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Remy K, Raasveld FV, Saqr H, Khouri KS, Hwang CD, Austen WG, Valerio IL, Eberlin KR, Gfrerer L. The neuroma map: A systematic review of the anatomic distribution, etiologies, and surgical treatment of painful traumatic neuromas. Surgery 2024; 176:1239-1246. [PMID: 39025690 DOI: 10.1016/j.surg.2024.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/01/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND This study analyzed all reported cases of painful traumatic neuromas to better understand their anatomic distribution, etiologies, and surgical treatment. METHODS PubMed, Embase, Cochrane, and Web of Science were searched in October 2023 for articles describing painful traumatic neuromas. RESULTS In total, 414 articles reporting 5,562 neuromas were included and categorized into head/neck, trunk, upper extremity, lower extremity, and autonomic nerves. Distribution was as follows: Head/neck: 83 articles reported on 393 neuromas (93.2% iatrogenic) most frequently involving the lingual (44.4%), cervical plexus (15.0%), great auricular (8.6%), inferior/superior alveolar (8.3%), and occipital (7.2%) nerves. Trunk: 47 articles reported on 552 neuromas (92.9% iatrogenic) most commonly involving the intercostal (40.0%), ilioinguinal (18.2%) and genitofemoral (16.2%) nerves. Upper extremity: 160 articles reported on 2082 neuromas (42.2% after amputation) most frequently involving the digital (47.0%), superficial radial (18.3%), and median (7.0%) nerves. Lower extremity: 128 articles reported on 2,531 neuromas (53.0% after amputation) most commonly involving the sural (17.9%), superficial peroneal (17.3%), and saphenous (16.0%) nerves. Autonomic nerves: 17 articles reported on 53 neuromas (100% iatrogenic) most frequently involving the biliary tract (64.2%) and vagus nerve (18.9%). Compared with the extremities, neuromas in the head/neck and trunk had significantly longer symptom duration before surgical treatment and the nerve end was significantly less frequently reconstructed after neuroma excision. CONCLUSION Painful neuromas are predominantly reported in the extremities yet may occur throughout the body primarily after iatrogenic injury. Knowledge of their anatomic distribution from head to toe will encourage awareness to avoid injury and expedite diagnosis to prevent treatment delay.
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Affiliation(s)
- Katya Remy
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Floris V Raasveld
- Hand and Arm Center, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Hazem Saqr
- Division of Plastic and Reconstructive Surgery, University of Pittsburgh, PA
| | - Kimberly S Khouri
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Hand and Arm Center, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Zamore Z, Yesantharao PS, Aravind P, Dellon AL. Economic Cost-Benefit Analysis of Nerve Implanted into Muscle versus Targeted Muscle Reinnervation versus Regenerative Peripheral Nerve Interface, for Treatment of the Painful Neuroma. J Reconstr Microsurg 2024; 40:642-647. [PMID: 38382640 DOI: 10.1055/a-2273-3940] [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: 02/23/2024]
Abstract
BACKGROUND This study investigated the relative cost utility of three techniques for the management of symptomatic neuromas after neuroma excision: (1) implantation of nerve into muscle, (2) targeted muscle reinnervation (TMR), and (3) regenerative peripheral nerve interface (RPNI). METHODS The costs associated with each procedure were determined using Common Procedural Terminology codes in combination with data from the Centers for Medicaid and Medicare Services Physician and Facility 2020 Fee Schedules. The relative utility of the three procedures investigated was determined using changes in Patient-Reported Outcomes Measurement Information System (PROMIS) and Numeric Rating Scale (NRS) pain scores as reported per procedure. The relative utility of each procedure was reported in terms of quality-adjusted life years (QALYs), as is standard in the literature. RESULTS The least expensive option for the surgical treatment of painful neuromas was nerve implantation into an adjacent muscle. In contrast, for the treatment of four neuromas, as is common postamputation, TMR without a microscope was found to cost $50,061.55 per QALY gained, TMR with a microscope was found to cost $51,996.80 per QALY gained, and RPNI was found to cost $14,069.28 per QALY gained. While RPNI was more expensive than nerve implantation into muscle, it was still below the standard willingness-to-pay threshold of $50,000 per QALY, while TMR was not. CONCLUSION Evaluation of costs and utilities associated with the various surgical options for the management of painful neuromas suggest that nerve implantation into muscle is the least expensive option with the best improvement in QALY, while demonstrating comparable outcomes to TMR and RPNI with regard to pain symptoms.
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Affiliation(s)
- Zachary Zamore
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pooja S Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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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4
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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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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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Harnoncourt L, Gstoettner C, Pflaum L, Laengle G, Aszmann OC. [Fillet flap transfer as alternative to conventional lower limb amputation]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:651-659. [PMID: 38985169 PMCID: PMC11341707 DOI: 10.1007/s00113-024-01460-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND The fitting of a prosthesis after lower limb amputation is associated with several challenges. Skeletal stump-prosthesis interfaces and selective nerve transfer can partially overcome these but are also associated with new impairments that emphasize the necessity of innovative approaches. The concept of so-called spare part surgery with the use of fillet flaps could play an important role in this respect. OBJECTIVE An overview of the classical prosthesis-associated discomforts, advantages and disadvantages of treatment strategies and presentation of alternative surgical concepts. MATERIAL AND METHODS A selective literature search was carried out considering the experiences of the authors and perspectives with respect to the advantages and disadvantages of the surgical treatment options. Furthermore, a clinical case is presented. RESULTS AND CONCLUSION The transfer of the sole of the foot as a fillet flap to the weight-bearing region of the amputation stump offers a number of benefits, such as creating a fully weight-bearing stump, prevention of neuralgia, preserved sensation and conservation of the body image. As long as the calcaneal region is not impaired, this technique can be performed in amputations below as well as above the knee. The question of whether parts of the bone should be included in the transfer must be individually evaluated for each patient. This approach enables optimization of the residual limb stump for the subsequent fitting of a prosthesis for the patient.
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Affiliation(s)
- L Harnoncourt
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Wien, Österreich
| | - C Gstoettner
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Wien, Österreich
- Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - L Pflaum
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Wien, Österreich
| | - G Laengle
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Wien, Österreich
- Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - O C Aszmann
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Wien, Österreich.
- Universitätsklinik für Plastische, Ästhetische und Rekonstruktive Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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ALfaifi NY, Winokur EJ. Integrating Complementary Therapies in Managing Phantom Limb Pain: A Case Review. Pain Manag Nurs 2024:S1524-9042(24)00221-2. [PMID: 39147681 DOI: 10.1016/j.pmn.2024.07.007] [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: 03/15/2023] [Revised: 06/18/2024] [Accepted: 07/12/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES This paper describes phantom limb pain (PLP), its impact on patients, and the various treatment options, including pharmacologic and complementary therapies. It investigates the efficacy of incorporating complementary and alternative therapies, both invasive and noninvasive, for amputees who have not achieved satisfactory results with pharmacologic treatments and suffer from adverse drug events. Furthermore, with the predicted increase in limb amputations, it is crucial for nurses, as frontline providers, to understand PLP, be prepared to manage persistent pain and associated psychological and functional issues and educate patients and families about alternative treatment options. APPROACH The review includes recent studies on pharmacologic interventions for PLP, case reports, and randomized clinical trials on non-pharmacologic complementary therapies, covering both invasive and noninvasive modalities. Studies from 2013 to 2022 were identified using the PubMed search engine with terms such as "Amputation," "phantom limb pain," "invasive therapies," and "non-invasive therapies." RESULTS AND CONCLUSION The pathogenesis of PLP remains unclear, complicating the identification of causes and the selection of targeted therapies for each patient. Uncontrolled PLP can severely impact the quality of life, causing psychological distress and loss of productivity. Traditional pharmacologic therapy often requires supplementation with other options due to PLP's refractory nature. A comprehensive, multimodal treatment plan, including non-pharmacologic therapies, can enhance rehabilitation and reduce complications. Incorporating these therapies can decrease reliance on medications, particularly opioids, and mitigate side effects. Although many potential PLP treatments exist, further clinical studies are needed to determine their effectiveness and establish protocols for optimizing patient outcomes.
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Affiliation(s)
- Njood Y ALfaifi
- Patricia A. Chin School of Nursing, Rongxiang Xu College of Health and Human Services, California State University, Los Angeles, California.
| | - Elizabeth J Winokur
- Patricia A. Chin School of Nursing, Rongxiang Xu College of Health and Human Services, California State University, Los Angeles, California
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Hale ES, Tadisina KK, Jose J, Xu KY. Imaging the Nerve "Allograft to Muscle Target" Technique in Neuroma Management. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6058. [PMID: 39129847 PMCID: PMC11315502 DOI: 10.1097/gox.0000000000006058] [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: 01/03/2024] [Accepted: 06/17/2024] [Indexed: 08/13/2024]
Abstract
Neuroma management has gained significant attention in the peripheral nerve literature in the past decade. Alongside techniques such as targeted muscle reinnervation and regenerative peripheral nerve interface, another technique known as the "allograft to nowhere" has emerged. This approach involves the placement of an extended allograft at the end of a nerve, creating a regrowth zone in cases where muscle or nerve targets are not available. Although technique and outcomes research has been performed regarding the above techniques, there is a lack of imaging studies to examine postoperative outcomes. The authors present a case of recurrent neuroma management using a combined nerve allograft to nowhere + muscle target, supported by postoperative imaging.
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Affiliation(s)
- Eva S. Hale
- From the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | | | - Jean Jose
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Fla
| | - Kyle Y. Xu
- From the Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Fla
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9
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Casadei M, Miguel B, Rubione J, Fiore E, Mengelle D, Guerri-Guttenberg RA, Montaner A, Villar MJ, Constandil-Córdova L, Romero-Sandoval AE, Brumovsky PR. Mesenchymal Stem Cell Engagement Modulates Neuroma Microenviroment in Rats and Humans and Prevents Postamputation Pain. THE JOURNAL OF PAIN 2024; 25:104508. [PMID: 38484854 PMCID: PMC11283994 DOI: 10.1016/j.jpain.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
Postamputation pain is currently managed unsatisfactorily with neuron-targeted pharmacological and interventional therapies. Non-neuronal pain mechanisms have emerged as crucial factors in the development and persistence of postamputation pain. Consequently, these mechanisms offer exciting prospects as innovative therapeutic targets. We examined the hypothesis that engaging mesenchymal stem cells (MSCs) would foster local neuroimmune interactions, leading to a potential reduction in postamputation pain. We utilized an ex vivo neuroma model from a phantom limb pain patient to uncover that the oligodeoxynucleotide IMT504 engaged human primary MSCs to promote an anti-inflammatory microenvironment. Reverse translation experiments recapitulated these effects. Thus, in an in vivo rat model, IMT504 exhibited strong efficacy in preventing autotomy (self-mutilation) behaviors. This effect was linked to a substantial accumulation of MSCs in the neuroma and associated dorsal root ganglia and the establishment of an anti-inflammatory phenotype in these compartments. Centrally, this intervention reduced glial reactivity in the dorsal horn spinal cord, demonstrating diminished nociceptive activity. Accordingly, the exogenous systemic administration of MSCs phenocopied the behavioral effects of IMT504. Our findings underscore the mechanistic relevance of MSCs and the translational therapeutic potential of IMT504 to engage non-neuronal cells for the prevention of postamputation pain. PERSPECTIVE: The present study suggests that IMT504-dependent recruitment of endogenous MSCs within severely injured nerves may prevent post-amputation pain by modifying the inflammatory scenario at relevant sites in the pain pathway. Reinforcing data in rat and human tissues supports the potential therapeutic value of IMT504 in patients suffering postamputation pain.
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Affiliation(s)
- Mailín Casadei
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Bernardo Miguel
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Julia Rubione
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Esteban Fiore
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Diego Mengelle
- Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | - Alejandro Montaner
- Instituto de Ciencia y Tecnología “César Milstein”, CONICET-Fundación Pablo Cassará, Buenos Aires, Argentina, C1440FFX
| | - Marcelo J. Villar
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | | | - Pablo R. Brumovsky
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
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10
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Ahmed S, Roth D, Hulsman L, Gross JN, Weber EL, Archual A, Christie BM, Danforth RM, Adkinson JM, Hassanein AH. Active nerve management for above the knee amputation: A comparison of through the wound versus posterior approach. J Plast Reconstr Aesthet Surg 2024; 94:40-42. [PMID: 38749367 DOI: 10.1016/j.bjps.2024.05.007] [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: 02/19/2024] [Accepted: 05/03/2024] [Indexed: 06/17/2024]
Abstract
Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.
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Affiliation(s)
- Shahnur Ahmed
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dylan Roth
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Luci Hulsman
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey N Gross
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin L Weber
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anthony Archual
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brian M Christie
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rachel M Danforth
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joshua M Adkinson
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Huang HH, Hargrove LJ, Ortiz-Catalan M, Sensinger JW. Integrating Upper-Limb Prostheses with the Human Body: Technology Advances, Readiness, and Roles in Human-Prosthesis Interaction. Annu Rev Biomed Eng 2024; 26:503-528. [PMID: 38594922 DOI: 10.1146/annurev-bioeng-110222-095816] [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: 04/11/2024]
Abstract
Significant advances in bionic prosthetics have occurred in the past two decades. The field's rapid expansion has yielded many exciting technologies that can enhance the physical, functional, and cognitive integration of a prosthetic limb with a human. We review advances in the engineering of prosthetic devices and their interfaces with the human nervous system, as well as various surgical techniques for altering human neuromusculoskeletal systems for seamless human-prosthesis integration. We discuss significant advancements in research and clinical translation, focusing on upper limbprosthetics since they heavily rely on user intent for daily operation, although many discussed technologies have been extended to lower limb prostheses as well. In addition, our review emphasizes the roles of advanced prosthetics technologies in complex interactions with humans and the technology readiness levels (TRLs) of individual research advances. Finally, we discuss current gaps and controversies in the field and point out future research directions, guided by TRLs.
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Affiliation(s)
- He Helen Huang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, North Carolina, USA;
| | - Levi J Hargrove
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
- Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Max Ortiz-Catalan
- Medical Bionics Department, University of Melbourne, Melbourne, Australia
- Bionics Institute, Melbourne, Australia
| | - Jonathon W Sensinger
- Institute of Biomedical Engineering, University of New Brunswick, Fredericton, New Brunswick, Canada;
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12
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Li AT, Garcia N, Angliss M, Paul E, Gray S, Bruscino-Raiola F. Acute versus non-acute targeted muscle reinnervation for pain control following major limb amputation: A comparative study. J Plast Reconstr Aesthet Surg 2024; 94:229-237. [PMID: 38823079 DOI: 10.1016/j.bjps.2024.05.011] [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: 09/23/2022] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Targeted muscle reinnervation (TMR) has been shown to reduce phantom limb pain (PLP) and residual limb pain (RLP) after major limb amputation. However, the effect of the timing of surgery on pain control and quality of life outcomes is controversial. We conducted a retrospective study to compare the outcomes of acute TMR for pain prevention with non-acute TMR for the treatment of established pain. METHODS All patients treated with TMR in our institution between January 2018 and December 2021 were evaluated at 6, 12, 18 and 24 months post-operatively. Pain intensity and quality of life outcomes were assessed using the Brief Pain Inventory (Pain Severity and Pain Interference scales) and Pain Catastrophizing Scale. Outcomes were compared between acute and non-acute TMR using the Wilcoxon ranked-sum test or Fisher's exact test as appropriate. Multilevel mixed-effects linear regression was used to account for repeat measures and potential pain confounders. RESULTS Thirty-two patients with 38 major limb amputations were included. Acute TMR patients reported significantly lower RLP and PLP scores, pain interference and pain catastrophisation at all time points (p < 0.05). Acute TMR was significantly associated with lower pain severity and pain interference in a linear mixed-effects model accounting for patient age, gender, amputation indication, amputation site, time post-TMR and repeated surveys (p < 0.05). There was no significant difference in the complication rate (p = 0.51). CONCLUSION Acute TMR was associated with clinically and statistically significant pain outcomes that were better than that in non-acute TMR. This suggests that TMR should be performed with preventative intent, when possible, as part of a multidisciplinary approach to pain management, rather than deferred until the development of chronic pain.
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Affiliation(s)
- Andrew T Li
- EJ Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Melbourne, Australia; Advanced Surgical Amputee Programme, The Alfred Hospital, Melbourne, Australia.
| | - Nicole Garcia
- EJ Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Melbourne, Australia; Advanced Surgical Amputee Programme, The Alfred Hospital, Melbourne, Australia
| | - Margaret Angliss
- EJ Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Melbourne, Australia; Advanced Surgical Amputee Programme, The Alfred Hospital, Melbourne, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Monash/Alfred Biostatistics Consulting Platform, The Alfred Hospital, Melbourne, Australia
| | - Steven Gray
- EJ Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Melbourne, Australia; Advanced Surgical Amputee Programme, The Alfred Hospital, Melbourne, Australia
| | - Frank Bruscino-Raiola
- EJ Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Melbourne, Australia; Advanced Surgical Amputee Programme, The Alfred Hospital, Melbourne, Australia
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13
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Festin C, Ortmayr J, Maierhofer U, Tereshenko V, Blumer R, Schmoll M, Carrero-Rojas G, Luft M, Laengle G, Farina D, Bergmeister KD, Aszmann OC. Creation of a biological sensorimotor interface for bionic reconstruction. Nat Commun 2024; 15:5337. [PMID: 38914540 PMCID: PMC11196281 DOI: 10.1038/s41467-024-49580-8] [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: 08/07/2023] [Accepted: 06/12/2024] [Indexed: 06/26/2024] Open
Abstract
Neuromuscular control of bionic arms has constantly improved over the past years, however, restoration of sensation remains elusive. Previous approaches to reestablish sensory feedback include tactile, electrical, and peripheral nerve stimulation, however, they cannot recreate natural, intuitive sensations. Here, we establish an experimental biological sensorimotor interface and demonstrate its potential use in neuroprosthetics. We transfer a mixed nerve to a skeletal muscle combined with glabrous dermal skin transplantation, thus forming a bi-directional communication unit in a rat model. Morphological analyses indicate reinnervation of the skin, mechanoreceptors, NMJs, and muscle spindles. Furthermore, sequential retrograde labeling reveals specific sensory reinnervation at the level of the dorsal root ganglia. Electrophysiological recordings show reproducible afferent signals upon tactile stimulation and tendon manipulation. The results demonstrate the possibility of surgically creating an interface for both decoding efferent motor control, as well as encoding afferent tactile and proprioceptive feedback, and may indicate the way forward regarding clinical translation of biological communication pathways for neuroprosthetic applications.
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Affiliation(s)
- Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Joachim Ortmayr
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- 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
| | - Martin Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Génova Carrero-Rojas
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
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Cauley RP, Rahmani B, Adebagbo OD, Park J, Garvey SR, Chen A, Nickman S, Tobin M, Valentine L, Weidman AA, Singhal D, Dowlatshahi A, Lin SJ, Lee BT. Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review. J Reconstr Microsurg 2024. [PMID: 38782025 DOI: 10.1055/a-2331-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS (1) medical optimization and prehabilitation, (2) surgical mitigation techniques. CONCLUSION Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.
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Affiliation(s)
- Ryan P Cauley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Rahmani
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun D Adebagbo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - John Park
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sasha Nickman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Micaela Tobin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan Dowlatshahi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Granata G, Di Iorio R, Ilari S, Angeloni BM, Tomasello F, Cimmino AT, Carrarini C, Marrone A, Iodice F. Phantom limb syndrome: from pathogenesis to treatment. A narrative review. Neurol Sci 2024:10.1007/s10072-024-07634-1. [PMID: 38853232 DOI: 10.1007/s10072-024-07634-1] [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: 11/24/2023] [Accepted: 06/04/2024] [Indexed: 06/11/2024]
Abstract
Phantom Limb Syndrome (PLS) can be defined as the disabling or painful sensation of the presence of a body part that is no longer present after its amputation. Anatomical changes involved in Phantom Limb Syndrome, occurring at peripheral, spinal and brain levels and include the formation of neuromas and scars, dorsal horn sensitization and plasticity, short-term and long-term modifications at molecular and topographical levels. The molecular reorganization processes of Phantom Limb Syndrome include NMDA receptors hyperactivation in the dorsal horn of the spinal column leading to inflammatory mechanisms both at a peripheral and central level. At the brain level, a central role has been recognized for sodium channels, BDNF and adenosine triphosphate receptors. In the paper we discuss current available pharmacological options with a final overview on non-pharmacological options in the pipeline.
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Affiliation(s)
- Giuseppe Granata
- Institute of Neurology, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Riccardo Di Iorio
- Institute of Neurology, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Sara Ilari
- Laboratory of Physiology and Pharmacology of Pain, IRCCS San Raffaele, Rome, Italy
| | | | - Fabiola Tomasello
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Claudia Carrarini
- Department of Neuroscience, Catholic University of the Sacred Heart, Rome, Italy
- Institute of Neurology and Neurorehabilitation, IRCCS San Raffaele, Via Della Pisana 235, 00160, Rome, Italy
| | - Antonio Marrone
- Institute of Neurology and Neurorehabilitation, IRCCS San Raffaele, Via Della Pisana 235, 00160, Rome, Italy
| | - Francesco Iodice
- Institute of Neurology and Neurorehabilitation, IRCCS San Raffaele, Via Della Pisana 235, 00160, Rome, Italy.
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16
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Gstoettner C, Laengle G, Harnoncourt L, Sassu P, Aszmann OC. Targeted muscle reinnervation in bionic upper limb reconstruction: current status and future directions. J Hand Surg Eur Vol 2024; 49:783-791. [PMID: 38366374 DOI: 10.1177/17531934241227795] [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: 02/18/2024]
Abstract
Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man-machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Leopold Harnoncourt
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Paolo Sassu
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
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17
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Hysong AA, Melamed E, Delarosa MR, Daley DN, Loeffler BJ, Gaston RG. Feasibility of Nerve Transfer to Palmaris Longus in Forearm-Level TMR: Anatomic Study and Clinical Series. Hand (N Y) 2024; 19:562-567. [PMID: 36510365 PMCID: PMC11141416 DOI: 10.1177/15589447221137615] [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: 12/15/2022]
Abstract
BACKGROUND Targeted muscle re-innervation (TMR) is increasingly being used for treatment of postamputation pain and myoelectric prosthesis (MYP) control. Palmaris longus (PL) is a potential target following transradial amputation. The purpose of this study was to determine the branching pattern of the median nerve (MN) as it pertains to the PL motor branch entry point (MEP) and to present clinical results of patients who had PL used as a target. METHODS Eight cadaveric arms were dissected and branching patterns of the MN were documented. Additionally, we reviewed adult patients from a prospectively collected database who underwent TMR using PL. We recorded patient-reported outcomes and signal strength generated by the PL. RESULTS The average distance from the medial epicondyle to PL MEP was 53 mm. All palmaris motor branches passed through a chiasm within the flexor digitorum superficialis muscle belly, which was a mean of 18 mm away from the MN proper. Patients with long-term follow-up reported an average Pain visual analog scale of 3.3 and Disabilities of the Arm, Shoulder and Hand of 46.2. All but one patient were using an MYP, and all generated at least 10 mV of signal from the PL, which is ample signal for surface electrode detection and MYP control. There were no postoperative neuromas and only one patient-reported postoperative phantom limb pain. CONCLUSIONS Palmaris longus is a suitable target for TMR. Our objective measurements and anatomic relationships may help surgeons consistently find the PL's motor branch. Our series of patients reveal sufficient signal strength and acceptable clinical outcomes following TMR using the PL.
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Affiliation(s)
| | | | | | - Dane N. Daley
- Medical University of South Carolina, Charleston, USA
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18
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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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19
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Keen MP, Al-Ajam Y, Kang N. Targeted muscle reinnervation surgery in a patient with neurofibromatosis type 1. JPRAS Open 2024; 40:259-261. [PMID: 38689635 PMCID: PMC11059442 DOI: 10.1016/j.jpra.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Miss P. Keen
- Imperial College School of Medicine, London, SW7 2AZ, UK
| | | | - N. Kang
- Royal Free Hospital, London NW3 2QG, UK
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20
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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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Rivero S, Stevens NM. The nonsalvageable tibia: amputation and prosthetics. OTA Int 2024; 7:e306. [PMID: 38840707 PMCID: PMC11149746 DOI: 10.1097/oi9.0000000000000306] [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] [Received: 10/18/2023] [Revised: 11/17/2023] [Accepted: 12/01/2023] [Indexed: 06/07/2024]
Abstract
Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.
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Aman M, Struebing F, Mayrhofer-Schmid M, Harhaus L, Kneser U, Böcker AH. [Bionic Surgery Meets Bionic Reconstruction - First In-human use of Robotic Microsurgery in Targeted Muscle Reinnervation]. HANDCHIR MIKROCHIR P 2024; 56:257-260. [PMID: 38513691 DOI: 10.1055/a-2241-5678] [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: 03/23/2024] Open
Abstract
Robotic microsurgery is an emerging field in reconstructive surgery, which provides benefits such as improved precision, optimal ergonomics, and reduced tremors. However, only a few robotic platforms are available for performing microsurgical procedures, and successful nerve coaptation is still a challenge. Targeted muscle reinnervation (TMR) is an innovative reconstructive procedure that rewires multiple nerves to remnant stump muscles, thereby reducing neuroma and phantom limb pain and improving the control of bionic prostheses. The precision of surgical techniques is critical in reducing axonal sprouting around the coaptation site to minimise the potential for neuroma formation. This study reports the first use of a microsurgical robotic platform for multiple nerve transfers in a patient undergoing TMR for bionic extremity reconstruction. The Symani robotic platform, combined with external microscope magnification, was successfully used, and precise handling of nerve tissue and coaptation was easily feasible even in anatomically challenging environments. While the precision and stability offered by robotic assistance may be especially useful for nerve surgery, the high economic costs of robotic microsurgery remain a major challenge for current healthcare systems. In conclusion, this study demonstrated the feasibility of using a robotic microsurgical platform for nerve surgery and transfers, where precise handling of tissue is crucial and limited space is available. Future studies will explore the full potential of robotic microsurgery in the future.
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Affiliation(s)
- Martin Aman
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
| | - Felix Struebing
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
- Klinik für Plastische und Handchirurgie der Universität Heidelberg, Heidelberg, Germany
| | - Maximilian Mayrhofer-Schmid
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
- Klinik für Plastische und Handchirurgie der Universität Heidelberg, Heidelberg, Germany
| | - Leila Harhaus
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
- Klinik für Plastische und Handchirurgie der Universität Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
- Klinik für Plastische und Handchirurgie der Universität Heidelberg, Heidelberg, Germany
| | - Arne Hendrik Böcker
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Unfallklinik Ludwigshafen, Ludwigshafen, Germany
- Klinik für Plastische und Handchirurgie der Universität Heidelberg, Heidelberg, Germany
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23
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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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24
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Kwee E, Langeveld M, Duraku LS, Hundepool CA, Zuidam M. Surgical Treatment of Neuropathic Chronic Postherniorrhaphy Inguinal Pain: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:2812. [PMID: 38792355 PMCID: PMC11122157 DOI: 10.3390/jcm13102812] [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: 03/17/2024] [Revised: 04/14/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Neuropathic chronic postherniorrhaphy inguinal pain (CPIP) is a serious adverse outcome following inguinal hernia repair surgery. The optimal surgical treatment for neuropathic CPIP remains controversial in the current literature. This systematic review aims to evaluate the effectiveness of various surgical techniques utilized to manage neuropathic CPIP. Methods: The electronic databases Medline, Embase, Web of Science, Cochrane Central, and Google Scholar were searched. Inclusion criteria were defined to select studies reporting on the efficacy of surgical interventions in patients with neuropathic CPIP. The primary outcome was postoperative pain relief, as determined by postoperative numerical or nonnumerical pain scores. Results: Ten studies met the inclusion criteria. Three surgical techniques were identified: selective neurectomy, triple neurectomy, and targeted muscle reinnervation. Proportions of good postoperative results of the surgical techniques ranged between 46 and 88 percent. Overall, the surgical treatment of neuropathic CPIP achieved a good postoperative result in 68 percent (95% CI, 49 to 82%) of neuropathic CPIP patients (n = 244), with targeted muscle reinnervation yielding the highest proportion of good postoperative results. Conclusions: The surgical treatment of neuropathic CPIP is generally considered safe and has demonstrated effective pain relief across various surgical techniques. Targeted muscle reinnervation exhibits considerable potential for surpassing current success rates in inguinal hernia repair surgery.
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Affiliation(s)
- Esmee Kwee
- Department of Plastic, Reconstructive Surgery and Handsurgery, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (E.K.)
| | - Mirte Langeveld
- Department of Plastic, Reconstructive Surgery and Handsurgery, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (E.K.)
| | - Liron S. Duraku
- Department of Plastic, Reconstructive Surgery and Handsurgery, Amsterdam University Medical Center, 1105AZ Amsterdam, The Netherlands
| | - Caroline A. Hundepool
- Department of Plastic, Reconstructive Surgery and Handsurgery, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (E.K.)
| | - Michiel Zuidam
- Department of Plastic, Reconstructive Surgery and Handsurgery, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; (E.K.)
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25
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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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26
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Anderson AB, Rivera JA, McGlone PJ, Saberski ER, Tintle SM, Potter BK. Technical Trick: Cryoneurolysis for Subacute Pain Mitigation in Patients With Limb Loss. J Orthop Trauma 2024; 38:e191-e194. [PMID: 38252476 DOI: 10.1097/bot.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 01/23/2024]
Abstract
SUMMARY Pain after amputation is often managed by target muscle reinnervation (TMR) with the added benefit that TMR also provides improved myoelectric terminal device control. However, as TMR takes several months for the recipient muscles to reliably reinnervate, this technique does not address pain within the subacute postoperative period during which pain chronification, sensitization, and opioid dependence and misuse may occur. Cryoneurolysis, described herein, uses focused, extreme temperatures to essentially "freeze" the nerve, blocking nociception, and improving pain in treated nerves potentially reducing the chances of pain chronification, sensitization, and substance dependence or abuse.
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Affiliation(s)
- Ashley B Anderson
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Julio A Rivera
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD; and
| | - Patrick J McGlone
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Ean R Saberski
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Plastics and Reconstructive Surgery, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Scott M Tintle
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Benjamin K Potter
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
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27
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Bishay J, Yeap I, Wang T. The effectiveness of targeted muscle reinnervation in reducing pain and improving quality of life for patients following lower limb amputation. J Plast Reconstr Aesthet Surg 2024; 92:288-298. [PMID: 38599000 DOI: 10.1016/j.bjps.2024.03.013] [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: 12/21/2023] [Accepted: 03/18/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation. METHODS A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures. RESULTS In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores. CONCLUSION The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.
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Affiliation(s)
- Jeremy Bishay
- Department of Plastic Surgery, Royal North Shore Hospital, Reserve road, St Leonards, New South Wales 2065, Australia.
| | - Isobel Yeap
- Department of Plastic Surgery, Royal North Shore Hospital, Reserve road, St Leonards, New South Wales 2065, Australia
| | - Tim Wang
- Department of Plastic Surgery, Royal North Shore Hospital, Reserve road, St Leonards, New South Wales 2065, Australia
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28
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Slavin BR, Markowitz MI, Klifto KM, Prologo FJ, Taghioff SM, Dellon AL. Cryoanalgesia: Review with Respect to Peripheral Nerve. J Reconstr Microsurg 2024; 40:302-310. [PMID: 37751885 DOI: 10.1055/a-2182-1198] [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: 09/28/2023]
Abstract
BACKGROUND Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons. METHODS Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data were analyzed using Fisher's exact and analysis of variance tests. A similar approach was used for pudendal cryoanalgesia. RESULTS Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia with pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute postoperative pain. One study compared cryoanalgesia with local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia with epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using computed tomography imaging with positive outcomes for the patient with pain of pudendal nerve origin. CONCLUSION Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.
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Affiliation(s)
- Benjamin R Slavin
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Moses I Markowitz
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kevin M Klifto
- Division of Plastic Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Frank J Prologo
- Department of Biological Sciences, University of Georgia, Athens, Georgia
| | - Susan M Taghioff
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - A Lee Dellon
- Department of Neurosurgery and Plastic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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29
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Lemaire-Petit A, Milaire A, Amar S, Redais C, Chataigneau A, Bernard JN, Belkheyar Z, Mathieu L. Surgical treatment of painful neuroma in amputated and non-amputated patients: does the level of neurotomy affect clinical outcomes? Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02529-4. [PMID: 38662211 DOI: 10.1007/s00068-024-02529-4] [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: 01/21/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE To compare the outcomes of distal neurotomy (DN) versus proximal neurotomy (PN) for the surgical management of painful neuromas in amputees and non-amputees, whether used in passive or active treatment. METHODS A retrospective study was conducted on patients who underwent surgery for painful traumatic neuromas between 2019 and 2022. DN with neuroma excision was performed at the level of the injury or amputation. PN was performed using a separate proximal approach without neuroma excision. Outcomes included a Numerical Rating Scale (NRS) score and Patient-Reported Outcomes Measurement Information System (PROMIS) scores, as well as patients' subjective assessments. RESULTS A total of 33 patients were included: 17 amputees and 16 non-amputees. They totalized 43 neuromas treated by DN in 21 cases and PN in 22 cases. At the median follow-up time of 13 months, there were significant decreases in all NRS and PROMIS scores in the whole series. The decrease in limb pain scores was not significantly different between groups, except for the decrease in pain interference and patient satisfaction which were higher in the DN group. Sub-group analyses found the same significant differences in amputees. Targeted muscle reinnervation (TMR) was associated with a higher decrease in PROMIS scores. CONCLUSION DN seemed to give better results in amputees but there were confusing factors related to associated lesions. In other situations, the non-inferiority of PN was demonstrated. PN could be of interest for treating neuromas of superficial sensory nerves, for avoiding direct revision of a well-fitted stump and in conjunction with TMR.
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Affiliation(s)
- Aurore Lemaire-Petit
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart, 92140, France
| | - Alexia Milaire
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart, 92140, France
| | - Sarah Amar
- Department of Orthopedic and Trauma Surgery, Bégin Military Hospital, 69 Avenue de Paris, Saint-Mandé, 94160, France
| | - Claire Redais
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart, 92140, France
| | - Anaïs Chataigneau
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart, 92140, France
| | - Jean-Noël Bernard
- Department of Lower Extremity Surgery, Edouard Herriot Hospital, 5 Place d'Arsonval, Lyon, 69003, France
| | - Zoubir Belkheyar
- Brachial Plexus and Peripheral Nerve Surgery Unit, Mont-Louis Private Hospital, 8 rue de la Folie-Regnault, Paris, 75011, France
| | - Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, Clamart, 92140, France.
- Department of Hand and Upper Extremity Surgery, Edouard Herriot Hospital, 5 Place d'Arsonval, Lyon, 69003, France.
- Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, Paris, 75005, France.
- Military Biomedical Research Institute (IRBA), 1 Place Général Valérie André, Brétigny-sur-Orge, 91220, France.
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30
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Wan T, Li QC, Qin MY, Wang YL, Zhang FS, Zhang XM, Zhang YC, Zhang PX. Strategies for Treating Traumatic Neuromas with Tissue-Engineered Materials. Biomolecules 2024; 14:484. [PMID: 38672500 PMCID: PMC11048257 DOI: 10.3390/biom14040484] [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: 02/18/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Neuroma, a pathological response to peripheral nerve injury, refers to the abnormal growth of nerve tissue characterized by disorganized axonal proliferation. Commonly occurring after nerve injuries, surgeries, or amputations, this condition leads to the formation of painful nodular structures. Traditional treatment options include surgical excision and pharmacological management, aiming to alleviate symptoms. However, these approaches often offer temporary relief without addressing the underlying regenerative challenges, necessitating the exploration of advanced strategies such as tissue-engineered materials for more comprehensive and effective solutions. In this study, we discussed the etiology, molecular mechanisms, and histological morphology of traumatic neuromas after peripheral nerve injury. Subsequently, we summarized and analyzed current nonsurgical and surgical treatment options, along with their advantages and disadvantages. Additionally, we emphasized recent advancements in treating traumatic neuromas with tissue-engineered material strategies. By integrating biomaterials, growth factors, cell-based approaches, and electrical stimulation, tissue engineering offers a comprehensive solution surpassing mere symptomatic relief, striving for the structural and functional restoration of damaged nerves. In conclusion, the utilization of tissue-engineered materials has the potential to significantly reduce the risk of neuroma recurrence after surgical treatment.
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Affiliation(s)
- Teng Wan
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Qi-Cheng Li
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Ming-Yu Qin
- Suzhou Medical College, Soochow University, Suzhou 215026, China
| | - Yi-Lin Wang
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Feng-Shi Zhang
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Xiao-Meng Zhang
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Yi-Chong Zhang
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People’s Hospital, Beijing 100044, China; (T.W.)
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing 100044, China
- National Centre for Trauma Medicine, Beijing 100044, China
- Beijing Laboratory of Trauma and Nerve Regeneration, Peking University, Beijing 100044, China
- Peking University People’s Hospital Qingdao Hospital, Qingdao 266000, China
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31
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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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32
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Zhou W, Rahman MSU, Sun C, Li S, Zhang N, Chen H, Han CC, Xu S, Liu Y. Perspectives on the Novel Multifunctional Nerve Guidance Conduits: From Specific Regenerative Procedures to Motor Function Rebuilding. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2307805. [PMID: 37750196 DOI: 10.1002/adma.202307805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/19/2023] [Indexed: 09/27/2023]
Abstract
Peripheral nerve injury potentially destroys the quality of life by inducing functional movement disorders and sensory capacity loss, which results in severe disability and substantial psychological, social, and financial burdens. Autologous nerve grafting has been commonly used as treatment in the clinic; however, its rare donor availability limits its application. A series of artificial nerve guidance conduits (NGCs) with advanced architectures are also proposed to promote injured peripheral nerve regeneration, which is a complicated process from axon sprouting to targeted muscle reinnervation. Therefore, exploring the interactions between sophisticated NGC complexes and versatile cells during each process including axon sprouting, Schwann cell dedifferentiation, nerve myelination, and muscle reinnervation is necessary. This review highlights the contribution of functional NGCs and the influence of microscale biomaterial architecture on biological processes of nerve repair. Progressive NGCs with chemical molecule induction, heterogenous topographical morphology, electroactive, anisotropic assembly microstructure, and self-powered electroactive and magnetic-sensitive NGCs are also collected, and they are expected to be pioneering features in future multifunctional and effective NGCs.
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Affiliation(s)
- Weixian Zhou
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing, 100049, P. R. China
| | - Muhammad Saif Ur Rahman
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
- Key Laboratory of Optoelectronic Devices and Systems of Ministry of Education Guangdong province, College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, P. R. China
| | - Chengmei Sun
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
- Key Laboratory of Optoelectronic Devices and Systems of Ministry of Education Guangdong province, College of Physics and Optoelectronic Engineering, Shenzhen University, Shenzhen, 518060, P. R. China
| | - Shilin Li
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing, 100049, P. R. China
| | - Nuozi Zhang
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
| | - Hao Chen
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
| | - Charles C Han
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
- Materials Science and Engineering, University of Maryland, College Park, MD, 20742, USA
| | - Shanshan Xu
- Institute for Advanced Study, Shenzhen University, Shenzhen, 518060, P. R. China
- Materials Science and Engineering, University of Maryland, College Park, MD, 20742, USA
| | - Ying Liu
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety & CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing, 100049, P. R. China
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Lambie CJ, Moura SP, Eftekari SC, Sears LA, Donnelly D'AT, Shaffrey EC, Dingle AM. Social media analysis of pain outcomes following targeted muscle reinnervation. J Plast Reconstr Aesthet Surg 2024; 91:236-240. [PMID: 38428231 DOI: 10.1016/j.bjps.2024.02.051] [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: 12/03/2023] [Accepted: 02/04/2024] [Indexed: 03/03/2024]
Abstract
AIM Targeted muscle reinnervation (TMR) was developed to improve myoelectric prosthesis control for amputees; however, it has become an area of interest in pain modulation. Evidences indicate that this procedure alleviates chronic pain in amputees. The primary objective of this study was to use social media analysis to understand patients' post-operative pain, satisfaction, and recovery time after TMR. METHODS Data were collected from one Facebook group via posts and comments referencing TMR. Posts published between January 1, 2020, and March 24, 2023 were analyzed. Data collected included pain prior to surgery, pain in immediate post-op period, and change in pain after surgery. RESULTS Forty-three individuals commented on their TMR experience. Among them, 31 had favorable surgical outcomes, 7 felt that the surgery worsened their pain or there was no significant change in their pain levels, and 5 commented during the initial post-operative period. Twenty-four patients described their pain in the immediate post-operative period and all patients said that the post-operative pain was worse than chronic pain. Among the 28 authors who commented on overall reduction in chronic pain, 24 reported that TMR reduced their pain, whereas 4 reported no change or worsened pain. CONCLUSIONS The number of patients (24) who reported improvement in chronic pain aligns with the results in current literature suggesting that TMR is a viable treatment option for pain management. With the current medical management of similar conditions, up to 80% of patients remain unsatisfied with pain management. This analysis supports the evidence that TMR is an effective treatment for patients experiencing post-amputation pain.
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Affiliation(s)
- Caden J Lambie
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA.
| | - Steven P Moura
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Sahand C Eftekari
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Lucas A Sears
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - D 'Andrea T Donnelly
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Ellen C Shaffrey
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
| | - Aaron M Dingle
- Division of Plastics and Reconstructive Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA
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Wee C, Boas S, Coquillard C, Cai Y, Kurlander D, Maasarani S, Leavitt T, Long T, Lineberry K, Khouri J. Combined Targeted Muscle Reinnervation With Regenerative Peripheral Nerve Interfaces Decreases Long-Term Narcotic Use in Amputees: A Case Control Study. Ann Plast Surg 2024; 92:432-436. [PMID: 38527350 DOI: 10.1097/sap.0000000000003836] [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: 03/27/2024]
Abstract
PURPOSE Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. METHODS This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. RESULTS Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). CONCLUSIONS This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.
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Affiliation(s)
- Corinne Wee
- From the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel Boas
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Yida Cai
- Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - David Kurlander
- Department of Plastic Surgery, Rush University Medical Center, Chicago, IL
| | - Samantha Maasarani
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Tripp Leavitt
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX
| | - Tobias Long
- Penn State Department of Plastic Surgery, Reading, PA
| | | | - Joseph Khouri
- Division of Plastic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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Moradian S, Taritsa IC, Sharma S, Mioton L, Dumanian GA, Ko JH. Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5742. [PMID: 38623447 PMCID: PMC11018179 DOI: 10.1097/gox.0000000000005742] [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: 10/13/2023] [Accepted: 02/20/2024] [Indexed: 04/17/2024]
Abstract
Background Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. Methods A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Results Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. Conclusions TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.
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Affiliation(s)
- Simon Moradian
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Iulianna C. Taritsa
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Sripadh Sharma
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Lauren Mioton
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Gregory A. Dumanian
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jason H. Ko
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Cohen SP, Caterina MJ, Yang SY, Socolovsky M, Sommer C. Pain in the Context of Sensory Deafferentation. Anesthesiology 2024; 140:824-848. [PMID: 38470115 DOI: 10.1097/aln.0000000000004881] [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: 03/13/2024]
Abstract
Pain that accompanies deafferentation is one of the most mysterious and misunderstood medical conditions. Prevalence rates for the assorted conditions vary considerably but the most reliable estimates are greater than 50% for strokes involving the somatosensory system, brachial plexus avulsions, spinal cord injury, and limb amputation, with controversy surrounding the mechanistic contributions of deafferentation to ensuing neuropathic pain syndromes. Deafferentation pain has also been described for loss of other body parts (e.g., eyes and breasts) and may contribute to between 10% and upwards of 30% of neuropathic symptoms in peripheral neuropathies. There is no pathognomonic test or sign to identify deafferentation pain, and part of the controversy surrounding it stems from the prodigious challenges in differentiating cause and effect. For example, it is unknown whether cortical reorganization causes pain or is a byproduct of pathoanatomical changes accompanying injury, including pain. Similarly, ascertaining whether deafferentation contributes to neuropathic pain, or whether concomitant injury to nerve fibers transmitting pain and touch sensation leads to a deafferentation-like phenotype can be clinically difficult, although a detailed neurologic examination, functional imaging, and psychophysical tests may provide clues. Due in part to the concurrent morbidities, the physical, psychologic, and by extension socioeconomic costs of disorders associated with deafferentation are higher than for other chronic pain conditions. Treatment is symptom-based, with evidence supporting first-line antineuropathic medications such as gabapentinoids and antidepressants. Studies examining noninvasive neuromodulation and virtual reality have yielded mixed results.
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Affiliation(s)
- Steven P Cohen
- Departments of Anesthesiology, Neurology, Physical Medicine and Rehabilitation, Psychiatry and Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Departments of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Michael J Caterina
- Neurosurgery Pain Research Institute and Department of Biological Chemistry, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Su-Yin Yang
- Psychology Service, Woodlands Health, and Adjunct Faculty, Lee Kong Chian School of Medicine, Singapore
| | - Mariano Socolovsky
- Department of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
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Smith TP, Cognetti DJ, Cook A, Lynch TB, Alderete JF, Lybeck DO, Dowd TC. Similar rates of reoperation for neuroma after transtibial amputations with and without targeted muscle reinnervation. OTA Int 2024; 7:e297. [PMID: 38433988 PMCID: PMC10906631 DOI: 10.1097/oi9.0000000000000297] [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: 11/27/2022] [Revised: 09/13/2023] [Accepted: 10/14/2023] [Indexed: 03/05/2024]
Abstract
Objective To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR). Design Retrospective cohort study. Setting Level I trauma hospital and tertiary military medical center. Patients/Participants Adult patients undergoing transtibial amputations with and without TMR. Intervention Transtibial amputation with targeted muscle reinnervation. Main Outcome Measurements Reoperation for symptomatic neuroma. Results During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97). Conclusions Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Alyssa Cook
- San Antonio Military Medical Center, San Antonio, TX
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Liu WC, Raasveld FV, Mayrhofer-Schmid M, Eberlin KR, Valerio IL. Three Useful Tips and Tricks for Intraoperative Nerve Stimulation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5640. [PMID: 38463708 PMCID: PMC10923343 DOI: 10.1097/gox.0000000000005640] [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: 08/01/2023] [Accepted: 01/16/2024] [Indexed: 03/12/2024]
Abstract
Disposable handheld nerve stimulators are widely used in peripheral nerve surgery. Such devices stimulate a motor nerve or the motor component of a mixed nerve by applying electrical current to the proximal region, targeting the main nerve trunk. This stimulation then travels along the motor nerve, reaching the distal end to control the corresponding muscle(s). In this study, the authors demonstrate three useful tips and tricks for handheld nerve stimulation during targeted muscle reinnervation and peripheral nerve surgery. The three tips are (1) identification of proximal muscle contraction by retrograde electrical stimulation of a distal sensory nerve; (2) graded stimulation for identifying motor nerves within fibrotic scarred tissue beds or parallel to the major motor/mixed nerve of interest; and (3) proximal stimulation for validation of adequate post-targeted muscle reinnervation coaptation(s).
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Affiliation(s)
- Wen-Chih Liu
- From the Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
- Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Floris V Raasveld
- From the 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
| | - Maximilian Mayrhofer-Schmid
- From the Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive 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
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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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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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Lowe AL, Rivera Santana MV, Bopp T, Quinn KN, Johnson J, Ward C, Chung TH, Tuffaha S, Thakor NV. Volume loss during muscle reinnervation surgery is correlated with reduced CMAP amplitude but not reduced force output in a rat hindlimb model. Front Physiol 2024; 15:1328520. [PMID: 38426207 PMCID: PMC10902164 DOI: 10.3389/fphys.2024.1328520] [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: 10/26/2023] [Accepted: 02/01/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction: Muscle reinnervation (MR) surgery offers rehabilitative benefits to amputees by taking severely damaged nerves and providing them with new denervated muscle targets (DMTs). However, the influence of physical changes to muscle tissue during MR surgery on long-term functional outcomes remains understudied. Methods: Our rat hindlimb model of MR surgery utilizes vascularized, directly neurotized DMTs made from the lateral gastrocnemius (LG), which we employed to assess the impact of muscle tissue size on reinnervation outcomes, specifically pairing the DMT with the transected peroneal nerve. We conducted MR surgery with both DMTs at full volume and DMTs with partial volume loss of 500 mg at the time of surgery (n = 6 per group) and measured functional outcomes after 100 days of reinnervation. Compound motor action potentials (CMAPs) and isometric tetanic force production was recorded from reinnervated DMTs and compared to contralateral naïve LG muscles as positive controls. Results: Reinnervated DMTs consistently exhibited lower mass than positive controls, while DMTs with partial volume loss showed no significant mass reduction compared to full volume DMTs (p = 0.872). CMAP amplitudes were lower on average in reinnervated DMTs, but a broad linear correlation also exists between muscle mass and maximum CMAP amplitude irrespective of surgical group (R2 = 0.495). Surprisingly, neither MR group, with or without volume loss, demonstrated decreased force compared to positive controls. The average force output of reinnervated DMTs, as a fraction of the contralateral LG's force output, approached 100% for both MR groups, a notable deviation from the 9.6% (±6.3%) force output observed in our negative control group at 7 days post-surgery. Tissue histology analysis revealed few significant differences except for a marked decrease in average muscle fiber area of reinnervated DMTs with volume loss compared to positive controls (p = 0.001). Discussion: The results from our rat model of MR suggests that tissue electrophysiology (CMAPs) and kinesiology (force production) may recover on different time scales, with volumetric muscle loss at the time of MR surgery not significantly reducing functional outcome measurements for the DMTs after 100 days of reinnervation.
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Affiliation(s)
- Alexis L. Lowe
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Taylor Bopp
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kiara N. Quinn
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Johnnie Johnson
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Christopher Ward
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Tae Hwan Chung
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Sami Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Nitish V. Thakor
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD, 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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Harnoncourt L, Gstoettner C, Laengle G, Boesendorfer A, Aszmann O. [Prosthetic Fitting Concepts after Major Amputation in the Upper Limb - an Overview of Current Possibilities]. HANDCHIR MIKROCHIR P 2024; 56:84-92. [PMID: 38417811 PMCID: PMC10954373 DOI: 10.1055/a-2260-9842] [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: 11/29/2023] [Accepted: 01/31/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND The upper extremity and particularly the hands are crucial for patients in interacting with their environment, therefore amputations or severe damage with loss of hand function significantly impact their quality of life. In cases where biological reconstruction is not feasible or does not lead to sufficient success, bionic reconstruction plays a key role in patient care. Classical myoelectric prostheses are controlled using two signals derived from surface electrodes in the area of the stump muscles. Prosthesis control, especially in high amputations, is then limited and cumbersome. The surgical technique of Targeted Muscle Reinnervation (TMR) offers an innovative solution: The major arm nerves that have lost their target organs due to amputation are rerouted to muscles in the stump area. This enables the establishment of cognitive control signals that allow significantly improved prosthesis control. PATIENTS/MATERIALS AND METHODS A selective literature review on TMR and bionic reconstruction was conducted, incorporating relevant articles and discussing them considering the clinical experience of our research group. Additionally, a clinical case is presented. RESULTS Bionic reconstruction combined with Targeted Muscle Reinnervation enables intuitive prosthetic control with simultaneous movement of various prosthetic degrees of freedom and the treatment of neuroma and phantom limb pain. Long-term success requires a high level of patient compliance and intensive signal training during the prosthetic rehabilitation phase. Despite technological advances, challenges persist, especially in enhancing signal transmission and integrating natural sensory feedback into bionic prostheses. CONCLUSION TMR surgery represents a significant advancement in the bionic care of amputees. Employing selective nerve transfers for signal multiplication and amplification, opens up possibilities for improving myoelectric prosthesis function and thus enhancing patient care. Advances in the area of external prosthetic components, improvements in the skeletal connection due to osseointegration and more fluid signal transmission using wireless, fully implanted electrode systems will lead to significant progress in bionic reconstruction, both in terms of precision of movement and embodiment.
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Affiliation(s)
- Leopold Harnoncourt
- Klinisches Labor für Bionische Extremitätenrekonstruktion,
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie,
Medizinische Universität Wien, Wien, Austria
| | - Clemens Gstoettner
- Klinisches Labor für Bionische Extremitätenrekonstruktion,
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie,
Medizinische Universität Wien, Wien, Austria
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische
Chirurgie, Medizinische Universität Wien, Wien, Austria
| | - Gregor Laengle
- Klinisches Labor für Bionische Extremitätenrekonstruktion,
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie,
Medizinische Universität Wien, Wien, Austria
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische
Chirurgie, Medizinische Universität Wien, Wien, Austria
| | - Anna Boesendorfer
- Klinisches Labor für Bionische Extremitätenrekonstruktion,
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie,
Medizinische Universität Wien, Wien, Austria
| | - Oskar Aszmann
- Klinisches Labor für Bionische Extremitätenrekonstruktion,
Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie,
Medizinische Universität Wien, Wien, Austria
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische
Chirurgie, Medizinische Universität Wien, Wien, Austria
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Hespe GE, Brown DL. Management of Neuropathic Pain with Neurectomy Combined with Dermal Sensory Regenerative Peripheral Nerve Interface (DS-RPNI). Semin Plast Surg 2024; 38:48-52. [PMID: 38495065 PMCID: PMC10942836 DOI: 10.1055/s-0043-1778041] [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: 03/19/2024]
Abstract
Neuropathic pain affects a large percentage of the U.S. population and leads to tremendous morbidity. Numerous nonsurgical and surgical treatments have been utilized to try and manage neuropathic pain with varying degrees of success. Recent research investigating ways to improve prosthetic control have identified new mechanisms for preventing neuromas in both motor and sensory nerves with free muscle and dermal grafts, respectively. These procedures have been used to treat chronic neuropathic pain in nonamputees, as well, in order to reduce failure rates found with traditional neurectomy procedures. Herein, we focus our attention on Dermal Sensory-Regenerative Peripheral Nerve Interfaces (DS-RPNI, free dermal grafts) which can be used to physiologically "cap" sensory nerves following neurectomy and have been shown to significantly decrease neuropathic pain.
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Affiliation(s)
- Geoffrey E. Hespe
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David L. Brown
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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ElAbd R, Dow T, Jabori S, Alhalabi B, Lin SJ, Dowlatshahi S. Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review. Plast Reconstr Surg 2024; 153:494-508. [PMID: 37104493 DOI: 10.1097/prs.0000000000010598] [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: 04/28/2023]
Abstract
BACKGROUND It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.
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Affiliation(s)
- Rawan ElAbd
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
- Division of Plastic and Reconstructive Surgery, Jaber AlAhmad AlSabah Hospital
| | - Todd Dow
- Division of Plastic and Reconstructive Surgery, Dalhousie University
| | - Sinan Jabori
- Division of Plastic and Reconstructive Surgery, University of Miami
| | - Becher Alhalabi
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
| | | | - Sammy Dowlatshahi
- Division of Plastic and Reconstructive Surgery
- Division of Hand Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School
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Chang BL, Hill AL, Mondshine J, Harbour PW, Episalla NC, Attinger CE, Kleiber GM. Primary Targeted Muscle Reinnervation in Above-Knee Amputations in Patients with Unsalvageable Limbs from Limb-Threatening Ischemia or Infection. J Reconstr Microsurg 2024; 40:109-117. [PMID: 37142250 DOI: 10.1055/a-2086-0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Amputees frequently suffer from chronic pain in both their residual limbs (RLP) and phantom limbs (PLP) following their amputation. Targeted muscle reinnervation (TMR) is a nerve transfer technique that has been demonstrated to improve pain secondarily and at time of amputation. The goal of this study is to report on the efficacy of primary TMR at time of above-knee level amputations in the setting of limb-threatening ischemia or infection. METHODS This is a retrospective review of a single-surgeon experience with TMR in patients undergoing through- or above-knee level amputations from January 2018 to June 2021. Patient charts were reviewed for the comorbidities in the Charlson Comorbidity Index. Postoperative notes were assayed for presence and absence of RLP and PLP, overall pain severity, chronic narcotic use, ambulatory status, and complications. A control group of patients undergoing lower limb amputation who did not receive TMR from January 2014 to December 2017 was used for comparison. RESULTS Forty-one patients with through- or above-knee level amputations and primary TMR were included in this study. The tibial and common peroneal nerves were transferred in all cases to motor branches to the gastrocnemius, semimembranosus, semitendinosus, and biceps femoris. Fifty-eight patients with through- or above-knee level amputations without TMR were included for comparison. The TMR group had significantly less overall pain (41.5 vs. 67.2%, p = 0.01), RLP (26.8 vs. 44.8%, p = 0.04), and PLP (19.5 vs. 43.1%, p = 0.02). There were no significant differences in complication rates. CONCLUSION TMR can safely and effectively be performed at time of a through- and above-knee level amputation and improves pain outcomes.
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Affiliation(s)
- Brian L Chang
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Alison L Hill
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Joshua Mondshine
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Patrick W Harbour
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Nicole C Episalla
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Christopher E Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Grant M Kleiber
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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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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48
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Phair J, Choinski K, Inglesby DC, Diamond S, Sultan SM. Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations. Vascular 2024; 32:154-161. [PMID: 36062583 DOI: 10.1177/17085381221124982] [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: 11/17/2022]
Abstract
OBJECTIVE The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. METHODS Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. RESULTS TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. CONCLUSIONS TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.
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Affiliation(s)
- John Phair
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krystina Choinski
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dani C Inglesby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn Diamond
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Steven M Sultan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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49
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Quinn KN, Tian Y, Budde R, Irazoqui PP, Tuffaha S, Thakor NV. Neuromuscular implants: Interfacing with skeletal muscle for improved clinical translation of prosthetic limbs. Muscle Nerve 2024; 69:134-147. [PMID: 38126120 DOI: 10.1002/mus.28029] [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: 02/28/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
After an amputation, advanced prosthetic limbs can be used to interface with the nervous system and restore motor function. Despite numerous breakthroughs in the field, many of the recent research advancements have not been widely integrated into clinical practice. This review highlights recent innovations in neuromuscular implants-specifically those that interface with skeletal muscle-which could improve the clinical translation of prosthetic technologies. Skeletal muscle provides a physiologic gateway to harness and amplify signals from the nervous system. Recent surgical advancements in muscle reinnervation surgeries leverage the "bio-amplification" capabilities of muscle, enabling more intuitive control over a greater number of degrees of freedom in prosthetic limbs than previously achieved. We anticipate that state-of-the-art implantable neuromuscular interfaces that integrate well with skeletal muscle and novel surgical interventions will provide a long-term solution for controlling advanced prostheses. Flexible electrodes are expected to play a crucial role in reducing foreign body responses and improving the longevity of the interface. Additionally, innovations in device miniaturization and ongoing exploration of shape memory polymers could simplify surgical procedures for implanting such interfaces. Once implanted, wireless strategies for powering and transferring data from the interface can eliminate bulky external wires, reduce infection risk, and enhance day-to-day usability. By outlining the current limitations of neuromuscular interfaces along with potential future directions, this review aims to guide continued research efforts and future collaborations between engineers and specialists in the field of neuromuscular and musculoskeletal medicine.
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Affiliation(s)
- Kiara N Quinn
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yucheng Tian
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ryan Budde
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Pedro P Irazoqui
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sami Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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50
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Saffari S, Saffari TM, Janis JE. Secondary Trigger Point Deactivation Surgery for Nerve Compression Headaches: A Scoping Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5620. [PMID: 38405132 PMCID: PMC10887444 DOI: 10.1097/gox.0000000000005620] [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: 10/11/2023] [Accepted: 01/09/2024] [Indexed: 02/27/2024]
Abstract
Background Primary trigger point deactivation surgery has been successful in reducing or eliminating nerve compression headaches between 79% and 90% of the time. The aim of this review article was to discuss the factors that contribute to index trigger point deactivation surgery failure, the importance of reevaluating trigger points following failure, and the options for secondary surgery. Methods A literature search was performed using a combination of keywords involving "chronic headache" and "nerve deactivation surgery," in databases until February 2023. Results Data of 1071 patients were evaluated and included (11 articles). The failure rate after index trigger point deactivation surgery occurs is approximately 12%, primarily due to incomplete primary trigger point deactivation. Secondary trigger points may not appear until the primary trigger is eliminated, which occurs in 17.8% of patients. Reevaluation of previously diagnosed trigger points as well as uncovered trigger points and additional preoperative testing is indicated to help determine candidacy for further surgical deactivation. To address scarring that could contribute to failure, corticosteroid injection, acellular dermal matrix, adipofascial fat, or expanded polytetrafluoroethylene sleeves have been described with beneficial effects. For neuroma management, regenerative peripheral nerve interface, targeted muscle reinnervation, a combination of both, relocation nerve grafting, or nerve capping have also been described. Neurectomy can be performed when patients prefer anesthesia and/or paresthesia over current pain symptoms. Conclusion Secondary trigger point deactivation surgery is indicated when there is suspicion of incomplete deactivation, internal scarring, neuroma, or newly-diagnosed trigger points.
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Affiliation(s)
- Sara Saffari
- From the Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minn
- Department of Plastic Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Tiam M. Saffari
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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