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Elbasiouny SM. The neurophysiology of sensorimotor prosthetic control. BMC Biomed Eng 2024; 6:9. [PMID: 39350271 PMCID: PMC11443900 DOI: 10.1186/s42490-024-00084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 07/31/2024] [Indexed: 10/04/2024] Open
Abstract
Movement is a central behavior of daily living; thus lost or compromised movement due to disease, injury, or amputation causes enormous loss of productivity and quality of life. While prosthetics have evolved enormously over the years, restoring natural sensorimotor (SM) control via a prosthesis is a difficult problem which neuroengineering has yet to solve. With a focus on upper limb prosthetics, this perspective article discusses the neurophysiology of motor control under healthy conditions and after amputation, the development of upper limb prostheses from early generations to current state-of-the art sensorimotor neuroprostheses, and how postinjury changes could complicate prosthetic control. Current challenges and future development of smart sensorimotor neuroprostheses are also discussed.
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Affiliation(s)
- Sherif M Elbasiouny
- Department of Biomedical, Industrial and Human Factors Engineering, College of Engineering and Computer Science, Wright State University, Dayton, OH, USA.
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine, College of Science and Mathematics, Wright State University, Dayton, OH, USA.
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2
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Ganesh Kumar N, Chestek CA, Cederna PS, Kung TA. Realizing Upper Extremity Bionic Limbs: Leveraging Neuroprosthetic Control Strategies. Plast Reconstr Surg 2024; 154:713e-724e. [PMID: 37927033 DOI: 10.1097/prs.0000000000011183] [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: 11/07/2023]
Abstract
SUMMARY Innovations in prosthetic devices and neuroprosthetic control strategies have opened new frontiers for the treatment and rehabilitation of individuals undergoing amputation. Commercial prosthetic devices are now available with sophisticated electrical and mechanical components that can closely replicate the functions of the human musculoskeletal system. However, to truly recognize the potential of such prosthetic devices and develop the next generation of bionic limbs, a highly reliable prosthetic device control strategy is required. In the past few years, refined surgical techniques have enabled neuroprosthetic control strategies to record efferent motor and stimulate afferent sensory action potentials from a residual limb with extraordinary specificity, signal quality, and long-term stability. As a result, such control strategies are now capable of facilitating intuitive, real-time, and naturalistic prosthetic experiences for patients with amputations. This article summarizes the current state of upper extremity neuroprosthetic devices and discusses the leading control strategies that are critical to the ongoing advancement of prosthetic development and implementation.
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Affiliation(s)
| | - Cynthia A Chestek
- Department of Biomedical Engineering and Computer Science, University of Michigan
| | - Paul S Cederna
- From the Section of Plastic Surgery, Department of Surgery
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Rees AB, Mastracci JC, Posey SL, Loeffler BJ, Gaston RG. Managing Major Peripheral Nerves in Forearm-Level Amputations With TMR and RPNI: What's the Best Recipe? Hand (N Y) 2024:15589447241277842. [PMID: 39262236 DOI: 10.1177/15589447241277842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) prevent symptomatic neuroma formation in amputees. Forearm-level amputations present multiple muscular targets, making it challenging to determine the ideal treatment. The purpose of this study was to evaluate the best TMR targets, role of RPNI, and appropriate patient-selection criteria in forearm-level amputations. We hypothesized that deep and distal TMR targets would best prevent symptomatic neuromas, RPNI would prove a success adjunct, and patients with poorly controlled diabetes would not develop symptomatic neuromas regardless of nerve management. METHODS We retrospectively identified forearm-level amputations performed between 2017 and 2022. Patients with TMR by outside providers, follow-up <6 months, or insufficient documentation were excluded. Demographics, surgical nerve management, and postoperative complications were collected. The primary outcome was development of a painful neuroma determined by the Eberlin criteria. Patients undergoing TMR were divided a priori into two groups, superficial and proximal versus deep and distal TMR targets, and were compared. RESULTS Thirty-nine patients met inclusion criteria, and 16 developed a symptomatic neuroma. No patients with a deep or distal TMR target developed a symptomatic neuroma. One nerve out of 12 treated with RPNI developed a symptomatic neuroma. No patient with poorly controlled diabetes developed a symptomatic neuroma, despite no advanced nerve management. CONCLUSIONS In a case series of forearm amputations, deep and distal TMR targets prevented symptomatic neuroma formation more than superficial and proximal targets. Regenerative peripheral nerve interface is a useful adjunct for neuroma control, especially for the radial sensory nerve. Patients with poorly controlled diabetes may not require advanced nerve management. LEVEL OF EVIDENCE Level IV retrospective case series.
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Affiliation(s)
- Andrew B Rees
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Samuel L Posey
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Bryan J Loeffler
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
- OrthoCarolina Hand Center, Charlotte, NC, USA
| | - R Glenn Gaston
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
- OrthoCarolina Hand Center, Charlotte, NC, USA
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4
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Huang J, Wang P, Wang W, Wei J, Yang L, Liu Z, Li G. Using Electrical Muscle Stimulation to Enhance Electrophysiological Performance of Agonist-Antagonist Myoneural Interface. Bioengineering (Basel) 2024; 11:904. [PMID: 39329646 PMCID: PMC11444137 DOI: 10.3390/bioengineering11090904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 09/02/2024] [Accepted: 09/04/2024] [Indexed: 09/28/2024] Open
Abstract
The agonist-antagonist myoneural interface (AMI), a surgical method to reinnervate physiologically-relevant proprioceptive feedback for control of limb prostheses, has demonstrated the ability to provide natural afferent sensations for limb amputees when actuating their prostheses. Following AMI surgery, one potential challenge is atrophy of the disused muscles, which would weaken the reinnervation efficacy of AMI. It is well known that electrical muscle stimulus (EMS) can reduce muscle atrophy. In this study, we conducted an animal investigation to explore whether the EMS can significantly improve the electrophysiological performance of AMI. AMI surgery was performed in 14 rats, in which the distal tendons of bilateral solei donors were connected and positioned on the surface of the left biceps femoris. Subsequently, the left tibial nerve and the common peroneus nerve were sutured onto the ends of the connected donor solei. Two stimulation electrodes were affixed onto the ends of the donor solei for EMS delivery. The AMI rats were randomly divided into two groups. One group received the EMS treatment (designated as EMS_on) regularly for eight weeks and another received no EMS (designated as EMS_off). Two physiological parameters, nerve conduction velocity (NCV) and motor unit number, were derived from the electrically evoked compound action potential (CAP) signals to assess the electrophysiological performance of AMI. Our experimental results demonstrated that the reinnervated muscles of the EMS_on group generated higher CAP signals in comparison to the EMS_off group. Both NCV and motor unit number were significantly elevated in the EMS_on group. Moreover, the EMS_on group displayed statistically higher CAP signals on the indirectly activated proprioceptive afferents than the EMS_off group. These findings suggested that EMS treatment would be promising in enhancing the electrophysiological performance and facilitating the reinnervation process of AMI.
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Affiliation(s)
- Jianping Huang
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen 518055, China
- University of Chinese Academy of Sciences, Beijing 100864, China
| | - Ping Wang
- Biomedical Sensing Engineering and Technology Research Center, Shandong University, Jinan 250000, China;
| | - Wei Wang
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
| | - Jingjing Wei
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
| | - Lin Yang
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
| | - Zhiyuan Liu
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
- Biomedical Sensing Engineering and Technology Research Center, Shandong University, Jinan 250000, China;
| | - Guanglin Li
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen 518055, China; (J.H.); (W.W.); (J.W.); (L.Y.)
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen 518055, China
- University of Chinese Academy of Sciences, Beijing 100864, China
- The SIAT Branch, Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen 518055, China
- Shandong Zhongke Advanced Technology Co., Ltd., Jinan 250000, China
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Pancholi S, Wachs JP, Duerstock BS. Use of Artificial Intelligence Techniques to Assist Individuals with Physical Disabilities. Annu Rev Biomed Eng 2024; 26:1-24. [PMID: 37832939 DOI: 10.1146/annurev-bioeng-082222-012531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Assistive technologies (AT) enable people with disabilities to perform activities of daily living more independently, have greater access to community and healthcare services, and be more productive performing educational and/or employment tasks. Integrating artificial intelligence (AI) with various agents, including electronics, robotics, and software, has revolutionized AT, resulting in groundbreaking technologies such as mind-controlled exoskeletons, bionic limbs, intelligent wheelchairs, and smart home assistants. This article provides a review of various AI techniques that have helped those with physical disabilities, including brain-computer interfaces, computer vision, natural language processing, and human-computer interaction. The current challenges and future directions for AI-powered advanced technologies are also addressed.
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Affiliation(s)
- Sidharth Pancholi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA;
| | - Juan P Wachs
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Bradley S Duerstock
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA;
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana, USA
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Vonu PM, Shekouhi R, Crawford K, Hones KM, Chim H. Targeted Muscle Reinnervation: Factors Predisposing to Successful Pain Score Reduction. Ann Plast Surg 2024; 92:S426-S431. [PMID: 38857008 DOI: 10.1097/sap.0000000000003976] [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: 06/11/2024]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) has demonstrated efficacy in reducing neuroma and chronic pain. In this article, we investigated postoperative outcomes in our patient cohort, with a focus on the role of nonmodifiable factors such as patient age and gender. METHODS Patients who had extremity TMR from April 2018 to October 2022 were reviewed. Outcomes of interest included patient age, gender, cause and type of amputation, delayed versus immediate TMR, as well as postoperative improvement in pain as assessed by numerical rating score (NRS). RESULTS A total of 40 patients underwent TMR on 47 limbs. Mean age was 46.2 ± 17.0 years. Delayed TMR (27, 57.4%) was most commonly performed, followed by immediate and delayed-immediate at 11 (23.4%) and 9 (19.1%), respectively. Amputation level was most commonly above-knee in 20 (42.6%) patients, followed by below-knee (12, 25.5%), transhumeral (8, 17.0%), transradial (6, 12.8%), and shoulder (1, 2.1%). The median time interval between amputation and TMR was 12 months. The median preoperative NRS assessing residual limb pain (RLP) for patients who underwent delayed TMR was 10. The median postoperative NRS assessing RLP for all patients was 0 (interquartile range25-75: 0-5) and significantly improved compared with preoperative NRS (P < 0.001). At the last follow-up for limbs that had delayed and delayed-immediate TMR (n = 36), 33 (91.7%) limbs had more than 50% resolution of RLP. There was a significant difference in median postoperative NRS by gender (4 in men and 0 in women) (P < 0.05). Postoperative median NRS also favored younger patients (0, <50 years compared with 4.5, >50 years) (P < 0.05). Multiple linear regression analysis showed that, of different variables analyzed, only male gender and older age were predictive of poorer postoperative outcomes. CONCLUSION TMR showed high efficacy in our cohort, with improved short-term outcomes in women and younger patients.
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Affiliation(s)
- Peter M Vonu
- From the Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, FL
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Yuan M, Gallo M, Gallo L, Huynh MHQ, McRae M, McRae MC, Thoma A, Coroneos CJ, Voineskos SH. Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces Versus Standard Management in the Treatment of Limb Amputation: A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2024; 32:253-264. [PMID: 38681253 PMCID: PMC11046287 DOI: 10.1177/22925503221107462] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Introduction: Painful neuromas are a common postoperative complication of limb amputation often treated with secondary reinnervation. Surgical reinnervation include Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interface (RPNI), and can be primary and secondary. The aim of this review is to assess the effects of primary TMR/RPNI at the time of limb amputation on the incidence and intensity of post-operative neuroma and pain. Methods: This review was registered a priori on PROSPERO (CRD42021264360). A search of the following databases was performed in June 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and non-randomized studies assessing amputation with a reinnervation strategy (TMR, RPNI) were included. Outcomes evaluated included the incidences of painful neuroma, phantom limb pain (PLP), residual limb pain (RLP), as well as severity of pain, and Pain intensity, behavior, and interference (PROMIS). Results: Eleven studies were included in this systematic review, and five observational studies for quantitative synthesis. Observational study evidence suggests that TMR/RPNI results in a statistically significant reduction in incidence, pain scores and PROMIS scores of PLP and RLP. Decreased incidence of neuromas favored primary TMR/RPNI, but this did not achieve statistical significance (p = 0.07). Included studies had moderate to critical risk of bias. Conclusion: The observational data suggests that primary TMR/RPNI reduces incidence, pain scores and PROMIS scores of PLP and RLP. Going forward, randomized trials are warranted to evaluate this research question, particularly to improve the certainty of evidence.
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Affiliation(s)
- Morgan Yuan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Matteo Gallo
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Minh HQ Huynh
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
| | - Mark McRae
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
| | - Matthew C. McRae
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
| | - Achilleas Thoma
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
| | - Christopher J. Coroneos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
| | - Sophocles H. Voineskos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact (HEI)
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8
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Finkelstein ER, Hui-Chou H, Fullerton N, Jose J. Experience with ultrasound neurography for postoperative evaluation of targeted muscle reinnervation. Skeletal Radiol 2024; 53:811-816. [PMID: 37665347 DOI: 10.1007/s00256-023-04441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/09/2023] [Accepted: 08/26/2023] [Indexed: 09/05/2023]
Abstract
Targeted muscle reinnervation (TMR) was originally developed as a means for increasing intuitive prosthesis control, though later found to play a role in phantom limb pain and neuroma prevention. There is a paucity of literature describing the clinical course of patients with poor TMR surgical outcomes and the value of imaging in the postoperative recovery period. This report will illustrate the potential utility of ultrasound neurography to accurately differentiate TMR surgical outcomes in two patients that received upper extremity amputation and subsequent reconstruction with TMR. Ultrasound evaluation of TMR sites in patient 1 confirmed successful reinnervation, evident by nerve fascicle continuity and eventual integration of the transferred nerve into the target muscle. Conversely, the ultrasound of patient 2 showed discontinuity of the nerve fascicles, neuroma formation, and muscle atrophy in all three sites of nerve transfer, suggesting an unsuccessful procedure and poor functional recovery. Ultrasound neurography is uniquely able to capture the longitudinal trajectory of rerouted nerves to confirm continuity and eventual reinnervation into muscle. Therefore, the application of ultrasound in a postoperative setting can correctly identify instances of failed TMR before this information would become available through clinical evaluation. Early identification of poor TMR outcomes may benefit future patients by fostering the discovery of failure mechanisms and aiding in further surgical planning to improve functional outcomes.
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Affiliation(s)
- Emily R Finkelstein
- Dewitt Daughtry Family Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
- Division of Plastic Surgery, University of Miami Hospital, 1400 NW 12Th Ave, Miami, FL, 33136, USA.
| | - Helen Hui-Chou
- Department of Orthopedic Surgery, Divison of Hand, Peripheral Nervem and Upper Extremity Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Natalia Fullerton
- Dewitt Daughtry Family Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean Jose
- Department of Clinical Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Tereshenko V, Dotzauer DC, Schmoll M, Harnoncourt L, Carrero Rojas G, Gfrerer L, Eberlin KR, Austen WG, Blumer R, Farina D, Aszmann OC. Peripheral neural interfaces: Skeletal muscles are hyper-reinnervated according to the axonal capacity of the surgically rewired nerves. SCIENCE ADVANCES 2024; 10:eadj3872. [PMID: 38416828 PMCID: PMC10901366 DOI: 10.1126/sciadv.adj3872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
Advances in robotics have outpaced the capabilities of man-machine interfaces to decipher and transfer neural information to and from prosthetic devices. We emulated clinical scenarios where high- (facial) or low-neural capacity (ulnar) donor nerves were surgically rewired to the sternomastoid muscle, which is controlled by a very small number of motor axons. Using retrograde tracing and electrophysiological assessments, we observed a nearly 15-fold functional hyper-reinnervation of the muscle after high-capacity nerve transfer, demonstrating its capability of generating a multifold of neuromuscular junctions. Moreover, the surgically redirected axons influenced the muscle's physiological characteristics, by altering the expression of myosin heavy-chain types in alignment with the donor nerve. These findings highlight the remarkable capacity of skeletal muscles to act as biological amplifiers of neural information from the spinal cord for governing bionic prostheses, with the potential of expressing high-dimensional neural function for high-information transfer interfaces.
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Affiliation(s)
- Vlad Tereshenko
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Dominik C Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Martin Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Leopold Harnoncourt
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Genova Carrero Rojas
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Dario Farina
- Department of Bioengineering, Imperial College London, South Kensington Campus London, SW7 2AZ London, UK
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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10
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Reid RT, Johnson CC, Gaston RG, Loeffler BJ. Impact of Timing of Targeted Muscle Reinnervation on Pain and Opioid Intake Following Major Limb Amputation. Hand (N Y) 2024; 19:200-205. [PMID: 35822307 PMCID: PMC10953525 DOI: 10.1177/15589447221107696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake. METHODS Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption. RESULTS In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P = .01 and 6.2 vs. 1.9 at final P = .002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P = .72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P = .35) or at final follow-up (P = .68). CONCLUSIONS TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Risa T. Reid
- Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Christine C. Johnson
- Orthopaedic & Spine Center of the Rockies, Longmont, CO, USA
- OrthoCarolina Hand Center, Charlotte, NC, USA
| | - R. Glenn Gaston
- OrthoCarolina Hand Center, Charlotte, NC, USA
- Department of Orthopedics, Atrium Health, Charlotte, NC, USA
| | - Bryan J. Loeffler
- OrthoCarolina Hand Center, Charlotte, NC, USA
- Department of Orthopedics, Atrium Health, Charlotte, NC, USA
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11
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Markewych AN, Suvar T, Swanson MA, Graca MJ, Lubenow TR, McCarthy RJ, Buvanendran A, Kurlander DE. Approaches to neuropathic amputation-related pain: narrative review of surgical, interventional, and medical treatments. Reg Anesth Pain Med 2024:rapm-2023-105089. [PMID: 38307612 DOI: 10.1136/rapm-2023-105089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/26/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND/IMPORTANCE Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%. OBJECTIVE This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care. EVIDENCE REVIEW A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation. FINDINGS The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP. CONCLUSIONS Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.
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Affiliation(s)
| | - Tolga Suvar
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Marco A Swanson
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mateusz J Graca
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - David E Kurlander
- Department of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois, USA
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12
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Galbraith LG, Najafali D, Gatherwright JR. TMR Using a Free Rectus Flap after Transhumeral Amputation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5574. [PMID: 38348459 PMCID: PMC10861011 DOI: 10.1097/gox.0000000000005574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/11/2023] [Indexed: 02/15/2024]
Abstract
Targeted muscle reinnervation offers an approach to regain use of the affected extremity through electronic prosthesis while limiting phantom pain and neuroma limb production or pain. In this case report, we present the first reported case of leveraging the rectus flap for targeted muscle reinnervation. The case herein is of a 28-year-old woman who sustained a severe right upper extremity crush injury while being involved in a vehicular roll-over collision requiring right transhumeral amputation. Plastic surgery, orthopedic surgery, and vascular surgery were consulted to manage the right upper extremity injury.
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Affiliation(s)
- Logan G. Galbraith
- From the Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Daniel Najafali
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Ill
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Ernst J, Hahne JM, Markovic M, Schilling AF, Lorbeer L, Grade M, Felmerer G. Combining Surgical Innovations in Amputation Surgery-Robotic Harvest of the Rectus Abdominis Muscle, Transplantation and Targeted Muscle Reinnervation Improves Myocontrol Capability and Pain in a Transradial Amputee. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2134. [PMID: 38138237 PMCID: PMC10744371 DOI: 10.3390/medicina59122134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
Adding robotic surgery to bionic reconstruction might open a new dimension. The objective was to evaluate if a robotically harvested rectus abdominis (RA) transplant is a feasible procedure to improve soft-tissue coverage at the residual limb (RL) and serve as a recipient for up to three nerves due to its unique architecture and to allow the generation of additional signals for advanced myoelectric prosthesis control. A transradial amputee with insufficient soft-tissue coverage and painful neuromas underwent the interventions and was observed for 18 months. RA muscle was harvested using robotic-assisted surgery and transplanted to the RL, followed by end-to-end neurroraphy to the recipient nerves of the three muscle segments to reanimate radial, median, and ulnar nerve function. The transplanted muscle healed with partial necrosis of the skin mesh graft. Twelve months later, reliable, and spatially well-defined Hoffmann-Tinel signs were detectable at three segments of the RA muscle flap. No donor-site morbidities were present, and EMG activity could be detected in all three muscle segments. The linear discriminant analysis (LDA) classifier could reliably distinguish three classes within 1% error tolerance using only the three electrodes on the muscle transplant and up to five classes outside the muscle transplant. The combination of these surgical procedure advances with emerging (myo-)control technologies can easily be extended to different amputation levels to reduce RL complications and augment control sites with a limited surface area, thus facilitating the usability of advanced myoelectric prostheses.
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Affiliation(s)
- Jennifer Ernst
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
- Department of Trauma Surgery, Hannover Medical School, 30625 Hanover, Germany;
| | - Janne M. Hahne
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Marko Markovic
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Arndt F. Schilling
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Lisa Lorbeer
- Department of Trauma Surgery, Hannover Medical School, 30625 Hanover, Germany;
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Gunther Felmerer
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
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14
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Huynh THN, Kuruvilla DR, Nester MD, Zervoudakis G, Letson GD, Joyce DM, Binitie OT, Lazarides AL. Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives. Curr Oncol Rep 2023; 25:1457-1465. [PMID: 37999825 DOI: 10.1007/s11912-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques. RECENT FINDINGS The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.
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Affiliation(s)
- Thien Huong N Huynh
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Davis R Kuruvilla
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Matthew D Nester
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | | | | | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Odion T Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
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15
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Li Y, Huang J, Chen Y, Zhu S, Huang Z, Yang L, Li G. Nerve function restoration following targeted muscle reinnervation after varying delayed periods. Neural Regen Res 2023; 18:2762-2766. [PMID: 37449642 DOI: 10.4103/1673-5374.373659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Targeted muscle reinnervation has been proposed for reconstruction of neuromuscular function in amputees. However, it is unknown whether performing delayed targeted muscle reinnervation after nerve injury will affect restoration of function. In this rat nerve injury study, the median and musculocutaneous nerves of the forelimb were transected. The proximal median nerve stump was sutured to the distal musculocutaneous nerve stump immediately and 2 and 4 weeks after surgery to reinnervate the biceps brachii. After targeted muscle reinnervation, intramuscular myoelectric signals from the biceps brachii were recorded. Signal amplitude gradually increased with time. Biceps brachii myoelectric signals and muscle fiber morphology and grooming behavior did not significantly differ among rats subjected to delayed target muscle innervation for different periods. Targeted muscle reinnervation delayed for 4 weeks can acquire the same nerve function restoration effect as that of immediate reinnervation.
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Affiliation(s)
- Yuanheng Li
- Key Laboratory of Human-Machine Intelligence-Synergy Systems and Branch of Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
| | - Jiangping Huang
- Key Laboratory of Human-Machine Intelligence-Synergy Systems and Branch of Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
| | - Yuling Chen
- Department of Rehabilitation Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province; Department of Rehabilitation Medicine, Yibin Hospital of Traditional Chinese Medicine, Yibin, Sichuan Province, China
| | - Shanshan Zhu
- Key Laboratory of Human-Machine Intelligence-Synergy Systems and Branch of Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
| | - Zhen Huang
- Department of Rehabilitation Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province; Department of Rehabilitation Medicine, Yibin Hospital of Traditional Chinese Medicine, Yibin, Sichuan Province, China
| | - Lin Yang
- Key Laboratory of Human-Machine Intelligence-Synergy Systems and Branch of Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
| | - Guanglin Li
- Key Laboratory of Human-Machine Intelligence-Synergy Systems and Branch of Shenzhen Institute of Artificial Intelligence and Robotics for Society, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
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16
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Le ELH, Iorio ML, Greyson MA. Targeted muscle reinnervation in upper extremity amputations. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03736-2. [PMID: 37814069 DOI: 10.1007/s00590-023-03736-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation.
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Affiliation(s)
- Elliot L H Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA
| | - Mark A Greyson
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA.
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17
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Rask DMG, Adams MH, Liverneaux P, Plucknette BF, Wilson DJ, Alderete JF, Sabbag CM. Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:392-399. [PMID: 37499798 DOI: 10.1016/j.hansur.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.
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Affiliation(s)
- Dawn M G Rask
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mason H Adams
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA.
| | - Philippe Liverneaux
- ICube, University of Strasbourg, CNRS, 2-4 rue Boussingault, 67000 Strasbourg, France; Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 avenue Molière, 67200 Strasbourg, France
| | | | - David J Wilson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Joseph F Alderete
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Casey M Sabbag
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
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18
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Markewych A, Hansdorfer M, Blank A, Kokosis G, Kurlander DE. Forequarter Amputation: Reconstruction With Targeted Muscle Reinnervation to the Filet of Forearm Free Flap. Tech Hand Up Extrem Surg 2023; 27:136-139. [PMID: 36625182 DOI: 10.1097/bth.0000000000000424] [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: 06/17/2023]
Abstract
Forequarter amputation is a rarely indicated operation that has the potential for delayed wound healing, chronic pain, and dysfunction. Reconstruction in cases of skin and soft tissue loss may be particularly challenging. Here we present a 79-year-old female with recurrent, previously radiated left shoulder chondrosarcoma who underwent forequarter amputation with a 'spare parts' filet of forearm flap and targeted muscle reinnervation to the flap. The patient healed without complication and achieved reinnervation with minimal pain.
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Affiliation(s)
| | | | - Alan Blank
- Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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19
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Saltzman EB, Jerome JTJ, Gaston RG. Current Concepts and Management of Upper Limb Amputees. J Hand Microsurg 2023; 15:245-246. [PMID: 37701319 PMCID: PMC10495203 DOI: 10.1055/s-0043-1773775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
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20
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Ahmed MH, Kutsuzawa K, Hayashibe M. Transhumeral Arm Reaching Motion Prediction through Deep Reinforcement Learning-Based Synthetic Motion Cloning. Biomimetics (Basel) 2023; 8:367. [PMID: 37622971 PMCID: PMC10452356 DOI: 10.3390/biomimetics8040367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023] Open
Abstract
The lack of intuitive controllability remains a primary challenge in enabling transhumeral amputees to control a prosthesis for arm reaching with residual limb kinematics. Recent advancements in prosthetic arm control have focused on leveraging the predictive capabilities of artificial neural networks (ANNs) to automate elbow joint motion and wrist pronation-supination during target reaching tasks. However, large quantities of human motion data collected from different subjects for various activities of daily living (ADL) tasks are required to train these ANNs. For example, the reaching motion can be altered when the height of the desk is changed; however, it is cumbersome to conduct human experiments for all conditions. This paper proposes a framework for cloning motion datasets using deep reinforcement learning (DRL) to cater to training data requirements. DRL algorithms have been demonstrated to create human-like synergistic motion in humanoid agents to handle redundancy and optimize movements. In our study, we collected real motion data from six individuals performing multi-directional arm reaching tasks in the horizontal plane. We generated synthetic motion data that mimicked similar arm reaching tasks by utilizing a physics simulation and DRL-based arm manipulation. We then trained a CNN-LSTM network with different configurations of training motion data, including DRL, real, and hybrid datasets, to test the efficacy of the cloned motion data. The results of our evaluation showcase the effectiveness of the cloned motion data in training the ANN to predict natural elbow motion accurately across multiple subjects. Furthermore, motion data augmentation through combining real and cloned motion datasets has demonstrated the enhanced robustness of the ANN by supplementing and diversifying the limited training data. These findings have significant implications for creating synthetic dataset resources for various arm movements and fostering strategies for automatized prosthetic elbow motion.
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Affiliation(s)
- Muhammad Hannan Ahmed
- Department of Robotics, Graduate School of Engineering, Tohoku University, Sendai 980-8579, Japan; (K.K.); (M.H.)
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21
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Sarhan SM, Al-Faiz MZ, Takhakh AM. A review on EMG/EEG based control scheme of upper limb rehabilitation robots for stroke patients. Heliyon 2023; 9:e18308. [PMID: 37533980 PMCID: PMC10391943 DOI: 10.1016/j.heliyon.2023.e18308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/03/2023] [Accepted: 07/13/2023] [Indexed: 08/04/2023] Open
Abstract
Stroke is a common worldwide health problem and a crucial contributor to gained disability. The abilities of people, who are subjected to stroke, to live independently are significantly affected since affected upper limbs' functions are essential for our daily life. This review article focuses on emerging trends in BCI-controlled rehabilitation techniques based on EMG, EEG, or EGM + EEG signals in the last few years. Working on developing rehabilitation robotics, is considered a wealthy scientific area for researchers in the last period. There is a significant advantage that the human acquires from the interaction between the machine and his body, rehabilitation for a patient's limb is very important to get the body limb recovery, and this is what is provided mostly by applying robotic devices.
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Affiliation(s)
- Saad M. Sarhan
- Department of Biomedical Engineering, College of Engineering, Al-Nahrain University, Baghdad, Iraq
| | - Mohammed Z. Al-Faiz
- Department of Control and Computer, College of Information Engineering, Al-Nahrain University, Baghdad, Iraq
| | - Ayad M. Takhakh
- Department of Biomechanics, College of Engineering, Al-Nahrain University, Baghdad, Iraq
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22
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Henderson JT, Koenig ZA, Climov M, Gelman J. Targeted Muscle Reinnervation: A Systematic Review of Nerve Transfers for the Upper Extremity. Ann Plast Surg 2023; 90:462-470. [PMID: 37146311 DOI: 10.1097/sap.0000000000003498] [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: 05/07/2023]
Abstract
INTRODUCTION/BACKGROUND Despite inspiring improvements in postamputation pain and prosthetic control, targeted muscle reinnervation (TMR) continues to be underused. With some consistency for recommended nerve transfers developing in the literature, it is necessary to systematize these techniques and simplify their incorporation into routine amputation and neuroma care. This systematic review explores the coaptations reported in the literature to date. METHODS A systematic review of the literature was performed to collect all reports describing nerve transfers in the upper extremity. The preference was directed toward original studies presenting surgical techniques and coaptations used in TMR. All target muscle options were presented for each nerve transfer in the upper extremity. RESULTS Twenty-one original studies describing TMR nerve transfers throughout the upper extremity met inclusion criteria. A comprehensive list of transfers reported for major peripheral nerves at each upper extremity amputation level was included in tables. Ideal nerve transfers were suggested based on convenience and frequency with which certain coaptations were reported. CONCLUSIONS Increasingly frequent studies are published with convincing outcomes with TMR and numerous options for nerve transfers and target muscles. It is prudent to appraise these options to provide patients with optimal outcomes. Certain muscles are more consistently targeted and can serve as a baseline plan for the reconstructive surgeon interested in incorporating these techniques.
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Affiliation(s)
- Joshua T Henderson
- From the Division of Plastic Surgery, Department of Surgery, West Virginia University, Morgantown, WV
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23
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Vu PP, Vaskov AK, Lee C, Jillala RR, Wallace DM, Davis AJ, Kung TA, Kemp SWP, Gates DH, Chestek CA, Cederna PS. Long-term upper-extremity prosthetic control using regenerative peripheral nerve interfaces and implanted EMG electrodes. J Neural Eng 2023; 20:026039. [PMID: 37023743 PMCID: PMC10126717 DOI: 10.1088/1741-2552/accb0c] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 04/08/2023]
Abstract
Objective.Extracting signals directly from the motor system poses challenges in obtaining both high amplitude and sustainable signals for upper-limb neuroprosthetic control. To translate neural interfaces into the clinical space, these interfaces must provide consistent signals and prosthetic performance.Approach.Previously, we have demonstrated that the Regenerative Peripheral Nerve Interface (RPNI) is a biologically stable, bioamplifier of efferent motor action potentials. Here, we assessed the signal reliability from electrodes surgically implanted in RPNIs and residual innervated muscles in humans for long-term prosthetic control.Main results.RPNI signal quality, measured as signal-to-noise ratio, remained greater than 15 for up to 276 and 1054 d in participant 1 (P1), and participant 2 (P2), respectively. Electromyography from both RPNIs and residual muscles was used to decode finger and grasp movements. Though signal amplitude varied between sessions, P2 maintained real-time prosthetic performance above 94% accuracy for 604 d without recalibration. Additionally, P2 completed a real-world multi-sequence coffee task with 99% accuracy for 611 d without recalibration.Significance.This study demonstrates the potential of RPNIs and implanted EMG electrodes as a long-term interface for enhanced prosthetic control.
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Affiliation(s)
- Philip P Vu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Alex K Vaskov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, United States of America
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Christina Lee
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Ritvik R Jillala
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Dylan M Wallace
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Alicia J Davis
- University of Michigan Hospital Orthotics & Prosthetics Center Ann Arbor, Ann Arbor, MI 48109, United States of America
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Stephen W P Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Deanna H Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, United States of America
- School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, United States of America
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI 48109, United States of America
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Paul S Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States of America
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, United States of America
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24
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Walsh AR, Lu J, Rodriguez E, Diamond S, Sultan SM. The Current State of Targeted Muscle Reinnervation: A Systematic Review. J Reconstr Microsurg 2023; 39:238-244. [PMID: 35988579 DOI: 10.1055/s-0042-1755262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited. METHODS The EMBASE database was queried with the search terms "targeted muscle reinnervation" OR "TMR" AND "outcomes" OR "patient outcomes." Clinical human studies in English were eligible for inclusion, yielding 89 articles. After rigorous exclusion criteria, a total of 13 articles were included in this review. Study data including geographic location, patient demographics, TMR indication, amputation level, number of nerve transfers performed, length of follow-up, and reported outcomes were extracted and analyzed. RESULTS The included articles represent 338 patients (341 limbs). Average patient age was 47.4 years. Indication for amputation included trauma (n = 125), infection (n = 76) cancer/tumor resection (n = 71), ischemia (n = 18), failed Charcot reconstruction (n = 15), failed hardware (n = 9), burn (n = 4), and CRPS (n = 4). Five studies included upper extremity TMR only, two included lower extremity TMR only, and six included both upper and lower extremity TMR. TMR was performed in an immediate or delayed fashion, with an average of 2.2 nerve transfers performed per limb overall. Average length of follow-up was 22.3 months. In three studies, patients with phantom limb pain undergoing delayed TMR were found to have significant or trending toward significant reduction in pain after TMR using numeric rating scale and patient-reported outcomes measurement information system scales. One article reported 9/10 patients with improved or complete resolution of phantom limb pain after delayed TMR. Three studies found that patients undergoing immediate TMR had lower pain scores compared with non-TMR controls. CONCLUSION While there is evidence that TMR reduces neuroma-related pain and improves the quality of life for amputees, further outcomes studies are needed to study the patient experience with TMR on a larger scale. Establishing standardized, validated patient-reported outcomes assessment tools is critical to future investigation in this field.
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Affiliation(s)
- Amanda R Walsh
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jocelyn Lu
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Esdras Rodriguez
- Division of Plastic Hand and Microsurgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Shawn Diamond
- Division of Plastic Hand and Microsurgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Steven M Sultan
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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25
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Targeted muscle reinnervation prevents and reverses rat pain behaviors after nerve transection. Pain 2023; 164:316-324. [PMID: 35639439 DOI: 10.1097/j.pain.0000000000002702] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/23/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Targeted muscle reinnervation (TMR) is a clinical intervention that is rapidly becoming common in major limb amputation to prevent or reduce amputation-related pain. However, TMR is much less effective when applied long after injury compared with acute TMR. Since the mechanisms governing pain relief in TMR of amputated nerves are unknown, we developed a preclinical model as a platform for mechanistic examination. Following spared nerve injury (SNI), rats underwent either TMR, simple neuroma excision, or a sham manipulation of the injury site. These interventions were performed immediately or delayed (3 or 12 weeks) after SNI. Pain behavior was measured as sensitivity to mechanical stimuli (pin, von Frey, and dynamic brush) and thermal stimuli (acetone and radiant heat). Spared nerve injury produced hypersensitivity to all mechanical stimuli and cold, which persisted after sham surgery. Targeted muscle reinnervation at the time of SNI prevented the development of pain behaviors and performing TMR 3 weeks after SNI reversed pain behaviors to baseline. By contrast, TMR performed at 12 weeks after SNI had no effect on pain behaviors. Neuroma excision resulted in significantly less reduction in hyperalgesia compared with TMR when performed 3 weeks after SNI but had no effect at 12 weeks after SNI. In this model, the pain phenotype induced by nerve transection is reduced by TMR when performed within 3 weeks after injury. However, TMR delayed 12 weeks after injury fails to reduce pain behaviors. This replicates clinical experience with limb amputation, supporting validity of this model for examining the mechanisms of TMR analgesia.
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Tham JL, Sood A, Saffari TM, Khajuria A. The effect of targeted muscle reinnervation on post-amputation pain and functional outcomes: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-02021-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee C, Vaskov AK, Gonzalez MA, Vu PP, Davis AJ, Cederna PS, Chestek CA, Gates DH. Use of regenerative peripheral nerve interfaces and intramuscular electrodes to improve prosthetic grasp selection: a case study. J Neural Eng 2022; 19:10.1088/1741-2552/ac9e1c. [PMID: 36317254 PMCID: PMC9942093 DOI: 10.1088/1741-2552/ac9e1c] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Objective.Advanced myoelectric hands enable users to select from multiple functional grasps. Current methods for controlling these hands are unintuitive and require frequent recalibration. This case study assessed the performance of tasks involving grasp selection, object interaction, and dynamic postural changes using intramuscular electrodes with regenerative peripheral nerve interfaces (RPNIs) and residual muscles.Approach.One female with unilateral transradial amputation participated in a series of experiments to compare the performance of grasp selection controllers with RPNIs and intramuscular control signals with controllers using surface electrodes. These experiments included a virtual grasp-matching task with and without a concurrent cognitive task and physical tasks with a prosthesis including standardized functional assessments and a functional assessment where the individual made a cup of coffee ('Coffee Task') that required grasp transitions.Main results.In the virtual environment, the participant was able to select between four functional grasps with higher accuracy using the RPNI controller (92.5%) compared to surface controllers (81.9%). With the concurrent cognitive task, performance of the virtual task was more consistent with RPNI controllers (reduced accuracy by 1.1%) compared to with surface controllers (4.8%). When RPNI signals were excluded from the controller with intramuscular electromyography (i.e. residual muscles only), grasp selection accuracy decreased by up to 24%. The participant completed the Coffee Task with 11.7% longer completion time with the surface controller than with the RPNI controller. She also completed the Coffee Task with 11 fewer transition errors out of a maximum of 25 total errors when using the RPNI controller compared to surface controller.Significance.The use of RPNI signals in concert with residual muscles and intramuscular electrodes can improve grasp selection accuracy in both virtual and physical environments. This approach yielded consistent performance without recalibration needs while reducing cognitive load associated with pattern recognition for myoelectric control (clinical trial registration number NCT03260400).
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Affiliation(s)
- Christina Lee
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Alex K. Vaskov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Philip P. Vu
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Alicia J. Davis
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H. Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
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Kim JS, Tian J, Gross A, Aggarwal S, May L, Leyngold IM. Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes. Ophthalmic Plast Reconstr Surg 2022; 38:577-582. [PMID: 35604391 DOI: 10.1097/iop.0000000000002210] [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: 11/27/2022]
Abstract
PURPOSE To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. METHODS A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. RESULTS A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. CONCLUSION Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.
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Affiliation(s)
- Jane S Kim
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical Center, Ann Arbor, Michigan, U.S.A
| | - James Tian
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Andrew Gross
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Sahil Aggarwal
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Lauren May
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Ilya M Leyngold
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, U.S.A
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Fulton ZW, Boothby BC, Phillips SA. Targeted Muscle Reinnervation for Trauma-Related Amputees: A Systematic Review. Cureus 2022; 14:e28474. [PMID: 36176851 PMCID: PMC9512320 DOI: 10.7759/cureus.28474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/05/2022] Open
Abstract
While amputation techniques have improved over time, questions remain around how to best treat neuromas and severed nerves in the amputee population, specifically for trauma-related amputees. This systematic review investigates and summarizes outcomes following targeted muscle reinnervation (TMR) for the trauma-related amputee population. Studies were classified based on primary or secondary TMR and relevant outcomes, including the ability to use a prosthesis, post-TMR opioid use, Patient-Reported Outcomes Measurement Information System (PROMIS) scores for phantom limb pain and residual limb pain, and overall pain resolution/reduction. Following TMR for trauma-related amputation, most patients experienced neuroma pain resolution (86.2%, 95% confidence interval [CI]: 67.2-95.0%) and overall pain reduction/resolution (90.7%, 95% CI: 82.2-95.4%). No differences were seen between primary and secondary TMR. Preliminary evidence indicates that TMR is effective for preventing or treating pain in patients with trauma-related amputation, whether used in the acute or delayed setting.
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Affiliation(s)
- Zachary W Fulton
- Orthopaedic Surgery, Mercy Health Saint Vincent Medical Center, Toledo, USA
| | - Benjamin C Boothby
- Orthopaedic Surgery, Mercy Health Saint Vincent Medical Center, Toledo, USA
| | - Seth A Phillips
- Orthopaedic Surgery, Mercy Health Saint Vincent Medical Center, Toledo, USA
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Anderson SR, Gupta N, Johnson EA, Johnson RM. Disruption of targeted muscle reinnervation due to heterotopic ossification in an amputated lower extremity. BMJ Case Rep 2022; 15:e249705. [PMID: 35568417 PMCID: PMC9109042 DOI: 10.1136/bcr-2022-249705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/17/2022] Open
Abstract
A patient in his late 40s presented after 1-year following below knee amputation and targeted muscle reinnervation (TMR) with new prosthesis intolerance and pinpoint pain, suspicious for neuroma. X-ray confirmed fibular heterotopic ossification (HO). Operative revision identified HO encompassing a TMR construct with a large neuroma requiring excision and neuroplasty revision. Now approximately 1-year post procedure, the patient remains active, pain-free and ambulating with a prosthetic. Amputated extremities can be at risk for development of HO. Although described in literature, the pathophysiology and timeline for HO development is not well understood. Preventative measures for HO have been described, yet results remain variable. The gold standard for existing HO remains to be operative excision. Due to the unpredictable nature and debilitating presentation, risk of HO should be incorporated into patient-physician discussions. Additionally, new prosthetic intolerance absent of prior trauma should raise suspicion for possible HO development.
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Affiliation(s)
- Spencer R Anderson
- Division of Plastic and Reconstructive Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
| | - Nishtha Gupta
- Wright State University Boonshoft School of Medicine, Fairborn, Ohio, USA
| | - Elise A Johnson
- Ross University School of Medicine - Barbados Campus, Miramar, Florida, USA
| | - Ron Michael Johnson
- Division of Plastic and Reconstructive Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
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Sturma A, Stamm T, Hruby LA, Bischof B, Salminger S, Gstoettner C, Prahm C, Pittermann A, Wakolbinger R, Hofer C, Farina D, Aszmann OC. Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation. J Hand Ther 2022; 35:58-66. [PMID: 33250398 DOI: 10.1016/j.jht.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a Delphi study based on a scoping literature review. INTRODUCTION Targeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists. PURPOSE OF THE STUDY We aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training. METHODS European clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round. RESULTS Experts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one. DISCUSSION Within this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists' practice. CONCLUSION Graded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction. LEVEL OF EVIDENCE Low.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Bioengineering, Imperial College London, London, United Kingdom; Health Assisting Engineering, University of Applied Sciences FH Campus Wien, Vienna, Austria
| | - Tanja Stamm
- Institute for Outcomes Research Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria.
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Cosima Prahm
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department for Plastic and Reconstructive Surgery, BG Trauma Clinic, Eberhard-Karls University, Tuebingen, Germany
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Robert Wakolbinger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | | | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
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Ehrl D, Wachtel N, Braig D, Kuhlmann C, Dürr HR, Schneider CP, Giunta RE. Defect Coverage after Forequarter Amputation—A Systematic Review Assessing Different Surgical Approaches. J Pers Med 2022; 12:jpm12040560. [PMID: 35455676 PMCID: PMC9031327 DOI: 10.3390/jpm12040560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/10/2022] Open
Abstract
Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.
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Affiliation(s)
- Denis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Nikolaus Wachtel
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
- Correspondence:
| | - David Braig
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Constanze Kuhlmann
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Hans Roland Dürr
- Orthopaedic Oncology, Department of Orthopaedics and Trauma Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany;
| | - Christian P. Schneider
- Department of Thoracic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany;
| | - Riccardo E. Giunta
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
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Cox HG, Gary CS, Kleiber GM. Treatment of Refractory Radial Sensory Neuroma With Function-Sparing Targeted Muscle Reinnervation to the Extensor Carpi Radialis Brevis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:112-115. [PMID: 36704385 PMCID: PMC9870804 DOI: 10.1016/j.jhsg.2022.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/06/2022] [Indexed: 01/29/2023] Open
Abstract
The radial sensory nerve can be injured during many common procedures, including intravenous cannulation, first extensor compartment release, and radial-sided wrist surgery. Injury to the nerve may result in neuroma formation that can lead to chronic and debilitating pain. Nonsurgical treatments and surgical interventions, including excision of the neuroma and burying the nerve into local muscle, are frequently ineffective. Here, we present a technique for treating recalcitrant neuromas of the radial sensory nerve with targeted muscle reinnervation to a redundant motor nerve branch of the extensor carpi radialis brevis.
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Affiliation(s)
- Hatcher G. Cox
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC,Corresponding author: Hatcher G. Cox, MD, Department of Plastic Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007.
| | - Cyril S. Gary
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - Grant M. Kleiber
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
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Stögner VA, Megerle K, Krezdorn N, Vogt PM. Major traumatic amputations and replantations of the upper extremity in Germany – National Quality Reports 2014 – 2018. JPRAS Open 2022; 32:98-110. [PMID: 35345616 PMCID: PMC8956841 DOI: 10.1016/j.jpra.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/07/2022] [Indexed: 11/12/2022] Open
Abstract
The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe. In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period. Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres. The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres. The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care. Level of evidence IV.
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Leone F, Gentile C, Cordella F, Gruppioni E, Guglielmelli E, Zollo L. A parallel classification strategy to simultaneous control elbow, wrist, and hand movements. J Neuroeng Rehabil 2022; 19:10. [PMID: 35090512 PMCID: PMC8796482 DOI: 10.1186/s12984-022-00982-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background In the field of myoelectric control systems, pattern recognition (PR) algorithms have become always more interesting for predicting complex electromyography patterns involving movements with more than 2 Degrees of Freedom (DoFs). The majority of classification strategies, used for the prosthetic control, are based on single, hierarchical and parallel linear discriminant analysis (LDA) classifiers able to discriminate up to 19 wrist/hand gestures (in the 3-DoFs case), considering both combined and discrete motions. However, these strategies were introduced to simultaneously classify only 2 DoFs and their use is limited by the lack of online performance measures. This study introduces a novel classification strategy based on the Logistic Regression (LR) algorithm with regularization parameter to provide simultaneous classification of 3 DoFs motion classes. Methods The parallel PR-based strategy was tested on 15 healthy subjects, by using only six surface EMG sensors. Twenty-seven discrete and complex elbow, hand and wrist motions were classified by keeping the number of electromyographic (EMG) electrodes to a bare minimum and the classification error rate under 10 %. To this purpose, the parallel classification strategy was implemented by using three classifiers one for each DoF: the “Elbow classifier”, the “Wrist classifier”, and the “Hand classifier” provided the simultaneous control of the elbow, hand, and wrist joints, respectively. Results Both the offline and real-time performance metrics were evaluated and compared with the LDA parallel classification results. The real-time recognition results were statistically better with the LR classifier with respect to the LDA classifier, for all motion classes (elbow, hand and wrist). Conclusions In this paper, a novel parallel PR-based strategy was proposed for classifying up to 3 DoFs: three joint classifiers were employed simultaneously for classifying 27 motion classes related to the elbow, wrist, and hand and promising results were obtained.
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Targeted Muscle Reinnervation in Partial Hand Amputations. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3542. [PMID: 34881140 PMCID: PMC8647892 DOI: 10.1097/gox.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022]
Abstract
Targeted muscle reinnervation (TMR) surgery has been shown to aid in prevention and treatment of neuropathic pain. Technical and anatomical descriptions of TMR surgery for upper extremity amputees (including transradial, transhumeral, and forequarter amputations) have been reported, yet such descriptions of TMR surgery for partial hand amputations are currently lacking. Herein we outline the technique of different types of partial hand amputation TMR surgeries to serve as a reference and guide. A retrospective review was performed by our multi-institutional team to identify clinical cases where partial hand TMR surgeries were performed. Patient demographics, characteristics, amputation subtype, nerve transfer, pain score, pain outcome, and functional outcome data were collected and analyzed. From January 2018 to September 2019, 13 patients underwent partial hand TMR procedures. Eight cases resulted from trauma, and 6 were secondary to oncologic procedures. The amputations consisted of 8 ray, 2 trans-metacarpal, 2 radial-sided hand, and 1 index finger amputation with recurrent painful neuromas. Twelve patients were weaned off narcotics completely and only 3 remained on a neuromodulator for ongoing pain control. Technical considerations for partial hand TMR surgery have been outlined, with early pilot data showing beneficial pain control outcomes.
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Targeted Muscle Reinnervation in Amputees: A Review of Current Techniques. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Connan M, Sierotowicz M, Henze B, Porges O, Albu-Schaeffer A, Roa M, Castellini C. Learning to teleoperate an upper-limb assistive humanoid robot for bimanual daily-living tasks. Biomed Phys Eng Express 2021; 8. [PMID: 34757953 DOI: 10.1088/2057-1976/ac3881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/10/2021] [Indexed: 11/12/2022]
Abstract
Objective.Bimanual humanoid platforms for home assistance are nowadays available, both as academic prototypes and commercially. Although they are usually thought of as daily helpers for non-disabled users, their ability to move around, together with their dexterity, makes them ideal assistive devices for upper-limb disabled persons, too. Indeed, teleoperating a bimanual robotic platform via muscle activation could revolutionize the way stroke survivors, amputees and patients with spinal injuries solve their daily home chores. Moreover, with respect to direct prosthetic control, teleoperation has the advantage of freeing the user from the burden of the prosthesis itself, overpassing several limitations regarding size, weight, or integration, and thus enables a much higher level of functionality.Approach.In this study, nine participants, two of whom suffer from severe upper-limb disabilities, teleoperated a humanoid assistive platform, performing complex bimanual tasks requiring high precision and bilateral arm/hand coordination, simulating home/office chores. A wearable body posture tracker was used for position control of the robotic torso and arms, while interactive machine learning applied to electromyography of the forearms helped the robot to build an increasingly accurate model of the participant's intent over time.Main results.All participants, irrespective of their disability, were uniformly able to perform the demanded tasks. Completion times, subjective evaluation scores, as well as energy- and time- efficiency show improvement over time on short and long term.Significance.This is the first time a hybrid setup, involving myoeletric and inertial measurements, is used by disabled people to teleoperate a bimanual humanoid robot. The proposed setup, taking advantage of interactive machine learning, is simple, non-invasive, and offers a new assistive solution for disabled people in their home environment. Additionnally, it has the potential of being used in several other applications in which fine humanoid robot control is required.
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Affiliation(s)
- Mathilde Connan
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Marek Sierotowicz
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Bernd Henze
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Oliver Porges
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Alin Albu-Schaeffer
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Maximo Roa
- Deutsches Zentrum fur Luft- und Raumfahrt Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, 82234, GERMANY
| | - Claudio Castellini
- Deutsches Zentrum fur Luft- und Raumfahrt DLR Institut fur Robotik und Mechatronik, Muenchener Strasse 20, Oberpfaffenhofen-Wessling, Bayern, 82234, GERMANY
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Forbes MKE, Cobb MW, Jeevaratnam MJ, King MI, Cubison LCT. Amputation Revision Surgery - Refining the surgical approach. Ten years of experience and 250 cases, impressions, outcomes, and thoughts for the future. Injury 2021; 52:3293-3298. [PMID: 33602538 DOI: 10.1016/j.injury.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The decision for revision amputation surgery requires a multi-disciplinary approach and the evidence on outcome data available in the current literature is limited. The aim of this observational, retrospective study was to investigate in patients undergoing stump revision, whether factors such as pathology and reason for the revision surgery affect surgical 'success' rates as primary outcomes. Secondary outcomes of interest include rehabilitation outcomes and complication rates. METHODS From December 2008 to November 2018, 250 amputation revision procedures were performed at our centre. Surgical and rehabilitation outcomes and indication for revision surgery were measured for each patient. RESULTS There was an overall surgical success rate of 81% and an overall rehabilitation success rate of 63%, with variable outcomes related to the indication for surgery. Revisions for bony pathology had excellent results from a surgical perspective (100%) and good results from a rehabilitation perspective (71%). Revisions for soft tissue pathology and neuroma had satisfactory results from a surgical perspective (81% and 74% respectively) and rehabilitation perspective (56% and 71% respectively). Surgical success rates for those undergoing revision surgery due to non-neuroma pain were poor. CONCLUSIONS We found that revision surgery for defined anatomical abnormalities, such as bone pathology or neuromata are associated with good outcomes. Surgical techniques, specifically related to the management of neuromas are continuing to develop, with promising results from the application of targeted muscle reinnervation (TMR) in the treatment of neuromata. The primary amputation surgeon should exercise caution when considering compromising bone length for soft tissue or skin coverage, as revision surgery can address the excision of skin graft or refashioning of the soft tissue envelope at a later stage. Careful patient selection is key to ensure we advocate offering our patients the right operation at the right time, for the right pathology.
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Affiliation(s)
| | - Mr Will Cobb
- Plastic Surgery Registrar, Queen Victoria Hospital, UK
| | | | - Mr Ian King
- Plastic Surgery Registrar, Queen Victoria Hospital, UK
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Kang NV, Woollard A, Michno DA, Al-Ajam Y, Tan J, Hansen E. A consecutive series of targeted muscle reinnervation (TMR) cases for relief of neuroma and phantom limb pain: UK perspective. J Plast Reconstr Aesthet Surg 2021; 75:960-969. [PMID: 34840118 DOI: 10.1016/j.bjps.2021.09.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/12/2021] [Accepted: 09/27/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Studies have suggested that targeted muscle reinnervation (TMR) can improve symptoms of neuroma pain (NP) and phantom limb pain (PLP) in patients. OBJECTIVES Our primary objective was to measure changes in NP and PLP levels following TMR surgery at 4-time points (baseline, 3, 6- and 12-months postoperatively). Secondary aims included identification of the character and rate of any surgical complications and patients' satisfaction with TMR. METHODS A retrospective review of outcomes of 36 patients who underwent TMR surgery to treat intractable NP and/or PLP after major amputation of an upper (UL) or lower limb (LL) at a single centre in London, UK over 7 years. The surgical techniques, complications, and satisfaction with TMR are described. RESULTS Forty TMR procedures were performed on 36 patients. Thirty patients had complete data for NP and PLP levels at all pre-defined time points. Significant improvements (p<0.01) in both types of pain were observed for both upper and LL amputees. However, there were varying patterns of recovery. For example, UL amputees experienced worsening of PLP in the first few months post-operatively whereas surgical complications were more common in LL cases. Patients were overwhelmingly satisfied with the improvements in their symptoms (90%). CONCLUSIONS TMR surgery appeared to relieve both NP and PLP although the retrospective nature of this study limits the strength of this conclusion. However, complication rates were high, and it is crucial for surgeons and patients to fully understand the course and outcomes of this novel surgery prior to undertaking treatment.
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Affiliation(s)
- Norbert Venantius Kang
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom.
| | - Alexander Woollard
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom
| | - Dominika Antonina Michno
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom
| | - Yazan Al-Ajam
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom
| | - Jaclyn Tan
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom
| | - Esther Hansen
- Royal Free Hospital, Department of Plastic and Reconstructive Surgery, Pond Street, London NW3 2QG, United Kingdom
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Ganesh Kumar N, Kung TA, Cederna PS. Regenerative Peripheral Nerve Interfaces for Advanced Control of Upper Extremity Prosthetic Devices. Hand Clin 2021; 37:425-433. [PMID: 34253315 DOI: 10.1016/j.hcl.2021.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The quest to find the ideal prosthetic device interface that enables intuitive control has motivated several recent innovations. Although current prosthetic device control strategies have advanced the field of neuroprosthetic control, they are limited in their ability to generate reliable, stable, and specific signals to replicate the complex movements of the upper extremity. The regenerative peripheral nerve interface (RPNI) is a promising solution to enhance prosthetic device control. This article describes the development of RPNIs and summarizes its successful use in the control of advanced prosthetic devices in patients with upper extremity amputations.
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Affiliation(s)
- Nishant Ganesh Kumar
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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Abstract
Brain-machine interfaces (BMI) are being developed to restore upper limb function for persons with spinal cord injury or other motor degenerative conditions. BMI and implantable sensors for myoelectric prostheses directly extract information from the central or peripheral nervous system to provide users with high fidelity control of their prosthetic device. Control algorithms have been highly transferable between the 2 technologies but also face common issues. In this review of the current state of the art in each field, the authors point out similarities and differences between the 2 technologies that may guide the implementation of common solutions to these challenges.
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Affiliation(s)
- Alex K Vaskov
- Robotics Institute, University of Michigan, 2505 Hayward St, Ann Arbor, MI 48109, USA
| | - Cynthia A Chestek
- Robotics Institute, University of Michigan, 2505 Hayward St, Ann Arbor, MI 48109, USA; Department of Biomedical Engineering, University of Michigan, 2200 Bonisteel Blvd, Ann Arbor, MI 48109, USA; Department of Electrical Engineering and Computer Science, University of Michigan, 1301 Beal Ave, Ann Arbor, MI 48109, USA; Neuroscience Graduate Program, University of Michigan, 204 Washtenaw Ave, Ann Arbor, MI 48109, USA.
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Application of Spare Parts in Combination with Targeted Muscle Reinnervation Surgery. Plast Reconstr Surg 2021; 147:279e-283e. [PMID: 33565835 DOI: 10.1097/prs.0000000000007594] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY Targeted muscle reinnervation is a contemporary technique designed to enhance an amputee's ability to operate a myoelectric prosthesis. This technique has been shown to decrease neuropathic pain, including neuroma and phantom limb pain. In certain amputations, especially forequarter and hindlimb levels, there may be no nearby recipient muscle sites, or the residual nerve may be too short to perform targeted muscle reinnervation. Applying the spare parts concept can help solve this problem by providing nerve autograft or additional muscle recipient sites within the spare parts flap for successful targeted muscle reinnervation surgery procedures. A retrospective review of all patients that underwent spare parts targeted muscle reinnervation reconstructions between 2016 and 2019 at two institutions was performed. Patients were assessed for healing, neuroma and phantom limb pain, and function. Twelve patients underwent targeted muscle reinnervation during spare parts reconstruction; eight were male and four were female. The mean patient age was 55.3 years (range, 16 to 72 years). For those with known soft-tissue deficit size, the surface area of the donor site spared by using spare parts reconstruction ranged from 216 to 856 cm2. None of the 12 patients subsequently experienced neuroma, and 75 percent had no phantom limb pain after 3 months. Three patients have obtained insurance-approved myoelectric prosthetics, and all three demonstrated intuitive control of targeted muscles. Using a spare parts reconstruction in conjunction with targeted muscle reinnervation may optimize reconstructive efforts in the setting of major limb amputations and aid in decreasing phantom limb and neuroma pain, and facilitate the possibility of functional prosthetic and/or myoelectric prosthesis use. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Karczewski AM, Dingle AM, Poore SO. The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements. Front Neurorobot 2021; 15:711028. [PMID: 34366820 PMCID: PMC8334559 DOI: 10.3389/fnbot.2021.711028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Over the last few decades there has been a push to enhance the use of advanced prosthetics within the fields of biomedical engineering, neuroscience, and surgery. Through the development of peripheral neural interfaces and invasive electrodes, an individual's own nervous system can be used to control a prosthesis. With novel improvements in neural recording and signal decoding, this intimate communication has paved the way for bidirectional and intuitive control of prostheses. While various collaborations between engineers and surgeons have led to considerable success with motor control and pain management, it has been significantly more challenging to restore sensation. Many of the existing peripheral neural interfaces have demonstrated success in one of these modalities; however, none are currently able to fully restore limb function. Though this is in part due to the complexity of the human somatosensory system and stability of bioelectronics, the fragmentary and as-yet uncoordinated nature of the neuroprosthetic industry further complicates this advancement. In this review, we provide a comprehensive overview of the current field of neuroprosthetics and explore potential strategies to address its unique challenges. These include exploration of electrodes, surgical techniques, control methods, and prosthetic technology. Additionally, we propose a new approach to optimizing prosthetic limb function and facilitating clinical application by capitalizing on available resources. It is incumbent upon academia and industry to encourage collaboration and utilization of different peripheral neural interfaces in combination with each other to create versatile limbs that not only improve function but quality of life. Despite the rapidly evolving technology, if the field continues to work in divided "silos," we will delay achieving the critical, valuable outcome: creating a prosthetic limb that is right for the patient and positively affects their life.
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Affiliation(s)
| | - Aaron M. Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin–Madison, Madison, WI, United States
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Idowu OP, Ilesanmi AE, Li X, Samuel OW, Fang P, Li G. An integrated deep learning model for motor intention recognition of multi-class EEG Signals in upper limb amputees. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 206:106121. [PMID: 33957375 DOI: 10.1016/j.cmpb.2021.106121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/14/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Recognition of motor intention based on electroencephalogram (EEG) signals has attracted considerable research interest in the field of pattern recognition due to its notable application of non-muscular communication and control for those with severe motor disabilities. In analysis of EEG data, achieving a higher classification performance is dependent on the appropriate representation of EEG features which is mostly characterized by one unique frequency before applying a learning model. Neglecting other frequencies of EEG signals could deteriorate the recognition performance of the model because each frequency has its unique advantages. Motivated by this idea, we propose to obtain distinguishable features with different frequencies by introducing an integrated deep learning model to accurately classify multiple classes of upper limb movement intentions. METHODS The proposed model is a combination of long short-term memory (LSTM) and stacked autoencoder (SAE). To validate the method, four high-level amputees were recruited to perform five motor intention tasks. The acquired EEG signals were first preprocessed before exploring the consequence of input representation on the performance of LSTM-SAE by feeding four frequency bands related to the tasks into the model. The learning model was further improved by t-distributed stochastic neighbor embedding (t-SNE) to eliminate feature redundancy, and to enhance the motor intention recognition. RESULTS The experimental results of the classification performance showed that the proposed model achieves an average performance of 99.01% for accuracy, 99.10% for precision, 99.09% for recall, 99.09% for f1_score, 99.77% for specificity, and 99.0% for Cohen's kappa, across multi-subject and multi-class scenarios. Further evaluation with 2-dimensional t-SNE revealed that the signal decomposition has a distinct multi-class separability in the feature space. CONCLUSION This study demonstrated the predominance of the proposed model in its ability to accurately classify upper limb movements from multiple classes of EEG signals, and its potential application in the development of a more intuitive and naturalistic prosthetic control.
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Affiliation(s)
- Oluwagbenga Paul Idowu
- Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen Engineering Laboratory of Neural Rehabilitation Technology, Shenzhen 518055, China
| | - Ademola Enitan Ilesanmi
- School of ICT, Sirindhorn International Institute of Technology, Thammasat University, Thailand
| | - Xiangxin Li
- Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen Engineering Laboratory of Neural Rehabilitation Technology, Shenzhen 518055, China
| | - Oluwarotimi Williams Samuel
- Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen Engineering Laboratory of Neural Rehabilitation Technology, Shenzhen 518055, China
| | - Peng Fang
- Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen Engineering Laboratory of Neural Rehabilitation Technology, Shenzhen 518055, China.
| | - Guanglin Li
- Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen 518055, China; Shenzhen Engineering Laboratory of Neural Rehabilitation Technology, Shenzhen 518055, China.
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Singh HP, Kumar P. Developments in the human machine interface technologies and their applications: a review. J Med Eng Technol 2021; 45:552-573. [PMID: 34184601 DOI: 10.1080/03091902.2021.1936237] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Human-machine interface (HMI) techniques use bioelectrical signals to gain real-time synchronised communication between the human body and machine functioning. HMI technology not only provides a real-time control access but also has the ability to control multiple functions at a single instance of time with modest human inputs and increased efficiency. The HMI technologies yield advanced control access on numerous applications such as health monitoring, medical diagnostics, development of prosthetic and assistive devices, automotive and aerospace industry, robotic controls and many more fields. In this paper, various physiological signals, their acquisition and processing techniques along with their respective applications in different HMI technologies have been discussed.
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Affiliation(s)
- Harpreet Pal Singh
- Department of Mechanical Engineering, Punjabi University, Patiala, India
| | - Parlad Kumar
- Department of Mechanical Engineering, Punjabi University, Patiala, India
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Vu PP, Vaskov AK, Irwin ZT, Henning PT, Lueders DR, Laidlaw AT, Davis AJ, Nu CS, Gates DH, Gillespie RB, Kemp SWP, Kung TA, Chestek CA, Cederna PS. A regenerative peripheral nerve interface allows real-time control of an artificial hand in upper limb amputees. Sci Transl Med 2021; 12:12/533/eaay2857. [PMID: 32132217 DOI: 10.1126/scitranslmed.aay2857] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/28/2019] [Accepted: 12/27/2019] [Indexed: 11/02/2022]
Abstract
Peripheral nerves provide a promising source of motor control signals for neuroprosthetic devices. Unfortunately, the clinical utility of current peripheral nerve interfaces is limited by signal amplitude and stability. Here, we showed that the regenerative peripheral nerve interface (RPNI) serves as a biologically stable bioamplifier of efferent motor action potentials with long-term stability in upper limb amputees. Ultrasound assessments of RPNIs revealed prominent contractions during phantom finger flexion, confirming functional reinnervation of the RPNIs in two patients. The RPNIs in two additional patients produced electromyography signals with large signal-to-noise ratios. Using these RPNI signals, subjects successfully controlled a hand prosthesis in real-time up to 300 days without control algorithm recalibration. RPNIs show potential in enhancing prosthesis control for people with upper limb loss.
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Affiliation(s)
- Philip P Vu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alex K Vaskov
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA
| | - Zachary T Irwin
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Phillip T Henning
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel R Lueders
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ann T Laidlaw
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alicia J Davis
- University of Michigan Hospital Orthotics and Prosthetics Center, Ann Arbor, MI 48109, USA
| | - Chrono S Nu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Deanna H Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA.,Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - R Brent Gillespie
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephen W P Kemp
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA. .,Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI 48109, USA.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul S Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA. .,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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Targeted Muscle Reinnervation: A Paradigm Shift for Neuroma Management and Improved Prosthesis Control in Major Limb Amputees. J Am Acad Orthop Surg 2021; 29:288-296. [PMID: 33405489 DOI: 10.5435/jaaos-d-20-00044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 11/19/2020] [Indexed: 02/01/2023] Open
Abstract
Targeted muscle reinnervation (TMR) is a procedure that redirects nerves severed by amputation to new muscle targets. In tandem with advances in myoelectric prosthetics, TMR surgery provides amputees with improved control of myoelectric prostheses and simultaneously prevents or treats painful neuromas. TMR also has an emerging role in the management of neuromas in a nonamputation setting, and it seems to be a powerful strategy to treat a wide variety of neuromas. Because the pattern of nerve transfers varies based on the availability of donor nerves and muscle targets, TMR is inherently nonprescriptive, and thus, an understanding of the principles of TMR is essential for its successful application. This review describes the rationale for and principles of TMR, and outlines techniques for TMR, which can be used at various amputation levels and for the management of neuromas in nonamputees.
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Millevolte AXT, Dingle AM, Ness JP, Novello J, Zeng W, Lu Y, Minor RL, Nemke B, Markel MD, Suminski AJ, Williams JC, Poore SO. Improving the Selectivity of an Osseointegrated Neural Interface: Proof of Concept For Housing Sieve Electrode Arrays in the Medullary Canal of Long Bones. Front Neurosci 2021; 15:613844. [PMID: 33790731 PMCID: PMC8006940 DOI: 10.3389/fnins.2021.613844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/16/2021] [Indexed: 01/15/2023] Open
Abstract
Sieve electrodes stand poised to deliver the selectivity required for driving advanced prosthetics but are considered inherently invasive and lack the stability required for a chronic solution. This proof of concept experiment investigates the potential for the housing and engagement of a sieve electrode within the medullary canal as part of an osseointegrated neural interface (ONI) for greater selectivity toward improving prosthetic control. The working hypotheses are that (A) the addition of a sieve interface to a cuff electrode housed within the medullary canal of the femur as part of an ONI would be capable of measuring efferent and afferent compound nerve action potentials (CNAPs) through a greater number of channels; (B) that signaling improves over time; and (C) that stimulation at this interface generates measurable cortical somatosensory evoked potentials through a greater number of channels. The modified ONI was tested in a rabbit (n = 1) amputation model over 12 weeks, comparing the sieve component to the cuff, and subsequently compared to historical data. Efferent CNAPs were successfully recorded from the sieve demonstrating physiological improvements in CNAPs between weeks 3 and 5, and somatosensory cortical responses recorded at 12 weeks postoperatively. This demonstrates that sieve electrodes can be housed and function within the medullary canal, demonstrated by improved nerve engagement and distinct cortical sensory feedback. This data presents the conceptual framework for housing more sophisticated sieve electrodes in bone as part of an ONI for improving selectivity with percutaneous connectivity toward improved prosthetic control.
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Affiliation(s)
- Augusto X T Millevolte
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States.,Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States
| | - Aaron M Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States
| | - Jared P Ness
- Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States
| | - Joseph Novello
- Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States
| | - Yan Lu
- Department of Medical Sciences, University of Wisconsin - Madison, Madison, WI, United States
| | - Rashea L Minor
- Department of Medical Sciences, University of Wisconsin - Madison, Madison, WI, United States
| | - Brett Nemke
- Department of Medical Sciences, University of Wisconsin - Madison, Madison, WI, United States
| | - Mark D Markel
- Department of Medical Sciences, University of Wisconsin - Madison, Madison, WI, United States
| | - Aaron J Suminski
- Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States.,Department of Medical Sciences, University of Wisconsin - Madison, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin - Madison, Madison, WI, United States
| | - Justin C Williams
- Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin - Madison, Madison, WI, United States
| | - Samuel O Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States.,Department of Biomedical Engineering, College of Engineering, University of Wisconsin - Madison, Madison, WI, United States
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Mereu F, Leone F, Gentile C, Cordella F, Gruppioni E, Zollo L. Control Strategies and Performance Assessment of Upper-Limb TMR Prostheses: A Review. SENSORS (BASEL, SWITZERLAND) 2021; 21:1953. [PMID: 33802231 PMCID: PMC8000641 DOI: 10.3390/s21061953] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
The evolution of technological and surgical techniques has made it possible to obtain an even more intuitive control of multiple joints using advanced prosthetic systems. Targeted Muscle Reinnervation (TMR) is considered to be an innovative and relevant surgical technique for improving the prosthetic control for people with different amputation levels of the limb. Indeed, TMR surgery makes it possible to obtain reinnervated areas that act as biological amplifiers of the motor control. On the technological side, a great deal of research has been conducted in order to evaluate various types of myoelectric prosthetic control strategies, whether direct control or pattern recognition-based control. In the literature, different control performance metrics, which have been evaluated on TMR subjects, have been introduced, but no accepted reference standard defines the better strategy for evaluating the prosthetic control. Indeed, the presence of several evaluation tests that are based on different metrics makes it difficult the definition of standard guidelines for comprehending the potentiality of the proposed control systems. Additionally, there is a lack of evidence about the comparison of different evaluation approaches or the presence of guidelines on the most suitable test to proceed for a TMR patients case study. Thus, this review aims at identifying these limitations by examining the several studies in the literature on TMR subjects, with different amputation levels, and proposing a standard method for evaluating the control performance metrics.
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Affiliation(s)
- Federico Mereu
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Francesca Leone
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Cosimo Gentile
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Francesca Cordella
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | | | - Loredana Zollo
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
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