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Targeted muscle re-innervation for superficial radial neuroma

    Overview

    Learn the Targeted muscle re-innervation for superficial radial neuroma surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Targeted muscle re-innervation for superficial radial neuroma surgical procedure.
    Targeted muscle reinnervation (TMR) is a technique developed for the management of symptomatic neuromas. The ideal method of management for a neuroma is not clear. Different techniques may be required for different nerves in different locations. As a general rule though, reconstruction of the nerve gap created after resection of a neuroma is the optimum method of restoring some afferent signalling to the sensory cortex of the brain. Reconstructive procedures like this depend on the tissue bed, the quality of the distal nerve stump and the nerve gap.
    Bridging a gap requires nerve graft and for some patients, the thought of creating a second nerve injury site for autologous nerve graft harvest, with the attendant risks of neuroma, sensory loss and neuropathic pain, is an unacceptable solution. TMR has demonstrated excellent results in the prevention of phantom pain, in the management of limb pain following amputation and in treating both mixed nerves and pure sensory nerves. The technique is “active” or reconstructive, directing regenerating axons into a distal motor branch of a nerve in the vicinity.
    The superficial radial nerve is challenging to treat when sensitised, due to the prominent location and tendency fro irritation by contact from clothing. There is no wholly reliable method for management of the SRN. Applying the technique of TMR to the SRN is starting to demonstrate promise.
    This technique demonstrates the use of TMR to treat a SRN proximal stump to the distal anterior interosseous nerve (AIN) to pronator quadratus (PQ) for the management of neuroma pain that followed injury to the SRN during injection to the thumb CMCJ. The initial attempts at neuroma management included in situ capping and relief was temporary, again becoming problematic at 2 years and being accompanied by CMCJ deterioration, in this case with pre-existing arthritis. Definitive treatment of the CMCJ arthritis with excision arthroplasty was planned and a decision to undertake TMR of the SRN at the same time was based on an attempt to find a more permanent resolution of the neuropathic pain.

    Indications

    Indications:
    The prime indication for this procedure is persistent neuropathic pain from a neuroma of the SRN where there is a contra-indication to reconstruction to the distal nerve stump. The technique is currently considered a salvage option due to the large area of skin denervation necessary from resection of the whole of the SRN trunk, even when the symptomatic neuroma may be on one of the main branches.
    Symptoms and examination:
    Symptomatic neuromas are associated with both contact “evoked” pain and “spontaneous” pain. The pain is characteristically neuropathic with sensations of tingling, burning or shooting often described by patients. There is usually extreme sensitivity to light touch with the hallmarks of dysaesthesia, allodynia and hyperalgesia. There is often avoidance behaviour. Patients will often have tried a number of different analgesic and neuromodulator medications to control their symptoms without long term benefit. There is usually notable apprehension when attempting to examine a patient with a cutaneous neuroma and they may flinch in anticipation of contact or draw their limb away. The examiner must be sensitive to the patient’s concerns and build up a rapport. Gently tapping from distal in a proximal direction along the course of the nerve under test may elicit a Tinel’s sign at the point of nerve irritation or neuroma. The Tinel’s sign, is positive when tingling or pins and needles is reported by the patient in the cutaneous territory of the nerve under test. The tingling sensations can be profound and prolonged and so to accurately determine the neuroma site, the examiner should avoid the main nerve trunk by commencing the examination distal to the neuroma and moving towards the neuroma and the nerve trunk.
    Investigations:
    A diagnostic peripheral nerve block under ultrasound guidance is recommended to determine that the symptomatic neuroma arises from the SRN. There is considerable overlap between the cutaneous territories of the SRN and the lateral cutaneous nerve of the forearm (LCNF) and often there are interconnecting branches in the periphery. The site of nerve block is therefore cricital. Blocking in the proximal forearm risks overspill of local anaesthetic to the adjacent nerve. The SRN lies here deep to the brachioradialis muscle and the LCNF lies in the superficial fat adjacent to the cephalic vein. A better site for blockade of the radial nerve is in the upper arm as it emerges from the spiral groove at the lateral 1/3 of the humerus. A small volume of local anaesthetic is required because more then 5 mls may spread distally to the interval between the biceps and the brachialis and affect a block of the LCNF as it emerges lateral to the biceps tendon.
    An ultrasound of the site of suspected neuroma may be performed. In some patients the area is so sensitive that US must be reserved from after the nerve block. In other cases, MRI may be preferable to avoid the contact irritation of the neuroma.
    Conservative management:
    Sensitive neuromas may be initially managed with desensitisation and neuromodulation physical therapy and oral neuromodulator medications. Central sensitisation pain may be optimised through mirror feedback therapy. Non-surgical methods of management may also include radiofrequency blockade and cryotherapy. Persistent neuropathic pain may require surgical management of the neuroma.
    Alternative operative management:
    There are numerous surgical procedures that have been described for the management of painful cutaneous neuromas. Resection and in-situ capping prevents adherence of any recurrent neuroma to the environment. Burying to bone or muscle are commonplace, although the evidence to support these techniques is poor. Loop co-aptation to a second nerve when there is another neuroma may provide a conduit for regeneration. Using processed nerve allograft to create a “graft to nowhere” is another option. For neuromas in continuity, neurolysis and wrapping with veins and collagen sheets may help pain. Resurfacing can be used when the soft tissues are of poor quality. When there is a poor distal function our no distal function, a neuroma in continuity may be resected and reconstructed with processed nerve allograft, without the risks associated with autologous nerve graft harvest from another site. In severe recalcitrant cases of neuropathic pain in damaged nerves, peripheral nerve implantable stimulators may be used to block the
    Contraindication:
    Surgery is not recommended when there is no defined neuroma site, there is no good response to the diagnostic nerve block, there is poor soft tissue at the site of the planned surgery, when there is active infection, in cases where the patient does not comprehend the problem or is non-compliant with the management plan.

    Setup

    The patient should have their pain medically optimised and neuromodulator medications are invaluable.
    The surgery requires a basic hand tray with West and Travers self-retaining retractors. A lead hand helps with limb positioning. Surgical silicone elastic loops are useful for tagging, retracting and handling the nerves to avoid trauma.
    Micro-instrumentation, an operating microscope, background material and microsurgical sutures are required for the co-aptation which can be supported by Tisseel fibrin glue.
    A nerve catheter may be placed proximal to the neuroma resection site on the affected nerve to help with peri-operative pain management.
    The patient can have either a general anaesthetic with a regional block addition, or regional anaesthesia in isolation.
    An arm tourniquet and wool padding should be applied to the upper arm.

    Operation – 1

    The WHO checklist is completed. The confirmation of the limb marking, the site and procedure is performed.
    The limb is elevated and then prepped after tourniquet inflation.

    Do not allow preparation material to soak the wool padding under the tourniquet.
    The skin preparation should be to the level of the tourniquet.

    The drapes are placed around the limb which is positioned on an arm table.
    The site marking is still visible and should be confirmed with the scrub team as a “STOP moment”.

    The arm is positioned using a lead hand.Skin incisions are marked. This case involved a superficial radial nerve (SRN) neuroma resulting from nerve trauma sustained during steroid injection to the CMCJ of the thumb for arthritis pain.
    Previous exploration identified the neuroma in a branch of the SRN. The neuroma was resected and a bioresorbable Neurocap was placed over the proximal stump without intra-neural neurolysis. The plan was to minimise dissection of the nerve and its branches and to prevent further damage, scarring or sensitisation.
    There was improvement for 2 years, however pain recurrent and the deteriorating function from the arthritic CMCJ necessitated trapezium excision. The decision was to perform the SRN exploration and TMR at the same time to manage the neuropathic pain.. The TMR was selected due to the need for a wider denervation of the whole SRN territory to resect and relocate the nerve stump after neuroma resection.
    This procedure is therefore combined with a trapezium excision and ligament stabilisation procedure. The radial and dorsal incision is to expose the SRN and perform the trapezium excision., The volar incision is to expose the distal AIN for the tMR and also to raise the FCR tendon strip for the stabilisation.

    The skin is incised to expose the SRN and the recurrent neuroma. The skin is incised to expose the SRN and the recurrent neuroma. The scar extends distal to the prior exposure to allow exposure of the dorsal CMCJ capsule.

    Small veins are divided after bipolar cautery.

    The dorsal skin flaps is elevated to identify the superficial radial neuroma at the site of previous capping.The swelling within the nerve stump is demonstrated at the tip of the dissecting scissors.

    The volar skin flap is next elevated identifying further nerve branches from the main SRN trunk.These branches must be carefully identified and dissected back to the main trunk which will then be directed to the AIN as TMR.
    The original neuroma was on a small branch and it was capped in situ to prevent having to do intranural dissection with a risk of causing pain and scarring on unaffected branches.
    TMR is a different approach and involves sacrifice of the nerve trunk with re-direction to reduce the pain amplification and sensitisation that follows a loss of normal afferent signalling.

    A Mixter is passed deep to the nerve branch to facilitate passage of a sloop.Sloops are essential for nerve direction, enabling handling and gentle retraction for neurolysis without risking injury.

    The neuroma is firmly tethered to the deeper structure.
    The Mixter has been passed deep to the nerve. The 90 degree fine tips to these forceps are a useful tool in the nerve surgeon’s kit.

    A sloop is introduced into the MIxter jaws and care should be take when closing the Mixter to avoid direct injury to the deep surface of the nerve.

    The sloop should be positioned in the jaws to ensure that its is not prominent and there is no snagging on the deep surface of the nerve as the Mixter is withdrawn.

    The is used for retraction of the nerve.

    The sloop is used to retract the SRN and the neuroma is mobilised from the scar in the original surgery bed.Tether points to the skin are divided.

    The previously capped neuroma is now free, although there is some tether proximal to the site of capping.
    The sloop allows gentle retraction if the nerve so that a circumferential neurolysis can be completed. The neuroma is still tethered to the deep tissues.

    The neuroma is excised and will be sent for histological analysis.

    The neuroma has been resected and will be sent for histology.
    The previous management was capping after resection of the neuroma. The capping used the Polyganics Neurcap, which is a bioresorbable polymer cap that maintains mechanical integrity for approximately 3 months before undergoing hydrolysis and resorption by 18 months. The polymer is a Poly lactose of polycaprolactone. The philosophy is to resect the neuroma and then shield the end of the cut nerve in a chamber, allowing a controlled outgrowth without tether to the nerve environment. The small tapered end is the original neuroma site.
    CN – Capped neuroma
    B – Intact adjacent nerve branch
    RN – Recurrent neuroma proximal to the site of capping

    A fine prolene suture is placed in the SRN, post neuroma resection.This can be used to identify the nerve and facilitate the later re-routing for the tMR procedure.

    Lateral cutaneous nerve of forearm branches are seen and protected from further injury.
    These small branches are not involved in the neuroma and should be preserved. It is worth noting that in many cases there are communicating branches between the SRN and the LCNF. The origin of the pain can be identified using pre-operative targeted peripheral nerve local anaesthetic blocks.

    The SRN is mobilised and tagged to identify it.The sloop can be removed because there is no distal tether point and it can no longer be used for traction.

    The suture placed in the SRN end can now be used to provide traction during proximal nerve dissection and neurolysis.There are additional dorsal branches from the SRN that will be included in the tMR only if they cannot be kept in situ without intramural dissection of the affected branch and rotated without tension to the AIN.

    The whole of the affected SRN proximal stump will be directed to the AIN for the TMR procedure.
    The SRN trunk is mobilised with other potentially undamaged branches.
    A deep connection with the dorsal branch is sectioned. The handling of the end of the SRN should be minimised, however this will be further debrided prior to the co-aptation.

    The forearm is supinated and supported in a lead hand and the skin of the volar forearm is incised.The exposure of the terminal AIN is through an incision between the digital flexors on the radial side and the ulnar neuromuscular bundle and the FCU on the ulnar side.

    This case also involves resection of the trapezium and FCR harvest for a ligamentous stabilisation procedure and so a more radial incision than normal has been planned.

    The FCR and the PL tendons are identified.The FCR will be split and a distally based strip raised for thumb metacarpal base stabilisation after the concomitant trapezium excision.

    Operation – 2

    The ulnar neuromuscular bundle is identified radial and deep to the FCU tendon.The deep investing fascia of the forearm is incised and the neurovascuar bundle is exposed on the ulnar side of the distal forearm. This will be protected. Placement of self-retaining retractors should be careful to prevent local trauma to these structures.
    The FDS tendons and the FCU are the anchor points for the self-retaining retractor.

    The FDP tendons are separated from the ulnar neuromuscular bundle.There are small feeding perforator vessels that must be divided after bipolar cautery. The deep plane is between the ulnar side of the fDP tendons to the digits and the Ulnar artery and nerve.

    The plane can be cleared and a digit inserted can be used for gentle blunt dissection to th pronator quadratus. The FDP can then be further retracted to the radial side with a Langenbeck retractor.

    Any residual vascular leashes can be cauterised and any tenosynovial bands are incised.The plane should be developed over an 8cm length.

    The AIN and artery can be seen under fascia lying on the interosseous membrane proximal to the PQ.Muscle reflections and origins proximally from the ulna must be divided to expose the interssoeus membrane.

    Cautery is used to divide any perforating vessels from the AIA to the deep surface of the FDP.There is usually a 15mm long perforator approximately 30mm proximal to the proximal edge of the PQ. This must be divided to allow mobilisation of the AIN and cautery used to reduce the risk of a post-operative deep haematoma forming in the wound.

    The nerve can be seen in the fat around the AIA on the interosseous membrane, proximal to the PQ.The nerve will be mobilised from the artery and venae commitantes over approximately 6cm to gain sufficient length of distal AIN stump for direct suture co-aptation with the proximal SRN stump, avoiding the need for an interposition graft.
    FDP – Flexor Digitorum Profundus
    AIA – Anterior Interossues Artery
    AIN – Anterior Interosseous Nerve
    UNVB – Ulnar Neuro Vascular Bundle

    The neurolysis of the AIN should be performed carefully to avoid damage to the AIA.Jamieson scissors can be used to dissect longitudinally along the AIN, in the plane between the artery and nerve.

    Any large perforating vessels from the AIA to the FDP must be divided after bipolar cautery.These vessels can be a source of post-operative bleeding and must be adequately cauterised. The failure to divide them limits the dissection of the AIN proximally, compromises the viable distal AIN stump length available and limits the mobilisation of this recipient nerve branch.

    A Mixter is passed deep to the AIN between the nerve and the artery.The Mixter is fine tipped and has a 90 degree angle to the jaws. The ends are sufficiently blunt that with a small window created with the scissor dissection, the tips can be passed under the nerve with minimal risk of direct trauma.

    A sloop is introduced to the Mixter jaws and drawn carefully under the AIN.The sloop allows gentle traction on the nerve to facilitate dissection and proximal neurolysis.

    The neurolysis is completed over the whole length of the required distal AIN without nerve sectioning.If the AIN is sectioned too early, then the nerve must be handles with forceps to allow further dissection. This would risk trauma. I do not section the AIN proximally until it is clear how much nerve length is required due to the level of SRN section and the local anatomy of the SRN or the branch for TMR.
    Note that in a case where the SRN section is proximal will need an interposition graft or allograft as the AIN cannot be harvested beyond the branch to the FPL. The FPL must not be denervated or the branch injured as this is a critical function to be preserved. The PQ will be denervated as the function mis not critical (due to the intact Pronator teres) and the deeply placed PQ muscle bed provides a healthy intramuscular neural plexus to receive the regenerating SRN axons.
    The use of an interposition processed nerve allograft where there is insufficiency length is described as a procedure as another operative technique in Orthoracle.

    A passage is created on the radial side of the wrist between the radial artery and the FCR and deep to the digital flexors to allow passage of the SRN proximal stump to the deep layer above PQ.The tract must be under the digital flexor including the FPK and the FDP. Too superficial will create tension on the nerve during digit or writ motion and there is a small risk of median nerve injury or palmar branch medial nerve if the tract is in the incorrect plane.

    The Mixter is passed through the tunnel, from volar to dorsal aspect of the wrist
    and a sloop then delivered retrograde from . dorsal to volar.The safest way is to open the fascia longitudinally ulnar to the radial artery and then to develop the plane from the ulnar forearm with finger dissection, before passing a Mixter through the tunnel from deep to superficial, emerging on the radial side of the forearm with the Mixter tips.

    The second sloop (blue) is looped and the free ends inserted to the Mixter jaws.
    The loop is drawn through the tunnel.

    The SRN proximal nerve stump is pulled through the blue sloop loop and then atruamatically the SRN can be drawn through the tunnel from proximal, radial and superficial to distal deep and ulnar so that it lies in close proximity with the Ain distal stump.The yellow sloop remains around the neurolyses but intact distal AIN.

    The blue sloop is finally prepared for the SRN stump and the SRN is introduced to the blue sloop loop

    The SRN is introduced to the blue sloop loop.
    The end of the SRN that has been clipped will be debrided prior to nerve co-aptation.

    The sloop is carefully drawn into the tunnel delivering the SRN stump.A Langenbeck retractor is facilitating retraction of the digital flexors to expose the PQ. The self-retaining retractor has been repositioned more deeply in the wound. Care should be taken with the ulnar side jaws of the retractor that they do not contact the ulnar artery or nerve, They should be in contact with the FCU tendon only on this side.

    The SRN is delivered safely to the PQ surface adjacent to the AIN distal supply to PQ and the wrist.The SRN stump will need deriding. The distal AIN supplies innervation to the PQ (somatic) and sensory proprioceptive supply to the wrist joint. There is no cutaneous sensory supply from the AIN.

    The AIN can be sectioned proximally now that the required length is established.The yellow sloop lifts the AIN from the bed and avoids injury to the AIA during the neurotomy.

    A microsurgical background is introduced to the wound shed and the retractors adjusted to allow full exposure of the co-aptation site for the microsurgical neurorraphy.The SRN can be debrided and there is still sufficient AIN for a tension free co-aptation.

    A microscope asisietd neurorraphy is performed using 9’0 nylon interrupted sutures.2-3 sutures are sufficient for the co-aptation and they will be augmented with a Tisseel fibrin glue. The nerve ends should be gentle apposed without distortion of the fascicle structure.

    The first suture is tied and cut.
    If there is redundancy in the loop or SRN and AIN this is not an issue. In a functional motor nerve transfer, too much redundancy may increase the reinnervation distance. In such cases additional trimming of the recipient nerve motor branch brings the neurorraphy site closer to the motor point of the recipient muscle, ensuring more rapid reinnervation. However, this is not a problem in TMR for nerve pain and the loop can be safely left.

    There is a slight size mismatch between the proximal and distal nerve crop-sections evident so an even spread is obtained with 3 epineural sutures, each place 120 degrees apart.
    The background material improves visualisation of the nerve in the surgery bed and the rough surface improves nerve stability. The suture material shows up well against the light yellow background.

    Operation – 3

    The neurorraphy is completed by placement of the third 9’0 nylon epieneural suture.
    A well-placed co-aptation, deep to the digital flexors with run off for the regerationg axons to the PQ muscle bed is an excellent recipient site for the axons formerly causing the neuroma.

    Tisseel fibrin tissue glue (Baxter) is defrosted and used to support the co-aptation.The Tisseel is supplied in a double syringe frozen The syringes contain the substrate and the activator. The syringe removed from the freer and checked for expiry date. It is then placed in a sterile bowl with ward saline or water to defrost. A 4cc sized syringe is sufficient for this TMR co-aptation.
    The two syringes are connected with a 2 into 1 connector and a cannula then attached that permits mixing of the solutions at the tip of the cannula.

    The microsurgery background is used during the application of the Tisseel to creat a circumferential layer across the co-aptation site.The Tisseel is delivered along the edge of the nerve and the nerve is then moved on top of that layer. Next more Tisseel is applied on the exposed upper surface and then the background is folded over with the nerve lying in the crease while is activates for a few seconds.

    If the background material is removed and then is needed, more Tisseel can be applied to the exposed AIA as a sealant to reduce the risk of post-operative bleeding.
    The repair is cycled through wrist and finger movement to ensure that there is no traction against the co-aptation site. The wound is now ready for closure.

    A layered closure is completed using absorbable subcuticular sutures.
    Vicryl ininterrupted 4’0 and then Monacril 4’0 subcuticular are my preferred sutures.

    Steristrips are used to cover the closed wounds.
    Note that there is a dorsal wound that was used to resect the neuroma nd mobilise the SRN. Through the dorsal wound the trapezium was also excised. The volar wound was for the co-aptation of the tMR but was also used to harvest a strip of the FCR for stabilisation of the thumb metacarpal base following the excision arthroplasty. The excision arthroplasty of the thumb CMCJ and FCR ligament stabilisation and interposition is described as a separate operative technique elsewhere in the Orthoracle Hand and wrist atlas.

    Dressings are placed over the closed wounds.

    The dressing is completed with a volar slab of Plaster of Paris.The MCPJs should be able to fully flex. in this case the cast includes the MCPJ of the thumb due to a concomitant trapezium excision for arthritis. In this case some form of soft splint age will be continued from 2-6 weeks after surgery.

    Post Operative

    The WHO signet is completed.
    The limb is dressed and placed in a volar slab of Plaster of Paris to provide some post-operative splinting and to prevent excessive motion of the wrist. In this case there was a concomitant trapezium excision and reconstruction.
    Typically a cast for TMR in the upper limb is used until first dressing change at 7-10 days post-operatively. The splint doe not need to continue beyond this point as there is no tension in the nerve co-aptation due to the donor distal and recipient proximal arrangement of the neurorraphy which renders is tension free.
    The limb should be monitored after tourniquet release to ensure that there is no bleeding, digital perfusion is normal and the dressings are not too constricting.
    The operation note and discharge summary are completed.
    Take home analgesic medications are prescribed.
    A review in the clinic is planned for 7-10 days post-operatively when the dressings will be removed, the wound assessed and early mobilisation can be commenced.
    I recommend that is the patient is already on neuromodular medications, then these should be continued in the per-operative period for 6-12 weeks before graduated reduction.
    Cognitive therapies, neurorehabilitation strategies and mirror therapy can be commenced when the wound is left open.
    Topical management of the wound with massage and emollient massage reduced sensitisation, encourages engagement, reduced avoidance and can speed up the process of scar maturation.
    The expectation os that the neuropathic pain will reduce in the 6-12 weeks following the surgery. The improvement may be monitored using pain scores, neuroma scores and an analgesia diary.

    Recommended Reading

    TMR is a relatively new application of nerve transfer surgery aimed at reducing neuropathic pain from neuromas and the phantom limb pain experiences following amputation. The evidence in lower limb amputation as an intervention for neuroma and as prophylaxis during the index amputation period is good. Well constructed randomised controlled trials have been completed to support the emerging evidence base. The role of TMR is sensory nerve neuroma management is less well defined. The introduction of the technique to the “toolbox” for neuroma reconstruction is based on the variable results of the existing techniques. Simple neuroma resection, capping, burying to muscle or bone or “allografts to nowhere” are all described and have their proponents, however in a case with a distal nerve stump an active (reconstructive) technique is to be recommended, restoring the afferent pathway. When there is no distal nerve stump available for a graft, typically passive (ablative) procedures are performed, although using an active technique (graft to nowhere or TMR) provide an interval with reduced evoked pain and allow central down regulation of the pain pathways.
    References:
    Arnold DMJ, Wilkens SC, Coert JH, Chen NC, Ducic I, Eberlin KR. Diagnostic Criteria for Symptomatic Neuroma. Ann Plast Surg. 2019 Apr;82(4):420-427.
    doi: 10.1097/SAP.0000000000001796. Erratum in: Ann Plast Surg. 2019 Jul;83(1):120. PubMed PMID: 30855369
    This paper describes the diagnostic criteria for defining a neuroma. In a case with a history consistent with a nerve injury, poor recovery, a positive Tinel’s sign and good pain response to a local anaesthetic block, then a neuroma may be diagnoses. The neuroma may be confirmed with US or MRI imaging.
    Eberlin KR, Ducic I. Surgical Algorithm for Neuroma Management: A Changing Treatment Paradigm. Plast Reconstr Surg Glob Open. 2018 Oct 16;6(10):e1952.
    doi: 10.1097/GOX.0000000000001952. eCollection 2018 Oct. PubMed PMID: 30534497; PubMed Central PMCID: PMC6250458
    This paper reports the different methods for surgical management of neuromas and classifies procedures as ablative / passive or reconstructive / active.The techniques of TMR and RPNI are discussed in the active category alongside grafts to nowehere, graft to distal stump and loop Centro-central anastomosis.
    Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, Challenges, and Pitfalls after Targeted Muscle Reinnervation in High-Level Amputees: Is It Worth the Effort? Plast Reconstr Surg. 2019 Dec;144(6):1037e-1043e.
    doi: 10.1097/PRS.0000000000006277. PubMed PMID: 31764652
    30 patients with upper limb amputation were treated, 19 for improved prosthetic control and 11 for neuroma pain management over a 5 year period. All achieved a myoelectric signal and in the 10 at final follow up analysis there was improved function. There were cases of abandonment of prosthetics after otherwise successful surgery and the conclusion was that there would need to be improvements in the biotechnological interface to improve adoption and long term use of advanced prosthetics in the future.
    Chappell AG, Jordan SW, Dumanian GA. Targeted Muscle Reinnervation for Treatment of Neuropathic Pain. Clin Plast Surg. 2020 Apr;47(2):285-293. doi: 10.1016/j.cps.2020.01.002. Epub 2020 Feb 5. Review.
    PubMed PMID: 32115054
    This review reports that the development of an active regeneration through TMR is superior to direct muscle implantation in the management of nerve pain.
    Fracol ME, Dumanian GA, Janes LE, Bai J, Ko JH. Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation. Plast Reconstr Surg Glob Open. 2020 Jan 17;8(1):e2545.
    doi: 10.1097/GOX.0000000000002545. eCollection 2020 Jan. PubMed PMID: 32095388; PubMed Central PMCID: PMC7015593
    This paper explores the concept of sensory only TMR for the prevention or management of neuroma pain. The technique ds=escribes direct transfer of the rural nerve proximal stump to the lateral gastrocnemius branch to direct the regenerating sensory axons to deeper tissues, away from the skin.
    Janes LE, Fracol ME, Ko JH, Dumanian GA. Management of Unreconstructable Saphenous Nerve Injury with Targeted Muscle Reinnervation. Plast Reconstr Surg Glob Open. 2020 Jan 17;8(1):e2383.
    doi: 10.1097/GOX.0000000000002383. eCollection 2020 Jan. PubMed PMID: 32095383; PubMed Central PMCID: PMC7015600
    This clinical series of 18 cases reports saphenous branch transfer to adjacent motor branches. Two patients had recurrent pain, 6 were lost to follow-up and 10 noted pain resolution after the TMR.
    Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol. J Surg Oncol. 2019 Sep;120(3):348-358. doi: 10.1002/jso.25586. Epub 2019 Jun 13. PubMed PMID: 31197851
    This is a cohort study of 31 patients having primary TMR at the time of oncologic amputations. The authors report fewer neuromas and less neuroma pain intensity than in a cross-section sample of oncological amputees treated elsewhere.
    Valerio IL, Dumanian GA, Jordan SW, Mioton LM, Bowen JB, West JM, Porter K, Ko JH, Souza JM, Potter BK. Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation. J Am Coll Surg. 2019 Mar;228(3):217-226. doi: 10.1016/j.jamcollsurg.2018.12.015. Epub 2019 Jan 8. PubMed PMID: 30634038
    This is a multi-institutional cohort study of 51 patients undergoing TMR at the time of major limb amputation compared to 438 major limb amputees. A number of measures were performed including a PROMIS score and a numerical rating scale. The interventional cohort experiences less phantom limb pain and less residual limb pain. The authors recommend TMR at the time of amputation to reduce limb pain and phantom pain.
    Dumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, Ertl WJ, Tintle SM, Nanos GP, Valerio IL, Kuiken TA, Apkarian AV, Porter K, Jordan SW. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Ann Surg. 2019 Aug;270(2):238-246. doi: 10.1097/SLA.0000000000003088. PubMed PMID: 30371518
    This is an RCT and 28 patients with limb pain after amputation were randomised to either standard care or TMR. There were 3 cross-over patients to the TMR arm. The authors recommend TMR for the management of residual limb pain.
    Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted Muscle Reinnervation Technique in Below-Knee Amputation. Plast Reconstr Surg. 2019 Jan;143(1):309-312. doi: 10.1097/PRS.0000000000005133. PubMed PMID: 30589808
    This study reports on the use of TMR in the management of below knee amputation patients and notes that untreated there is a rate of 25% residual limb pain. All patients report phantom pain at 1 month, however by 3 months, all patients had phantom limb pain resolution. The patients were followed to one year and the paper supports extending the use of TMR to the below knee amputation patient.
    Arnold DMJ, Wilkens SC, Coert JH, Chen NC, Ducic I, Eberlin KR. Diagnostic Criteria for Symptomatic Neuroma. Ann Plast Surg. 2019 Apr;82(4):420-427. doi: 10.1097/SAP.0000000000001796. Erratum in: Ann Plast Surg. 2019 Jul;83(1):120. PubMed PMID: 30855369
    This paper describes the diagnostic criteria for defining a neuroma. In a case with a history consistent with a nerve injury, poor recovery, a positive Tinel’s sign and good pain response to a local anaesthetic block, then a neuroma may be diagnoses. The neuroma may be confirmed with US or MRI imaging.
    Eberlin KR, Ducic I. Surgical Algorithm for Neuroma Management: A Changing Treatment Paradigm. Plast Reconstr Surg Glob Open. 2018 Oct 16;6(10):e1952. doi: 10.1097/GOX.0000000000001952. eCollection 2018 Oct. PubMed PMID: 30534497; PubMed Central PMCID: PMC6250458
    This paper reports the different methods for surgical management of neuromas and classifies procedures as ablative / passive or reconstructive / active.The techniques of TMR and RPNI are discussed in the active category alongside grafts to nowehere, graft to distal stump and loop Centro-central anastomosis.
    Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, Challenges, and Pitfalls after Targeted Muscle Reinnervation in High-Level Amputees: Is It Worth the Effort? Plast Reconstr Surg. 2019 Dec;144(6):1037e-1043e. doi: 10.1097/PRS.0000000000006277. PubMed PMID: 31764652
    30 patients with upper limb amputation were treated, 19 for improved prosthetic control and 11 for neuroma pain management over a 5 year period. All achieved a myoelectric signal and in the 10 at final follow up analysis there was improved function. There were cases of abandonment of prosthetics after otherwise successful surgery and the conclusion was that there would need to be improvements in the biotechnological interface to improve adoption and long term use of advanced prosthetics in the future.
    Chappell AG, Jordan SW, Dumanian GA. Targeted Muscle Reinnervation for Treatment of Neuropathic Pain. Clin Plast Surg. 2020 Apr;47(2):285-293. doi: 10.1016/j.cps.2020.01.002. Epub 2020 Feb 5. Review. PubMed PMID: 32115054
    This review reports that the development of an active regeneration through TMR is superior to direct muscle implantation in the management of nerve pain.
    Fracol ME, Dumanian GA, Janes LE, Bai J, Ko JH. Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation. Plast Reconstr Surg Glob Open. 2020 Jan 17;8(1):e2545. doi: 10.1097/GOX.0000000000002545. eCollection 2020 Jan. PubMed PMID: 32095388; PubMed Central PMCID: PMC7015593
    This paper explores the concept of sensory only TMR for the prevention or management of neuroma pain. The technique ds=escribes direct transfer of the rural nerve proximal stump to the lateral gastrocnemius branch to direct the regenerating sensory axons to deeper tissues, away from the skin.
    Janes LE, Fracol ME, Ko JH, Dumanian GA. Management of Unreconstructable Saphenous Nerve Injury with Targeted Muscle Reinnervation. Plast Reconstr Surg Glob Open. 2020 Jan 17;8(1):e2383. doi: 10.1097/GOX.0000000000002383. eCollection 2020 Jan. PubMed PMID: 32095383; PubMed Central PMCID: PMC7015600
    This clinical series of 18 cases reports saphenous branch transfer to adjacent motor branches. Two patients had recurrent pain, 6 were lost to follow-up and 10 noted pain resolution after the TMR.
    Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol. J Surg Oncol. 2019 Sep;120(3):348-358. doi: 10.1002/jso.25586. Epub 2019 Jun 13. PubMed PMID: 31197851
    This is a cohort study of 31 patients having primary TMR at the time of oncologic amputations. The authors report fewer neuromas and less neuroma pain intensity than in a cross-section sample of oncological amputees treated elsewhere.
    Valerio IL, Dumanian GA, Jordan SW, Mioton LM, Bowen JB, West JM, Porter K, Ko JH, Souza JM, Potter BK. Preemptive Treatment of Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb Amputation. J Am Coll Surg. 2019 Mar;228(3):217-226. doi: 10.1016/j.jamcollsurg.2018.12.015. Epub 2019 Jan 8. PubMed PMID: 30634038
    This is a multi-institutional cohort study of 51 patients undergoing TMR at the time of major limb amputation compared to 438 major limb amputees. A number of measures were performed including a PROMIS score and a numerical rating scale. The interventional cohort experiences less phantom limb pain and less residual limb pain. The authors recommend TMR at the time of amputation to reduce limb pain and phantom pain.
    Dumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, Ertl WJ, Tintle SM, Nanos GP, Valerio IL, Kuiken TA, Apkarian AV, Porter K, Jordan SW. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Ann Surg. 2019 Aug;270(2):238-246. doi: 10.1097/SLA.0000000000003088. PubMed PMID: 30371518
    This is an RCT and 28 patients with limb pain after amputation were randomised to either standard care or TMR. There were 3 cross-over patients to the TMR arm. The authors recommend TMR for the management of residual limb pain.
    Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted Muscle Reinnervation Technique in Below-Knee Amputation. Plast Reconstr Surg. 2019 Jan;143(1):309-312. doi: 10.1097/PRS.0000000000005133. PubMed PMID: 30589808
    This study reports on the use of TMR in the management of below knee amputation patients and notes that untreated there is a rate of 25% residual limb pain. All patients report phantom pain at 1 month, however by 3 months, all patients had phantom limb pain resolution. The patients were followed to one year and the paper supports extending the use of TMR to the below knee amputation patient.

    Reference

    • orthoracle.com

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