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Raasveld FV, Hoftiezer YAJ, Gomez-Eslava B, McCarty J, Valerio IL, Heng M, Eberlin KR. Early Postoperative Pain Course following Primary and Secondary Targeted Muscle Reinnervation: A Temporal Description of Pain Outcomes. J Reconstr Microsurg 2024. [PMID: 39191418 DOI: 10.1055/a-2404-7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exist regarding the early postoperative pain course for patients who undergo either primary (<14 days since amputation) or secondary (≥14 days) TMR. This study aims to outline the postoperative pain course for primary and secondary TMR during the first 6 postoperative months to aid in patient education and expectation management. METHODS Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effects models were utilized to visualize and compare pain courses between primary and secondary TMR patients. RESULTS A total of 203 amputees were included, with 40.9% being primary and 59.1% being secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month postoperative trajectory (p < 0.001) compared with secondary TMR patients, with a difference of Δ -1.0 at the day of TMR (primary = 4.5, secondary = 5.5), and a difference of Δ -1.4 at the 6-month mark (primary = 3.6, secondary = 5.0). Primary TMR patients also reported significantly lower Pain Interference (p < 0.001) and Pain Intensity scores (p < 0.001) over the complete trajectory of their care. CONCLUSION Primary TMR patients report lower pain during the first 6 months postoperatively compared with secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the postoperative pain course and managing patient expectations following TMR. LEVEL OF EVIDENCE Therapeutic - IV.
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Affiliation(s)
- Floris V Raasveld
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yannick Albert J Hoftiezer
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Plastic, Reconstructive and Hand Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Barbara Gomez-Eslava
- Department of Neurobiology, F.M. Kirby Neurobiology Center, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Justin McCarty
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marilyn Heng
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Best CSW, Kung TA. Current and Future Directions for Upper Extremity Amputations: Comparisons Between Regenerative Peripheral Nerve Interface and Targeted Muscle Reinnervation Surgeries. Clin Plast Surg 2024; 51:583-592. [PMID: 39216944 DOI: 10.1016/j.cps.2024.05.001] [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: 09/04/2024]
Abstract
Upper extremity amputation can lead to significant functional morbidity. The main goals after amputation are to minimize pain and maintain or improve functional status while optimizing the quality of life. Postamputation pain is common and can be addressed with regenerative peripheral nerve interface surgery or targeted muscle reinnervation surgery. Both modalities are effective in treating residual limb pain and phantom limb pain, as well as improving prosthetic use. Differences in surgical technique between the 2 approaches need to be weighed when deciding what strategy may be most appropriate for the patient.
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Affiliation(s)
- Christine S W Best
- Department of Surgery, Section of Plastic Surgery, University of Michigan, 1500 East Medical Center Drive, 2110 Taubman Center, SPC 5346, Ann Arbor, MI 48109-5346, USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic Surgery, University of Michigan, 1500 East Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48109-5231, USA.
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Raasveld FV, Mayrhofer-Schmid M, Johnston BR, Gomez-Eslava B, Hoftiezer YAJ, Liu WC, Valerio IL, Eberlin KR. Targeted muscle reinnervation at the time of amputation to prevent the development of neuropathic pain. J Plast Reconstr Aesthet Surg 2024; 97:13-22. [PMID: 39121547 DOI: 10.1016/j.bjps.2024.07.055] [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] [Received: 02/11/2024] [Revised: 07/22/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Targeted muscle reinnervation (TMR) is an established modality for the surgical management of neuropathic pain. Although the preventive effect of primary (acute) TMR at the time of amputation has been demonstrated previously, it remains unclear how many and which patients benefit most. Therefore, this study investigated the proportion of patients achieving sustained pain prophylaxis following amputation, as well as factors associated with its efficacy. METHODS Primary patients who underwent TMR with a minimum follow-up of 6 months between 2018 and 2023 were enrolled. Pain outcomes (numeric rating scale [NRS], 0-10), comorbidities, and surgical factors were collected from chart review. Patients achieving sustained pain prophylaxis (NRS of ≤3 for ≥3 months until final follow-up) were identified. Multilevel mixed-effect models and multivariable regression were used to visualize pain courses and identify associated factors. RESULTS Seventy-five patients who underwent primary TMR were included (median follow-up: 2.0 years), of whom 57.3% achieved sustained pain prophylaxis whereas 26.7% reported pain disappearance. Distal amputation levels (p = 0.036), a lower Elixhauser Comorbidity Index (p = 0.001), and the absence of psychiatric comorbidities (p = 0.039) were associated with pain prophylaxis. CONCLUSION This study demonstrates that more than half of all patients undergoing primary TMR achieved sustained pain prophylaxis, and approximately a quarter of patients achieved sustained pain disappearance. Several factors associated with these favorable outcomes are described. These results will aid in preoperative counseling, managing patient expectations, and selecting patients who may benefit most from primary TMR surgery. LEVEL OF EVIDENCE IV - Therapeutic.
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Affiliation(s)
- Floris V Raasveld
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America; Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Maximilian Mayrhofer-Schmid
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin R Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Barbara Gomez-Eslava
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States of America
| | - Yannick A J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America.
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van Vliet E, Raasveld FV, Liu WC, Valerio IL, Eberlin KR, Newman ET, Jarraya M, Simeone FJ, Husseini JS. Evaluation of MRI features of neuromas in oncological amputees, and the relation to pain. Skeletal Radiol 2024:10.1007/s00256-024-04779-0. [PMID: 39264418 DOI: 10.1007/s00256-024-04779-0] [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] [Received: 06/03/2024] [Revised: 08/05/2024] [Accepted: 08/20/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVE The impact of time on neuroma growth and morphology on pain intensity is unknown. This study aims to assess magnetic resonance imaging (MRI) differences between symptomatic and non-symptomatic neuromas in oncological amputees, and whether time influences MRI-detected neuroma dimensions and their association with pain. MATERIAL AND METHODS Oncological patients who underwent traditional extremity amputation were included. Post-amputation MRIs were assessed before decision for neuroma surgery. Chart review was performed for residual limb pain (numeric rating scale, 0-10) and the presence of neuropathic symptoms. Neuromas were classified as symptomatic or non-symptomatic, with neuroma size expressed as radiological neuroma-to-nerve-ratio (NNR). RESULTS Among 78 neuromas in 60 patients, the median NNR was 2.0, and 56 neuromas (71.8%) were symptomatic with a median pain score of 3.5. NNR showed no association with symptomatology or pain intensity but correlated with a longer time-to-neuroma-excision interval and a smaller nerve caliber. Symptomatic neuromas were associated with lower extremity amputation, T2 heterogeneity, and the presence of heterotopic ossification. Lower extremity amputation, T2 heterogeneity, perineural edema, and presence of heterotopic ossification were associated with more painful neuromas. CONCLUSION MRI features associated with symptomatic neuromas and pain intensity were identified. Awareness of the potential clinical significance of these imaging features may help in the interpretation of MRI exams and may aid clinicians in patient selection for neuroma surgery in oncological amputees.
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Affiliation(s)
- Eva van Vliet
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Floris V Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Kaohsiung Medical University Hospital, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - F Joseph Simeone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jad S Husseini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Weigel DT, Raasveld FV, Liu WC, Mayrhofer-Schmid M, Hwang CD, Tereshenko V, Renthal W, Woolf CJ, Valerio IL, Eberlin KR. Neuroma-to-Nerve Ratio: Does Size Matter? Neurosurgery 2024:00006123-990000000-01341. [PMID: 39248535 DOI: 10.1227/neu.0000000000003166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/07/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Anatomic features of neuromas have been explored in imaging studies. However, there has been limited research into these features using resected, ex vivo human neuroma specimens. The aim of this study was to investigate the influence that time may have on neuroma growth and size, and the clinical significance of these parameters. METHODS Patients who underwent neuroma excision between 2022 through 2023 were prospectively included in this study. Neuroma specimens were obtained after operative resection. Standardized neuroma size measurements, expressed as a neuroma-to-nerve ratio (NNR), were conducted with ImageJ software. Pain data (numeric rating scale, 0-10) were prospectively recorded during preoperative evaluation, and patient factors were collected from chart reviews. RESULTS Fifty terminal neuroma specimens from 31 patients were included, with 94.0% of the neuromas obtained from individuals with amputations. Most neuromas were excised from the lower extremities (n = 44, 88.0%). The neuromas had a median NNR of 2.45, and the median injury to neuroma excision interval was 6.3 years. Larger NNRs were associated with a longer injury to neuroma excision interval and with a smaller native nerve diameter. In addition, sensory nerves were associated with a larger NNR compared with mixed nerves. NNR was not associated with preoperative pain or with anatomical nerve distribution. CONCLUSION This study suggests that neuromas seem to continue to grow over time and that smaller nerves may form relatively larger neuromas. In addition, sensory nerves develop relatively larger neuromas compared with mixed nerves. Neuroma size does not appear to correlate with pain severity. These findings may stimulate future research efforts and contribute to a better understanding of symptomatic neuroma development.
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Affiliation(s)
- Daniel T Weigel
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Maastricht University, Maastricht, The Netherlands
| | - Floris V Raasveld
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wen-Chih Liu
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Maximilian Mayrhofer-Schmid
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlad Tereshenko
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William Renthal
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Clifford J Woolf
- Department for Neurobiology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Raasveld FV, Lans J, Valerio IL, Eberlin KR. Social Deprivation is Associated with Increased Pain in Patients Presenting with Neuropathic Pain. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5931. [PMID: 39148658 PMCID: PMC11326464 DOI: 10.1097/gox.0000000000005931] [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: 03/15/2024] [Accepted: 05/09/2024] [Indexed: 08/17/2024]
Abstract
Background Neuropathic pain following nerve injury can be debilitating and negatively impact quality of life. Targeted muscle reinnervation (TMR) is an efficacious technique for the management of neuropathic pain. However, this technique may be unequally available for many geographical locations. Therefore, the aim of this study was to evaluate the association between Area Deprivation Index (ADI) and preoperative pain in patients undergoing TMR for treatment of neuropathic pain. Methods Patients who underwent TMR for neuropathic pain in the lower and upper extremities were prospectively enrolled at our tertiary care clinic. A chart review was conducted to obtain socioeconomic, surgery, and comorbidity parameters. Preoperative pain scores (0-10 pain score index), and the ADI, reflecting deprivation status on a 0-100 scale, were collected. Results A total of 162 patients from 13 different states were included, of which 119 were amputees (74%). The median ADI was 25 (IQR: 16-41) and the median preoperative pain score was 6 (IQR: 5-8). A higher ADI was independently associated with higher preoperative pain. The time interval from nerve injury to TMR was not associated with ADI. Conclusions Patients undergoing surgical treatment of neuropathic pain from more socially deprived settings have increased pain experience upon initial evaluation, despite having similar time from nerve injury or amputation to TMR. These findings highlight the importance of identifying patients presenting from socially deprived settings, as this may impact their physical and mental health along with their coping mechanisms, resulting in increased pain.
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Affiliation(s)
- Floris V Raasveld
- From Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Jonathan Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Raasveld FV, Liu WC, Mayrhofer-Schmid M, Wainger BJ, Valerio IL, Renthal W, Eberlin KR. Neuroma Analysis in Humans: Standardizing Sample Collection and Documentation. J Surg Res 2024; 298:185-192. [PMID: 38626715 PMCID: PMC11178259 DOI: 10.1016/j.jss.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 02/22/2024] [Accepted: 03/16/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION The biology of symptomatic neuromas is poorly understood, particularly the factors causing pain in human neuromas. Pain presence varies among and within individuals, with some having painful and nonpainful neuromas. To bridge these knowledge gaps, our group developed a protocol for assessing neuroma pain and collecting tissue for molecular analysis. This manuscript outlines our workflow and challenges and aims to inspire other centers to share their experiences with these tissues. METHODS For every included patient and collected nerve or bone tissue specimens, we perform a detailed chart review and a multifaceted analysis of pain and pain perception immediately before surgery. We collect patient-reported outcome measures (PROMs) on pain, function, and mental well-being outcomes at preoperative assessment and at the 6-month follow-up postoperatively. Before surgery, the patient is assessed once again to obtain an immediate preoperative pain status and identify potential differences in pain intensity of different neuromas. Intraoperatively, specimens are obtained and their gross anatomical features are recorded, after which they are stored in paraformaldehyde or frozen for later sample analyses. Postoperatively, patients are contacted to obtain additional postoperative PROMs. RESULTS A total of 220 specimens of nerve tissue have been successfully obtained from 83 limbs, comprising 95 specimens of neuromas and 125 specimens of nerves located proximal to the neuromas or from controls. CONCLUSIONS Our approach outlines the methods combining specimen collection and examination, including both macroscopic and molecular biological features, with PROMs, encompassing physical and psychological aspects, along with clinical metadata obtained through clinical teams and chart review.
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Affiliation(s)
- Floris V Raasveld
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Wen-Chih Liu
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts; Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Maximilian Mayrhofer-Schmid
- Department of Orthopaedic Surgery, Hand and Arm Center, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts; Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Brian J Wainger
- Departments of Anesthesia, Critical Care & Pain Medicine and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts
| | - William Renthal
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston Massachusetts
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts.
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Hwang CD, Hoftiezer YAJ, Raasveld FV, Gomez-Eslava B, van der Heijden EPA, Jayakar S, Black BJ, Johnston BR, Wainger BJ, Renthal W, Woolf CJ, Eberlin KR. Biology and pathophysiology of symptomatic neuromas. Pain 2024; 165:550-564. [PMID: 37851396 DOI: 10.1097/j.pain.0000000000003055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/07/2023] [Indexed: 10/19/2023]
Abstract
ABSTRACT Neuromas are a substantial cause of morbidity and reduction in quality of life. This is not only caused by a disruption in motor and sensory function from the underlying nerve injury but also by the debilitating effects of neuropathic pain resulting from symptomatic neuromas. A wide range of surgical and therapeutic modalities have been introduced to mitigate this pain. Nevertheless, no single treatment option has been successful in completely resolving the associated constellation of symptoms. While certain novel surgical techniques have shown promising results in reducing neuroma-derived and phantom limb pain, their effectiveness and the exact mechanism behind their pain-relieving capacities have not yet been defined. Furthermore, surgery has inherent risks, may not be suitable for many patients, and may yet still fail to relieve pain. Therefore, there remains a great clinical need for additional therapeutic modalities to further improve treatment for patients with devastating injuries that lead to symptomatic neuromas. However, the molecular mechanisms and genetic contributions behind the regulatory programs that drive neuroma formation-as well as the resulting neuropathic pain-remain incompletely understood. Here, we review the histopathological features of symptomatic neuromas, our current understanding of the mechanisms that favor neuroma formation, and the putative contributory signals and regulatory programs that facilitate somatic pain, including neurotrophic factors, neuroinflammatory peptides, cytokines, along with transient receptor potential, and ionotropic channels that suggest possible approaches and innovations to identify novel clinical therapeutics.
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Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States
| | - Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- Department of Plastic, Reconstructive and Hand Surgery, Radboudumc, Nijmegen, the Netherlands
| | - Floris V Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Barbara Gomez-Eslava
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, United States
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - E P A van der Heijden
- Department of Plastic, Reconstructive and Hand Surgery, Radboudumc, Nijmegen, the Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Selwyn Jayakar
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Bryan James Black
- Department of Biomedical Engineering, UMass Lowell, Lowell, MA, United States
| | - Benjamin R Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Brian J Wainger
- Departments of Anesthesia, Critical Care & Pain Medicine and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Clifford J Woolf
- F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States
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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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Langeveld M, Bosman R, Hundepool CA, Duraku LS, McGhee C, Zuidam JM, Barker T, Juszczak M, Power DM. Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2024; 58:142-150. [PMID: 37616476 PMCID: PMC10756018 DOI: 10.1177/15385744231197097] [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: 08/26/2023]
Abstract
BACKGROUND Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.
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Affiliation(s)
- Mirte Langeveld
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Hand and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Romy Bosman
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Hand and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Caroline A Hundepool
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Liron S Duraku
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Christopher McGhee
- Hand and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Michiel Zuidam
- Department of Plastic, Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tom Barker
- Department of Vascular Surgery, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Maciej Juszczak
- Department of Vascular Surgery, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dominic M Power
- Hand and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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11
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Huo X, Huang P, Di H, Ma T, Jiang S, Yao J, Huang L. Risk Factors Analysis of Phantom Limb Pain in Amputees with Malignant Tumors. J Pain Res 2023; 16:3979-3992. [PMID: 38026454 PMCID: PMC10676115 DOI: 10.2147/jpr.s433996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Postamputation neuropathic pain is a common disease in patients with malignant tumor amputation, seriously affecting amputees' quality of life and mental health. The objective of this study was to identify independent risk factors for phantom limb pain in patients with tumor amputation and to construct a risk prediction model. Methods Patients who underwent amputation due to malignant tumors from 2013 to 2023 were retrospectively analyzed and divided into phantom limb pain group and non-phantom limb pain group. To determine which preoperative factors would affect the occurrence of phantom limb pain, we searched for candidate factors by univariate analysis and used multivariate logistic regression analysis to identify independent factors and construct a predictive model. The receiver operating characteristic curve (ROC) was drawn to further evaluate the accuracy of the prediction model in evaluating the phantom limb pain after amputation of bone and soft tissue tumors. Results Multivariate analysis showed that age (OR, 1.054; 95% CI, 1.027 to 1.080), preoperative pain (OR, 5.773; 95% CI, 2.362 to 14.104), number of surgeries (OR, 3.425; 95% CI, 1.505 to 7.795), amputation site (OR, 5.848; 95% CI, 1.837 to 18.620), amputation level (OR, 8.031; 95% CI, 2.491 to 25.888) were independent risk factors for phantom limb pain for bone and soft tissue tumors. The the area under the curve (AUC) of this model was 0.834. Conclusion Risk factors for postoperative phantom limb pain were the site of amputation, proximal amputation, preoperative pain, multiple amputations, and older age. These factors will help surgeons to individualize and stratify phantom limb pain and help patients with risk counseling. In particular, an informed clinical decision targeting those modifiable factors can be considered when needed.
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Affiliation(s)
- Xiulin Huo
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Peiying Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Hexuan Di
- Department of Orthopaedic Surgery, The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Tianxiao Ma
- Department of Orthopaedic Surgery, The Key Laboratory of Orthopedic Biomechanics of Hebei Province, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Sufang Jiang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
| | - Jie Yao
- Department of Anesthesiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, People’s Republic of China
| | - Lining Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People’s Republic of China
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12
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Hwang CD, Chegireddy V, Remy K, Irwin TJ, Valerio IL, Gfrerer L, Austen WG. The Use of Nerve Caps after Nerve Transection in Headache Surgery: Cadaver and Case Reports. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5234. [PMID: 37662472 PMCID: PMC10473362 DOI: 10.1097/gox.0000000000005234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/11/2023] [Indexed: 09/05/2023]
Abstract
Background Nerve transection with nerve reconstruction is part of the treatment algorithm for patients with refractory pain after greater occipital nerve (GON) and lesser occipital nerve (LON) decompression or during primary decompression when severe nerve injury or neuroma formation is present. Importantly, the residual nerve stump is often best addressed via contemporary nerve reconstruction techniques to avoid recurrent pain. As a primary aim of this study, nerve capping is explored as a potential viable alternative that can be utilized in certain headache cases to mitigate pain. Methods The technical feasibility of nerve capping after GON/LON transection was evaluated in cadaver dissections and intraoperatively. Patient-reported outcomes in the 3- to 4-month period were compiled from clinic visits. At 1-year follow-up, subjective outcomes and Migraine Headache Index scores were tabulated. Results Two patients underwent nerve capping as a treatment for headaches refractory to medical therapy and surgical decompressions with significant improvement to total resolution of pain without postoperative complications. These improvements on pain frequency, intensity, and duration remained stable at a 1-year time point (Migraine Headache Index score reductions of -180 to -205). Conclusions Surgeons should be equipped to address the proximal nerve stump to prevent neuroma and neuropathic pain recurrence. Next to known contemporary nerve reconstruction techniques such as targeted muscle reinnervation/regenerative peripheral nerve interface and relocation nerve grafting, nerve capping is another viable method for surgeons to address the proximal nerve stump in settings of GON and LON pain. This option exhibits short operative time, requires only limited dissection, and yields significant clinical improvement in pain symptoms.
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Affiliation(s)
- Charles D. Hwang
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Vishwanath Chegireddy
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Katya Remy
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Timothy J. Irwin
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
| | - Lisa Gfrerer
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medical College, New York, N.Y
| | - William G. Austen
- From the Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, Mass
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13
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Caragher SP, Khouri KS, Raasveld FV, Winograd JM, Valerio IL, Gfrerer L, Eberlin KR. The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5005. [PMID: 37360238 PMCID: PMC10287132 DOI: 10.1097/gox.0000000000005005] [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: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 06/28/2023]
Abstract
Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.
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Affiliation(s)
| | - Kimberly S. Khouri
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Floris V. Raasveld
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan M. Winograd
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Ian L. Valerio
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, N.Y
| | - Kyle R. Eberlin
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
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14
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Eberlin KR, Brown DA, Gaston RG, Kleiber GM, Ko JH, Kovach SJ, Loeffler BJ, MacKay BJ, Potter BK, Roubaud MS, Souza JM, Valerio IL, Dumanian GA. A Consensus Approach for Targeted Muscle Reinnervation in Amputees. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4928. [PMID: 37035125 PMCID: PMC10079335 DOI: 10.1097/gox.0000000000004928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023]
Abstract
Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.
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Affiliation(s)
- Kyle R. Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David A. Brown
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, N.C
| | - R. Glenn Gaston
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Grant M. Kleiber
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Jason H. Ko
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Stephen J. Kovach
- Division of Plastic Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pa
| | - Bryan J. Loeffler
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Brendan J. MacKay
- Department of Orthopedic Surgery, Texas Tech University Health Science Center, Lubbock, Tex
| | - Benjamin K. Potter
- Uniformed Services University – Walter Reed Department of Surgery, Bethesda, Md
| | - Margaret S. Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jason M. Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Gregory A. Dumanian
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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15
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Oka K, Kaji Y, Nakamura O, Yamaguchi K, Tobiume S, Nomura Y, Yamamoto T. Addition of a Vascular Bundle Accelerates Bone Union in Femoral Bone Defects. J Reconstr Microsurg 2023; 39:1-8. [PMID: 35272371 DOI: 10.1055/s-0042-1743256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Masquelet method has become increasingly popular for the treatment of bone defects in recent years. In this method, an induced membrane (IM) with abundant blood circulation, stem cells, and osteogenesis-promoting factors is formed by implanting bone cement during the first surgery. This IM stimulates bone formation in the bone defect after implantation of the bone graft during the second surgery. However, the Masquelet method requires two surgeries and thus a longer treatment period. In the present study, we investigated whether bone defects could be reconstructed in a single surgery by introducing a vascular bundle into the bone defect as an alternative to the IM, in addition to bone grafting. METHODS Thirty-six 12-week-old female Sprague-Dawley rats were used. After creating a 5-mm long bone defect in the femur, a mixture of autologous and artificial bone was grafted into the defect, and a saphenous arteriovenous vascular bundle was introduced. The animals were divided into three groups: the control group (bone defect only), the BG group (bone grafting only), and the BG + V group (bone grafting + vascular bundle introduction). After surgery, radiological and histological evaluations were performed to assess osteogenesis and angiogenesis in bone defects. RESULTS In the BG + V group, significant bone formation was observed in the bone defect on radiological and histological evaluations, and the amount of bone formation was significantly higher than that in the other two groups. Furthermore, cortical bone continuity was observed in many specimens in the BG + V group. On histological evaluation, the number of blood vessels was also significantly higher in the BG + V group than in the other two groups. CONCLUSION Our results suggest that the introduction of a vascular bundle in addition to bone grafting can promote bone formation in bone defects and allow for complete bone defect reconstruction in a single surgery.
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Affiliation(s)
- Kunihiko Oka
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Yoshio Kaji
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Osamu Nakamura
- Department of Orthopedic Surgery, Kagawa Prefectural Shirotori Hospital, Higashikagawa City, Kagawa, Japan
| | - Konosuke Yamaguchi
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Sachiko Tobiume
- Department of Orthopedic Surgery, Shikoku Medical Center for Children and Adults, Zentsuji City, Kagawa, Kagawa, Japan
| | - Yumi Nomura
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
| | - Tetsuji Yamamoto
- Department of Orthopedic Surgery, Faculty of Medicine, Kagawa University, Miki-Cho, Kita-gun, Kagawa, Japan
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16
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Onode E, Uemura T, Hama S, Yokoi T, Okada M, Takamatsu K, Nakamura H. Nerve-End Capping Treatment with a Polyglycolic Acid Conduit for Rat Sciatic Neuroma: A Preliminary Report. J Reconstr Microsurg 2022; 38:711-720. [PMID: 36122572 DOI: 10.1055/s-0042-1757208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The treatment of painful neuroma remains challenging. Recently, a nerve-end capping technique using a bioabsorbable nerve conduit was newly introduced to treat amputation neuroma. A collagen-coated polyglycolic acid (PGA) conduit has been commercially available for the reconstruction of peripheral nerve defects, yielding successful clinical outcomes. However, no experimental research has been conducted using this PGA nerve conduit as capping device for treating amputation neuroma. The purpose of this study was to investigate nerve-end capping treatment with the PGA conduit in the rat sciatic nerve amputation model, focusing on histological scar formation and neuroinflammation. METHODS Forty-seven rats were divided into two groups: no capping (transected nerve stump without capping; n = 25) and capping (nerve-end capping with collagen-coated PGA nerve conduit; n = 22). Twelve weeks after sciatic neurectomy, neuropathic pain was evaluated using the autotomy score. Stump neuromas were histologically evaluated or perineural scar and neuroinflammation. RESULTS While autotomy scores gradually exacerbated in both groups, they were consistently lower in the capping group at 4, 8, and 12 weeks postprocedure. Twelve weeks after surgery, the transected nerve stumps in the no-capping group had formed macroscopic bulbous neuromas strongly adhering to surrounding tissues, whereas they remained wrapped with the PGA nerve conduits loosely adhering to surrounding tissues in the capping group. Histologically, distal axonal fibers were expanded radially and formed neuromas in the no-capping group, while they were terminated within the PGA conduit in the capping group. Perineural scars and neuroinflammation were widely found surrounding the randomly sprouting nerve end in the no-capping group. In capped counterparts, scars and inflammation were limited to closely around the terminated nerve end. CONCLUSION Nerve-end capping with a collagen-coated PGA conduit after rat sciatic neurectomy might prevent neuroma formation by suppressing perineural scar formation and neuroinflammation around the nerve stump, potentially relieving neuropathic pain.
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Affiliation(s)
- Ema Onode
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Uemura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | - Shunpei Hama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Yokoi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Orthopaedic Surgery, Seikeikai Hospital, Osaka, Japan
| | - Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Orthopaedic Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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17
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Lans J, Groot OQ, Hazewinkel MH, Kaiser PB, Lozano-Calderón SA, Heng M, Valerio IL, Eberlin KR. Factors Related to Neuropathic Pain following Lower Extremity Amputation. Plast Reconstr Surg 2022; 150:446-455. [PMID: 35687412 PMCID: PMC10375758 DOI: 10.1097/prs.0000000000009334] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation. METHODS Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify independent factors associated with neuropathic pain. RESULTS Postoperative neuropathic pain was present in 584 patients (37 percent), with phantom limb pain occurring in 34 percent of patients and symptomatic neuromas occurring in 3.8 percent of patients. Proximal amputation level, normal creatinine levels, and a history of psychiatric disease were associated with neuropathic pain. Diabetes, hypothyroidism, and older age were associated with lower odds of developing neuropathic pain. CONCLUSIONS Neuropathic pain following lower extremity amputation is common. Factors influencing nerve regeneration, either increasing (proximal amputations and younger age) or decreasing (diabetes, hypothyroidism, and chronic kidney disease) it, play a role in the development of postamputation neuropathic pain. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Jonathan Lans
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Olivier Q. Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Merel H.J. Hazewinkel
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Philip B. Kaiser
- Foot & Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Santiago A. Lozano-Calderón
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, USA
| | - Ian L. Valerio
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kyle R. Eberlin
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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18
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Wu J, Zhang Y, Zhang X, Lin Z, Li G. Regenerative Peripheral Nerve Interfaces Effectively Prevent Neuroma Formation After Sciatic Nerve Transection in Rats. Front Mol Neurosci 2022; 15:938930. [PMID: 35875668 PMCID: PMC9301297 DOI: 10.3389/fnmol.2022.938930] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The disordered growth of nerve stumps after amputation leading to the formation of neuromas is an important cause of postoperative pain in amputees. This severely affects the patients' quality of life. Regenerative peripheral nerve interfaces (RPNIs) are an emerging method for neuroma prevention, but its postoperative nerve growth and pathological changes are yet to be studied. Methods The rat sciatic nerve transection model was used to study the effectiveness of RPNI in this experiment. The RPNI (experimental) group (n = 11) underwent RPNI implantation after sciatic nerve transection, while the control group (n = 11) only underwent sciatic nerve transection. Autotomy behavior, ultrasonography, and histopathology were observed for 2 months postoperatively. Results Compared to the control group, the incidence and size of the neuromas formed and the incidence and extent of autotomy were significantly reduced in the RPNI group. The axon density in the stump and degree of stump fibrosis were also significantly reduced in the RPNI group. Conclusion RPNI effectively prevented the formation of neuromas.
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Affiliation(s)
- Jiaqing Wu
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
| | - Yajun Zhang
- Trauma Medicine Center, Peking University People's Hospital, Beijing, China
| | - Xiaoyuan Zhang
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
| | - Zhiyu Lin
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Guangxue Li
- Department of Plastic Surgery, Peking University People's Hospital, Beijing, China
- *Correspondence: Guangxue Li
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19
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Trigeminal Traumatic Neuroma: a Comprehensive Review of the Literature Based On a Rare Case. Curr Pain Headache Rep 2022; 26:219-233. [PMID: 35119601 DOI: 10.1007/s11916-022-01018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Traumatic neuromas in general, and trigeminal traumatic neuromas in particular, are relatively rare entities originating from a damage to a corresponding nerve or its branches. This manuscript is a comprehensive review of the literature on trigeminal traumatic neuromas based on an interesting and challenging case of bilateral intraoral lesions. RECENT FINDINGS The diagnosis for this patient was bilateral trigeminal traumatic neuromas. It is possible that these patients have a genetic predisposition to the development of these lesions. It is a neuropathic pain condition and may mimic dental and other trigeminal pain entities. Topical treatment with lidocaine gel, utilizing a custom-made neurosensory stent, rendered the patient significant and sustained pain relief. Trigeminal traumatic neuromas present a diagnostic challenge even to a seasoned clinician, due to the complex clinical features that may mimic other entities. Topical medications such as local anesthetics may be a good viable alternative to systemic medications to manage the pain associated with the condition. Early identification of the lesion and the associated pain helps in the succinct management of symptomatic trigeminal traumatic neuromas.
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20
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Lans J, Westenberg RF, Gottlieb RE, Valerio IL, Chen NC, Eberlin KR. Long-Term Opioid Use Following Surgery for Symptomatic Neuroma. J Reconstr Microsurg 2022; 38:137-143. [PMID: 35100646 DOI: 10.1055/s-0041-1731640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. METHODS After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. RESULTS Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013). CONCLUSION Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.
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Affiliation(s)
- Jonathan Lans
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ritsaart F Westenberg
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rachel E Gottlieb
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ian L Valerio
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Neal C Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kyle R Eberlin
- Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
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21
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Heinzel JC, Dadun LF, Prahm C, Winter N, Bressler M, Lauer H, Ritter J, Daigeler A, Kolbenschlag J. Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions. J Pers Med 2021; 11:jpm11111200. [PMID: 34834552 PMCID: PMC8624495 DOI: 10.3390/jpm11111200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 01/12/2023] Open
Abstract
Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.
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Affiliation(s)
- Johannes C. Heinzel
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
- Correspondence: ; Tel.: +49-7071-6061038
| | - Lucy F. Dadun
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Cosima Prahm
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Natalie Winter
- Department of Neurology, Hertie Institute for Clinical Brain Research (HIH), University of Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany;
| | - Michael Bressler
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Henrik Lauer
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Jana Ritter
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Adrien Daigeler
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
| | - Jonas Kolbenschlag
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Klinik Tuebingen, University of Tuebingen, Schnarrenbergstraße 95, 72076 Tuebingen, Germany; (L.F.D.); (C.P.); (M.B.); (H.L.); (J.R.); (A.D.); (J.K.)
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22
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Agrawal N, Olafsson S, Pickrell BB, Heng M, Valerio IL, Eberlin KR. The Octopus Procedure Combined with Targeted Muscle Reinnervation for Elective Transhumeral Amputation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3931. [PMID: 34796085 PMCID: PMC8594661 DOI: 10.1097/gox.0000000000003931] [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: 08/20/2021] [Accepted: 09/08/2021] [Indexed: 12/01/2022]
Abstract
Optimizing prosthetic function and tolerance are key principles of performing an elective upper extremity amputation. It is common for upper extremity amputees to experience issues related to nonoptimal prosthetic control and pain. Targeted muscle reinnervation and regenerative peripheral nerve interfaces in elective transhumeral amputations have been introduced as techniques to address the paucity of signals that may exist for myoelectric control postamputation. These techniques require the denervation of muscle and rely on delayed muscle reinnervation to provide eventual signal amplification for prosthetic function. In addition, the fascicles cannot be separated enough to provide signals to each individual muscle. Use of native innervated forearm musculature can provide more immediate and specific signals for prosthetic use. These native muscles are often not available for use due to trauma, denervation, or dysvascularization. In elective amputations, they can be used as spare parts to provide more signals for the sensors on a myoelectric prosthetic. The concept has been used in partial hand amputations and allowed for individual digital control at the terminal prosthetic device. In this study, we describe a novel technique used for an elective transhumeral amputation utilizing native innervated, vascularized musculature to provide intuitive control of a myoelectric prosthetic.
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Affiliation(s)
- Nikhil Agrawal
- From the Long Island Plastic Surgical Group, Garden City, N.Y
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