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J Reconstr Microsurg 2020; 36(04): 235-240
DOI: 10.1055/s-0039-1700559
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome

Colin T. McNamara
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Anschutz Medical Center, University of Colorado, Boulder, Colorado
,
Matthew L. Iorio
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Anschutz Medical Center, University of Colorado, Boulder, Colorado
2   Department of Orthopedics, Anschutz Medical Center, University of Colorado, Boulder, Colorado
› Author Affiliations Funding None.
Further Information

Publication History

15 April 2019

12 September 2019

Publication Date:
05 November 2019 (online)

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Abstract

Background Secondary to vascular disease, oncological resection, or devastating trauma, lower extremity amputations are performed globally at a yearly rate exceeding 1 million patients. Three-quarters of these patients will develop chronic pain or phantom pain, which presents a functional limitation for prosthetic use and contributes to deconditioning and increased mortality. Targeted muscle reinnervation (TMR) presents a surgical solution to this problem as either a primary or secondary intervention.

Methods A review of the existing literature was conducted using a combination of the terms “phantom pain” “chronic pain,” “neuroma,” and “targeted muscle reinnervation” in Medline and PubMed.

Results Five articles were found which addressed TMR for pain syndromes, four of which involved lower extremity amputation. Four of the articles were retrospective reviews, and one was a randomized control trial. A total of 149 patients were included, of which 82 underwent lower extremity amputation. Ninety-two of the patients underwent prophylactic TMR, of which 57 were secondary procedures.

In patients who underwent TMR at the time of amputation, all studies reported a minimal development of symptomatic neuromas (27%). For secondary TMR, near-complete resolution of previous pain was found (90%). Phantom pain was noted to be similar to other studies in the literature but noted to improve over time with both primary (average drop of 3.5 out of 10 points on the numerical rating scale) and secondary (diminishing from 72% of patients to 13% over 6 months) operations.

Conclusion Although much of the current literature is limited to retrospective studies with few patients, these data point toward near-complete resolution of neuroma pain after treatment as well as complete prevention of chronic pain if TMR is used as a prophylactic measure during the index amputation.

This study was a level of evidence IV.

Keywords

nerve - targeted muscle reinnervation - lower extremity

Note

The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, the Department of Defense, nor the U.S. Government.


 

  • References

  • 1 Mioton LM, Dumanian GA. Targeted muscle reinnervation and prosthetic rehabilitation after limb loss. J Surg Oncol 2018; 118 (05) 807-814
    CrossrefPubMedSearch in Google Scholar
  • 2 Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008; 89 (03) 422-429
    CrossrefPubMedSearch in Google Scholar
  • 3 Esquenazi A, Yoo KS. Lower Limb Amputations – Epidemiology and Assessment. PM&R KnowledgeNow. June 3, 2016. Available at: now.aapmr.org/lower-limb-amputations-epidemiology-and-assessment
    PubMed
  • 4 Agnew SP, Schultz AE, Dumanian GA, Kuiken TA. Targeted reinnervation in the transfemoral amputee: a preliminary study of surgical technique. Plast Reconstr Surg 2012; 129 (01) 187-194
    CrossrefPubMedSearch in Google Scholar
  • 5 Doukas WC, Hayda RA, Frisch HM. , et al. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013; 95 (02) 138-145
    CrossrefPubMedSearch in Google Scholar
  • 6 Littman AJ, Boyko EJ, Thompson ML, Haselkorn JK, Sangeorzan BJ, Arterburn DE. Physical activity barriers and enablers in older Veterans with lower-limb amputation. J Rehabil Res Dev 2014; 51 (06) 895-906
    CrossrefPubMedSearch in Google Scholar
  • 7 Sinha R, van den Heuvel WJ, Arokiasamy P. Factors affecting quality of life in lower limb amputees. Prosthet Orthot Int 2011; 35 (01) 90-96
    CrossrefPubMedSearch in Google Scholar
  • 8 Singh RK, Prasad G. Long-term mortality after lower-limb amputation. Prosthet Orthot Int 2016; 40 (05) 545-551
    CrossrefPubMedSearch in Google Scholar
  • 9 Fortington LV, Geertzen JH, van Netten JJ, Postema K, Rommers GM, Dijkstra PU. Short and long term mortality rates after a lower limb amputation. Eur J Vasc Endovasc Surg 2013; 46 (01) 124-131
    CrossrefPubMedSearch in Google Scholar
  • 10 Aulivola B, Hile CN, Hamdan AD. , et al. Major lower extremity amputation: outcome of a modern series. Arch Surg 2004; 139 (04) 395-399
    CrossrefPubMedSearch in Google Scholar
  • 11 Dumanian GA, Potter BK, Mioton LM. , et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees. Ann Surg 2019; 270 (02) 238-246
    CrossrefPubMedSearch in Google Scholar
  • 12 Weeks SR, Anderson-Barnes VC, Tsao JW. Phantom limb pain: theories and therapies. Neurologist 2010; 16 (05) 277-286
    CrossrefPubMedSearch in Google Scholar
  • 13 Serino A, Akselrod M, Salomon R. , et al. Upper limb cortical maps in amputees with targeted muscle and sensory reinnervation. Brain 2017; 140 (11) 2993-3011
    CrossrefPubMedSearch in Google Scholar
  • 14 Kuiken TA, Dumanian GA, Lipschutz RD, Miller LA, Stubblefield KA. The use of targeted muscle reinnervation for improved myoelectric prosthesis control in a bilateral shoulder disarticulation amputee. Prosthet Orthot Int 2004; 28 (03) 245-253
    CrossrefPubMedSearch in Google Scholar
  • 15 Pet MA, Ko JH, Friedly JL, Mourad PD, Smith DG. Does targeted nerve implantation reduce neuroma pain in amputees?. Clin Orthop Relat Res 2014; 472 (10) 2991-3001
    CrossrefPubMedSearch in Google Scholar
  • 16 Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res 2014; 472 (10) 2984-2990
    CrossrefPubMedSearch in Google Scholar
  • 17 Valerio IL, Dumanian GA, Jordan SW. , et al. Preemptive treatment of phantom and residual limp pain with targeted muscle reinnervation at the time of major limb amputation. J Am Coll Surg 2019; 228 (03) 217-226
    CrossrefPubMedSearch in Google Scholar
  • 18 Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted muscle reinnervation technique in below-knee amputation. Plast Reconstr Surg 2019; 143 (01) 309-312
    CrossrefPubMedSearch in Google Scholar
  • 19 Penna A, Konstantatos AH, Cranwell W, Paul E, Bruscino-Raiola FR. Incidence and associations of painful neuroma in a contemporary cohort of lower-limb amputees. ANZ J Surg 2018; 88 (05) 491-496
    CrossrefPubMedSearch in Google Scholar
  • 20 Aydemir K, Demir Y, Güzelküçük Ü, Tezel K, Yilmaz B. Ultrasound findings of young and traumatic amputees with lower extremity residual limb pain in Turkey. Am J Phys Med Rehabil 2017; 96 (08) 572-577
    CrossrefPubMedSearch in Google Scholar
  • 21 Bowen JB, Wee CE, Kalik J, Valerio IL. Targeted muscle reinnervation to improve pain, prosthetic tolerance, and bioprosthetic outcomes in the amputee. Adv Wound Care (New Rochelle) 2017; 6 (08) 261-267
    CrossrefPubMedSearch in Google Scholar
  • 22 Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat 2011; 2011: 864605
    PubMedSearch in Google Scholar
  • 23 Morgan SJ, Friedly JL, Amtmann D, Salem R, Hafner BJ. A cross-sectional assessment of factors related to pain intensity and pain interference in lower limb prosthesis users. Arch Phys Med Rehabil 2017; 98 (01) 105-113
    CrossrefPubMedSearch in Google Scholar
  • 24 Raichle KA, Hanley MA, Molton I. , et al. Prosthesis use in persons with lower- and upper-limb amputation. J Rehabil Res Dev 2008; 45 (07) 961-972
    CrossrefPubMedSearch in Google Scholar
  • 25 Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev 2016; 10: CD006380
    PubMedSearch in Google Scholar
  • 26 Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res 2017; 10: 1861-1870
    CrossrefPubMedSearch in Google Scholar
  • 27 Eberlin KR, Ducic I. Surgical algorithm for neuroma management: a changing treatment paradigm. Plast Reconstr Surg Glob Open 2018; 6 (10) e1952
    CrossrefPubMedSearch in Google Scholar
  • 28 Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg 1986; 77 (03) 427-438
    CrossrefPubMedSearch in Google Scholar
  • 29 Mass DP, Ciano MC, Tortosa R, Newmeyer WL, Kilgore Jr ES. Treatment of painful hand neuromas by their transfer into bone. Plast Reconstr Surg 1984; 74 (02) 182-185
    CrossrefPubMedSearch in Google Scholar
  • 30 Herbert TJ, Filan SL. Vein implantation for treatment of painful cutaneous neuromas. A preliminary report. J Hand Surg [Br] 1998; 23 (02) 220-224
    CrossrefPubMedSearch in Google Scholar
  • 31 Domeshek LF, Krauss EM, Snyder-Warwick AK. , et al. Surgical treatment of neuromas improves patient-reported pain, depression, and quality of life. Plast Reconstr Surg 2017; 139 (02) 407-418
    CrossrefPubMedSearch in Google Scholar
  • 32 Hargrove LJ, Miller LA, Turner K, Kuiken TA. Myoelectric pattern recognition outperforms direct control for transhumeral amputees with targeted muscle reinnervation: a randomized control trial. Sci Rep 2017; 7 (01) 13840
    CrossrefPubMedSearch in Google Scholar
  • 33 Hargrove LJ, Simon AM, Lipschutz RD, Finucane SB, Kuiken TA. Real-time myoelectric control of knee and ankle motions for transfemoral amputees. JAMA 2011; 305 (15) 1542-1544
    CrossrefPubMedSearch in Google Scholar
  • 34 Morgan EN, Kyle Potter B, Souza JM, Tintle SM, Nanos III GP. Targeted muscle reinnervation for transradial amputation: description of operative technique. Tech Hand Up Extrem Surg 2016; 20 (04) 166-171
    CrossrefPubMedSearch in Google Scholar
  • 35 Tintle SM, LeBrun C, Ficke JR, Potter BK. What is new in trauma-related amputations. J Orthop Trauma 2016; 30 (Suppl. 03) S16-S20
    CrossrefPubMedSearch in Google Scholar
  • 36 Gart MS, Souza JM, Dumanian GA. Targeted muscle reinnervation in the upper extremity amputee: a technical roadmap. J Hand Surg Am 2015; 40 (09) 1877-1888
    CrossrefPubMedSearch in Google Scholar
  • 37 Cheesborough JE, Souza JM, Dumanian GA, Bueno Jr RA. Targeted muscle reinnervation in the initial management of traumatic upper extremity amputation injury. Hand (N Y) 2014; 9 (02) 253-257
    CrossrefPubMedSearch in Google Scholar
  • 38 Kuiken TA, Barlow AK, Hargrove L, Dumanian GA. Targeted muscle reinnervation for the upper and lower extremity. Tech Orthop 2017; 32 (02) 109-116
    CrossrefPubMedSearch in Google Scholar
  • 39 Fracol ME, Janes LE, Ko JH, Dumanian GA. Targeted muscle reinnervation in the lower leg: an anatomical study. Plast Reconstr Surg 2018; 142 (04) 541e-550e
    CrossrefPubMedSearch in Google Scholar
  • 40 Hess JR, Brenner MJ, Myckatyn TM, Hunter DA, Mackinnon SE. Influence of aging on regeneration in end-to-side neurorrhaphy. Ann Plast Surg 2006; 57 (02) 217-222
    CrossrefPubMedSearch in Google Scholar
  • 41 Watanabe O, Mackinnon SE, Tarasidis G, Hunter DA, Ball DJ. Long-term observation of the effect of peripheral nerve injury in neonatal and young rats. Plast Reconstr Surg 1998; 102 (06) 2072-2081 , discussion 2082–2084
    CrossrefPubMedSearch in Google Scholar
  • 42 Belin BM, Ball DJ, Langer JC, Bridge PM, Hagberg PK, Mackinnon SE. The effect of age on peripheral motor nerve function after crush injury in the rat. J Trauma 1996; 40 (05) 775-777
    CrossrefPubMedSearch in Google Scholar
  • 43 He B, Zhu Z, Zhu Q. , et al. Factors predicting sensory and motor recovery after the repair of upper limb peripheral nerve injuries. Neural Regen Res 2014; 9 (06) 661-672
    CrossrefPubMedSearch in Google Scholar
  • 44 Lohmeyer JA, Sommer B, Siemers F, Mailänder P. Nerve injuries of the upper extremity-expected outcome and clinical examination. Plast Surg Nurs 2009; 29 (02) 88-93
    CrossrefPubMedSearch in Google Scholar
  • 45 MacKenzie EJ, Bosse MJ, Kellam JF. , et al; The LEAP Study Group. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma 2000; 14 (07) 455-466
    CrossrefPubMedSearch in Google Scholar
  • 46 Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. Am J Phys Med Rehabil 2001; 80 (08) 563-571
    CrossrefPubMedSearch in Google Scholar
  • 47 Serizawa F, Sasaki S, Fujishima S, Akamatsu D, Goto H, Amada N. Mortality rates and walking ability transition after lower limb major amputation in hemodialysis patients. J Vasc Surg 2016; 64 (04) 1018-1025
    CrossrefPubMedSearch in Google Scholar
  • 48 Wukich DK, Ahn J, Raspovic KM, Gottschalk FA, La Fontaine J, Lavery LA. Comparison of transtibial amputations in diabetic patients with and without end-stage renal disease. Foot Ankle Int 2017; 38 (04) 388-396
    CrossrefPubMedSearch in Google Scholar