1
|
Rask DMG, Adams MH, Liverneaux P, Plucknette BF, Wilson DJ, Alderete JF, Sabbag CM. Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:392-399. [PMID: 37499798 DOI: 10.1016/j.hansur.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.
Collapse
Affiliation(s)
- Dawn M G Rask
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mason H Adams
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA.
| | - Philippe Liverneaux
- ICube, University of Strasbourg, CNRS, 2-4 rue Boussingault, 67000 Strasbourg, France; Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 avenue Molière, 67200 Strasbourg, France
| | | | - David J Wilson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Joseph F Alderete
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Casey M Sabbag
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| |
Collapse
|
2
|
Saltzman EB, Jerome JTJ, Gaston RG. Current Concepts and Management of Upper Limb Amputees. J Hand Microsurg 2023; 15:245-246. [PMID: 37701319 PMCID: PMC10495203 DOI: 10.1055/s-0043-1773775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
|
3
|
Bjorklund KA, Alexander J, Tulchin-Francis K, Yanes NS, Singh S, Valerio I, Klingele K, Scharschmidt T. Targeted Muscle Reinnervation for Limb Amputation to Avoid Neuroma and Phantom Limb Pain in Patients Treated at a Pediatric Hospital. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4944. [PMID: 37063502 PMCID: PMC10101300 DOI: 10.1097/gox.0000000000004944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/24/2023] [Indexed: 04/18/2023]
Abstract
Amputees frequently experience chronic neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) transfers transected nerves to nearby motor nerves to promote healing and prevent neuroma formation and PLP. The purpose of this study was to report outcomes of TMR in a series of children and young adults treated at a pediatric hospital. Methods Patients undergoing major limb amputation with TMR were included with minimum one year follow-up and completed questionnaires. Primary clinical outcomes included incidence of symptomatic neuromas, PLP, residual limb pain, narcotic use, and neuromodulator use. A follow-up phone survey was conducted assessing five pediatric Patient Reported Outcomes Measurement Information System (PROMIS) metrics adapted to assess residual limb and PLP. Results Nine patients (seven male and two female patients, avg. age = 16.83 ± 7.16 years) were eligible. Average time between surgery and phone follow-up was 21.3 ± 9.8 months. Average PROMIS Pediatric t-scores for measures of pain behavior, interference, quality-affective, and quality-sensory for both PLP and residual limb pain were nearly 1 standard deviation lower than the United States general pediatric population. One patient developed a symptomatic neuroma 1 year after surgery. Conclusions Compared with an adult patient sample reported by Valerio et al, our TMR patients at Nationwide Children's Hospital (NCH) showed similar PLP PROMIS t-scores in pain behavior (50.1 versus 43.9) and pain interference (40.7 versus 45.6). Both pediatric and adult populations had similar residual limb pain including PROMIS pain behavior (36.7 adult versus 38.6 pediatric) and pain interference (40.7 adult versus 42.7 pediatric). TMR at the time of amputation is feasible, safe, and should be considered in the pediatric population.
Collapse
Affiliation(s)
- Kim A. Bjorklund
- From the Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - John Alexander
- Department of Orthopedic Surgery, The Ohio State University, Columbus, Ohio
| | | | - Natasha S. Yanes
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Satbir Singh
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ian Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kevin Klingele
- Department of Orthopedic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
4
|
Boomgaardt J, Dastan K, Chan T, Shilling A, Abd-Elsayed A, Kohan L. An Algorithm Approach to Phantom Limb Pain. J Pain Res 2022; 15:3349-3367. [PMID: 36320223 PMCID: PMC9618240 DOI: 10.2147/jpr.s355278] [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: 12/22/2021] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. First recognized and described in 1551 by Ambroise Pare, research into its underlying pathology and effective treatments remains a very active and growing field. To date, however, there is little consensus regarding the optimal management of phantom limb pain. With few large well-designed clinical trials of which to make treatment recommendations, as well as significant heterogeneity in clinical response to available treatments, the management of PLP remains challenging. Below we summarize the current state of knowledge in the field, as well as propose an algorithm for the approach to the treatment of PLP.
Collapse
Affiliation(s)
- Jacob Boomgaardt
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
| | - Kovosh Dastan
- Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
| | - Tiffany Chan
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Ashley Shilling
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA,Correspondence: Lynn Kohan, Department of Anesthesiology, University of Virginia, 545 Ray C Hunt Suite 3168, Charlottesville, VA, 22903, USA, Tel +1-434-243-5676, Fax +1-434-243-5689, Email
| |
Collapse
|
5
|
Gardetto A, Baur EM, Prahm C, Smekal V, Jeschke J, Peternell G, Pedrini MT, Kolbenschlag J. Reduction of Phantom Limb Pain and Improved Proprioception through a TSR-Based Surgical Technique: A Case Series of Four Patients with Lower Limb Amputation. J Clin Med 2021; 10:jcm10174029. [PMID: 34501477 PMCID: PMC8432479 DOI: 10.3390/jcm10174029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Four patients underwent targeted sensory reinnervation (TSR), a surgical technique in which a defined skin area is first selectively denervated and then surgically reinnervated by another sensory nerve. In our case, either the area of the lateral femoral cutaneous nerve or the saphenous nerve was reinnervated by the sural nerve. Patients were then fitted with a special prosthetic device capable of transferring the sense of pressure from the sole of the prosthesis to the newly wired skin area. Pain reduction after TSR was highly significant in all patients. In three patients, permanent pain medication could even be discontinued, in one patient the pain medication has been significantly reduced. Two of the four patients were completely pain-free after the surgical intervention. Surgical rewiring of existing sensory nerves by TSR can provide the brain with new afferent signals seeming to originate from the missing limb. These signals help to reduce phantom limb pain and to restore a more normal body image. In combination with special prosthetic devices, the amputee can be provided with sensory feedback from the prosthesis, thus improving gait and balance.
Collapse
Affiliation(s)
- Alexander Gardetto
- Competence Center for Bionic Prosthetics, Department of Plastic, Aesthetic and Reconstructive Surgery with Hand Surgery, Brixsana Private Clinic, 39042 Bressanone, Italy
- Correspondence:
| | - Eva-Maria Baur
- Department of Plastic, Aesthetic and Reconstructive Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Cosima Prahm
- BG Trauma Center Tuebingen, Department of Hand, Plastic, Reconstructive and Burn Surgery, Eberhard Karls University Tuebingen, 72108 Tuebingen, Germany; (C.P.); (J.K.)
| | - Vinzenz Smekal
- AUVA Trauma Center Klagenfurt, Department of Trauma Surgery, 9020 Klagenfurt, Austria;
| | - Johannes Jeschke
- Department of Plastic, Aesthetic and Reconstructive Surgery, Maria Hilf Private Clinic, 9020 Klagenfurt, Austria;
| | - Gerfried Peternell
- Department of Exoprosthetics, AUVA Rehabilitation Clinic, 8144 Tobelbad, Austria;
| | - Michael T. Pedrini
- Department of Internal Medicine, Brixsana Private Clinic, 39042 Bressanone, Italy;
| | - Jonas Kolbenschlag
- BG Trauma Center Tuebingen, Department of Hand, Plastic, Reconstructive and Burn Surgery, Eberhard Karls University Tuebingen, 72108 Tuebingen, Germany; (C.P.); (J.K.)
| |
Collapse
|
6
|
Karczewski AM, Dingle AM, Poore SO. The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements. Front Neurorobot 2021; 15:711028. [PMID: 34366820 PMCID: PMC8334559 DOI: 10.3389/fnbot.2021.711028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Over the last few decades there has been a push to enhance the use of advanced prosthetics within the fields of biomedical engineering, neuroscience, and surgery. Through the development of peripheral neural interfaces and invasive electrodes, an individual's own nervous system can be used to control a prosthesis. With novel improvements in neural recording and signal decoding, this intimate communication has paved the way for bidirectional and intuitive control of prostheses. While various collaborations between engineers and surgeons have led to considerable success with motor control and pain management, it has been significantly more challenging to restore sensation. Many of the existing peripheral neural interfaces have demonstrated success in one of these modalities; however, none are currently able to fully restore limb function. Though this is in part due to the complexity of the human somatosensory system and stability of bioelectronics, the fragmentary and as-yet uncoordinated nature of the neuroprosthetic industry further complicates this advancement. In this review, we provide a comprehensive overview of the current field of neuroprosthetics and explore potential strategies to address its unique challenges. These include exploration of electrodes, surgical techniques, control methods, and prosthetic technology. Additionally, we propose a new approach to optimizing prosthetic limb function and facilitating clinical application by capitalizing on available resources. It is incumbent upon academia and industry to encourage collaboration and utilization of different peripheral neural interfaces in combination with each other to create versatile limbs that not only improve function but quality of life. Despite the rapidly evolving technology, if the field continues to work in divided "silos," we will delay achieving the critical, valuable outcome: creating a prosthetic limb that is right for the patient and positively affects their life.
Collapse
Affiliation(s)
| | - Aaron M. Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin–Madison, Madison, WI, United States
| | | |
Collapse
|
7
|
Targeted Muscle Reinnervation: A Paradigm Shift for Neuroma Management and Improved Prosthesis Control in Major Limb Amputees. J Am Acad Orthop Surg 2021; 29:288-296. [PMID: 33405489 DOI: 10.5435/jaaos-d-20-00044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 11/19/2020] [Indexed: 02/01/2023] Open
Abstract
Targeted muscle reinnervation (TMR) is a procedure that redirects nerves severed by amputation to new muscle targets. In tandem with advances in myoelectric prosthetics, TMR surgery provides amputees with improved control of myoelectric prostheses and simultaneously prevents or treats painful neuromas. TMR also has an emerging role in the management of neuromas in a nonamputation setting, and it seems to be a powerful strategy to treat a wide variety of neuromas. Because the pattern of nerve transfers varies based on the availability of donor nerves and muscle targets, TMR is inherently nonprescriptive, and thus, an understanding of the principles of TMR is essential for its successful application. This review describes the rationale for and principles of TMR, and outlines techniques for TMR, which can be used at various amputation levels and for the management of neuromas in nonamputees.
Collapse
|
8
|
Mereu F, Leone F, Gentile C, Cordella F, Gruppioni E, Zollo L. Control Strategies and Performance Assessment of Upper-Limb TMR Prostheses: A Review. SENSORS (BASEL, SWITZERLAND) 2021; 21:1953. [PMID: 33802231 PMCID: PMC8000641 DOI: 10.3390/s21061953] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
The evolution of technological and surgical techniques has made it possible to obtain an even more intuitive control of multiple joints using advanced prosthetic systems. Targeted Muscle Reinnervation (TMR) is considered to be an innovative and relevant surgical technique for improving the prosthetic control for people with different amputation levels of the limb. Indeed, TMR surgery makes it possible to obtain reinnervated areas that act as biological amplifiers of the motor control. On the technological side, a great deal of research has been conducted in order to evaluate various types of myoelectric prosthetic control strategies, whether direct control or pattern recognition-based control. In the literature, different control performance metrics, which have been evaluated on TMR subjects, have been introduced, but no accepted reference standard defines the better strategy for evaluating the prosthetic control. Indeed, the presence of several evaluation tests that are based on different metrics makes it difficult the definition of standard guidelines for comprehending the potentiality of the proposed control systems. Additionally, there is a lack of evidence about the comparison of different evaluation approaches or the presence of guidelines on the most suitable test to proceed for a TMR patients case study. Thus, this review aims at identifying these limitations by examining the several studies in the literature on TMR subjects, with different amputation levels, and proposing a standard method for evaluating the control performance metrics.
Collapse
Affiliation(s)
- Federico Mereu
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Francesca Leone
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Cosimo Gentile
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | - Francesca Cordella
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| | | | - Loredana Zollo
- Unit of Advanced Robotics and Human-Centred Technologies, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (F.M.); (F.L.); (C.G.); (F.C.)
| |
Collapse
|
9
|
Abstract
Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees. Cite this article: Bone Joint J 2021;103-B(3):430-439.
Collapse
Affiliation(s)
- Michael Geary
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Raymond Glenn Gaston
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA.,Reconstructive Center for Lost Limbs, OrthoCarolina Hand Center, Charlotte, North Carolina, USA
| | - Bryan Loeffler
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA.,Reconstructive Center for Lost Limbs, OrthoCarolina Hand Center, Charlotte, North Carolina, USA
| |
Collapse
|
10
|
Peters BR, Russo SA, West JM, Moore AM, Schulz SA. Targeted muscle reinnervation for the management of pain in the setting of major limb amputation. SAGE Open Med 2020; 8:2050312120959180. [PMID: 32974021 PMCID: PMC7495925 DOI: 10.1177/2050312120959180] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
The life altering nature of major limb amputations may be further complicated by
neuroma formation in up to 60% of the estimated 2 million major limb amputees in
the United States. This can be a source of pain and functional limitation of the
residual limb. Pain associated with neuromas may limit prosthetic limb use,
require reoperation, lead to opioid dependence, and dramatically reduce quality
of life. A number of management options have been described including excision
alone, excision with repair, excision with transposition, and targeted muscle
reinnervation. Targeted muscle reinnervation has been shown to reduce phantom
limb and neuroma pain for patients with upper and lower extremity amputations.
It may be performed at the time of initial amputation to prevent pain
development or secondarily for the treatment of established pain. Encouraging
outcomes have been reported, and targeted muscle reinnervation is emerging as a
leading surgical technique for pain prevention in patients undergoing major limb
amputations and pain management in patients with pre-existing amputations.
Collapse
Affiliation(s)
- Blair R Peters
- Division of Plastic Surgery, Washington University, St. Louis, MO, USA
| | - Stephanie A Russo
- Division of Plastic Surgery, Washington University, St. Louis, MO, USA
| | - Julie M West
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH, USA
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH, USA
| | - Steven A Schulz
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH, USA
| |
Collapse
|