with primary targeted muscle reinnervation and 100 patients undergoing below-knee amputation with standard traction neurectomy and muscle implantation. Outcome metrics included the presence of residual and phantom limb pain, pain severity, opioid use, ambulation ability, and mortality rates. RESULTS The targeted muscle reinnervation group was on average 60 years old with a body mass index of 29 kg/m2. Eighty-four percent had diabetes, 55 percent had peripheral vascular disease, and 43 percent had end-stage renal disease. Average follow-up was 9.6 months for the targeted muscle reinnervation group and 18.5 months for the nontargeted muscle reinnervation group. Seventy-one percent of targeted muscle reinnervation patients were pain free, compared with 36 percent (p < 0.01). Fourteen percent of targeted muscle reinnervation patients had residual limb pain, compared with 57 percent (p < 0.01). Nineteen percent of targeted muscle reinnervation patients had phantom limb pain, compared with 47 percent (p < 0.01). Six percent of targeted muscle reinnervation patients were on opioids, compared with 26 percent (p < 0.01); and 90.9 percent of targeted muscle reinnervation patients were ambulatory, compared with 70.5 percent (p < 0.01). CONCLUSION Targeted muscle reinnervation reduces pain and improves ambulation in patients undergoing below-knee amputation, which may be critical in improving morbidity and mortality rates in this comorbid patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Bolleboom A, de Ruiter GCW, Coert JH, Tuk B, Holstege JC, van Neck JW. Novel experimental surgical strategy to prevent traumatic neuroma formation by combining a 3D-printed Y-tube with an autograft. J Neurosurg 2019; 130:184-196. [PMID: 29424651 DOI: 10.3171/2017.8.jns17276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/08/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic neuromas may develop after nerve injury at the proximal nerve stump, which can lead to neuropathic pain. These neuromas are often resistant to therapy, and excision of the neuroma frequently leads to recurrence. In this study, the authors present a novel surgical strategy to prevent neuroma formation based on the principle of centro-central anastomosis (CCA), but rather than directly connecting the nerve ends to an autograft, they created a loop using a 3D-printed polyethylene Y-shaped conduit with an autograft in the distal outlets. METHODS The 3D-printed Y-tube with autograft was investigated in a model of rat sciatic nerve transection in which the Y-tube was placed on the proximal sciatic nerve stump and a peroneal graft was placed between the distal outlets of the Y-tube to form a closed loop. This model was compared with a CCA model, in which a loop was created between the proximal tibial and peroneal nerves with a peroneal autograft. Additional control groups consisted of the closed Y-tube and the extended-arm Y-tube. Results were analyzed at 12 weeks of survival using nerve morphometry for the occurrence of neuroma formation and axonal regeneration in plastic semi-thin sections. RESULTS Among the different surgical groups, the Y-tube with interposed autograft was the only model that did not result in neuroma formation at 12 weeks of survival. In addition, a 13% reduction in the number of myelinated axons regenerating through the interposed autograft was observed in the Y-tube with autograft model. In the CCA model, the authors also observed a decrease of 17% in the number of myelinated axons, but neuroma formation was present in this model. The closed Y-tube resulted in minimal nerve regeneration inside the tube together with extensive neuroma formation before the entrance of the tube. The extended-arm Y-tube model clearly showed that the majority of the regenerating axons merged into the Y-tube arm, which was connected to the autograft, leaving the extended plastic arm almost empty. CONCLUSIONS This pilot study shows that our novel 3D-printed Y-tube model with interposed autograft prevents neuroma formation, making this a promising surgical tool for the management of traumatic neuromas.
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Affiliation(s)
- Anne Bolleboom
- Departments of1Neuroscience, and.,2Plastic and Reconstructive Surgery, Erasmus University Medical Center, Rotterdam
| | | | - J Henk Coert
- 4Department of Plastic and Reconstructive Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Bastiaan Tuk
- 2Plastic and Reconstructive Surgery, Erasmus University Medical Center, Rotterdam
| | | | - Johan W van Neck
- 2Plastic and Reconstructive Surgery, Erasmus University Medical Center, Rotterdam
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Ives GC, Kung TA, Nghiem BT, Ursu DC, Brown DL, Cederna PS, Kemp SWP. Current State of the Surgical Treatment of Terminal Neuromas. Neurosurgery 2019; 83:354-364. [PMID: 29053875 DOI: 10.1093/neuros/nyx500] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/10/2017] [Indexed: 12/15/2022] Open
Abstract
Painful terminal neuromas resulting from nerve injury following amputation are common. However, there is currently no universally accepted gold standard of treatment for this condition. A comprehensive literature review is presented on the treatment of terminal neuromas. Four categories of terminal neuroma surgical procedures are assessed: epineurial closure; nerve transposition with implantation; neurorrhaphy, and alternate target reinnervation. Significant patient and case studies are highlighted in each section, focusing on surgical technique and patient outcome metrics. Studies presented consisted of a PubMed search for "terminal neuromas," without year limitation. The current available research supports the use of implantation into muscle for the surgical treatment of terminal neuromas. However, this technique has several fundamental flaws that limit its utility, as it does not address the underlying physiology behind neuroma formation. Regenerative peripheral nerve interfaces and targeted muscle reinnervation are 2 techniques that seem to offer the most promise in preventing and treating terminal neuroma formation. Both techniques are also capable of generating control signals which can be used for both motor and sensory prosthetic control. Such technology has the potential to lead to the future restoration of lost limb function in amputees. Further clinical research employing larger patient groups with high-quality control groups and reproducible outcome measures is needed to determine the most effective and beneficial surgical treatment for terminal neuromas. Primary focus should be placed on investigating techniques that most closely approximate the theoretically ideal neuroma treatment, including targeted muscle reinnervation and regenerative peripheral nerve interfaces.
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Affiliation(s)
- Graham C Ives
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bao Tram Nghiem
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel C Ursu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - David L Brown
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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Malessy MJA, de Boer R, Muñoz Romero I, Eekhof JLA, van Zwet EW, Kliot M, Dahan A, Pondaag W. Predictive value of a diagnostic block in focal nerve injury with neuropathic pain when surgery is considered. PLoS One 2018; 13:e0203345. [PMID: 30208078 PMCID: PMC6135496 DOI: 10.1371/journal.pone.0203345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/20/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECT In patients with focal nerve injury and neuropathic pain cutting the nerve to obtain permanent pain reduction can be considered. Surgery is indicated only if a diagnostic nerve block provides temporary pain relief. We evaluated the predictive value of a block on the outcome of surgery. METHODS In total, three blocks were performed at two week intervals. Patients were blinded to injections containing lidocaine 1% and a placebo was included. Surgery was offered regardless of the effect of the blocks. Twenty-four patients received 72 blocks. Sixteen patients opted for surgery, 5 patients refrained from surgery, and in 3 the blocks provided permanent pain relief. The predictive ability of the block on the outcome of surgery was assessed by calculating the area under a Receiver Operating Characteristic curve (AUC). RESULTS The AUC of the first lidocaine block was 0.35 with a 95% confidence interval from 0.077 to 0.62. At 95% confidence (two-sided), the AUC is less than 0.62, and hence the predictive ability of the block was poor. The outcome of the second lidocaine block and saline block did not change the conclusion of the first block. CONCLUSIONS We conclude that the use of blocks to select patients for surgery should be critically appraised. PERSPECTIVE A pain relieving response to one open block is currently considered mandatory before patients with focal nerve injury and neuropathic pain are offered surgery. Blinded blocks including a placebo show that responses for selection should be carefully interpreted because they may not be as predictive as generally presumed.
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Affiliation(s)
- Martijn J. A. Malessy
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralph de Boer
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ildefonso Muñoz Romero
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Neurological Center at the American British Cowdray Medical Center, Mexico City, Mexico
| | - Job L. A. Eekhof
- Department of Neurology, Alrijne Hospital, Leiden, The Netherlands
| | - Erik. W. van Zwet
- Department of Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel Kliot
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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