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Todd A. Kuiken - One of the best experts on this subject based on the ideXlab platform.
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targeted Muscle Reinnervation treats neuroma and phantom pain in major limb amputees a randomized clinical trial
Annals of Surgery, 2019Co-Authors: Gregory A. Dumanian, George P. Nanos, Jason M Souza, Lauren M. Mioton, William J.j. Ertl, Benjamin K. Potter, Ian L. Valerio, Jennifer E. Cheesborough, Scott M Tintle, Todd A. KuikenAbstract:Objective:To compare targeted Muscle Reinnervation (TMR) to “standard treatment” of neuroma excision and burying into Muscle for postamputation pain.Summary Background Data:To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve
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Myoelectric Pattern Recognition Outperforms Direct Control for Transhumeral Amputees with Targeted Muscle Reinnervation: A Randomized Clinical Trial.
Scientific reports, 2017Co-Authors: Levi J. Hargrove, Laura A. Miller, Kristi Turner, Todd A. KuikenAbstract:Recently commercialized powered prosthetic arm systems hold great potential in restoring function for people with upper-limb loss. However, effective use of such devices remains limited by conventional (direct) control methods, which rely on electromyographic signals produced from a limited set of Muscles. Targeted Muscle Reinnervation (TMR) is a nerve transfer procedure that creates additional recording sites for myoelectric prosthesis control. The effects of TMR may be enhanced when paired with pattern recognition technology. We sought to compare pattern recognition and direct control in eight transhumeral amputees who had TMR in a balanced randomized cross-over study. Subjects performed a 6–8 week home trial using direct and pattern recognition control with a custom prostheses made from commercially available parts. Subjects showed statistically better performance in the Southampton Hand Assessment Procedure (p = 0.04) and the Clothespin relocation task (p = 0.02). Notably, these tests required movements along 3 degrees of freedom. Seven of 8 subjects preferred pattern recognition control over direct control. This study was the first home trial large enough to establish clinical and statistical significance in comparing pattern recognition with direct control. Results demonstrate that pattern recognition is a viable option and has functional advantages over direct control.
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Targeted Muscle Reinnervation for the Upper and Lower Extremity.
Techniques in orthopaedics (Rockville Md.), 2017Co-Authors: Todd A. Kuiken, Ann K. Barlow, Levi J. Hargrove, Gregorgy A. DumanianAbstract:Myoelectric devices are controlled by electromyographic signals generated by contraction of residual Muscles, which thus serve as biological amplifiers of neural control signals. Although nerves severed by amputation continue to carry motor control information intended for the missing limb, loss of Muscle effectors due to amputation prevents access to this important control information. Targeted Muscle Reinnervation (TMR) was developed as a novel strategy to improve control of myoelectric upper limb prostheses. Severed motor nerves are surgically transferred to the motor points of denervated target Muscles, which, after Reinnervation, contract in response to neural control signals for the missing limb. TMR creates additional control sites, eliminating the need to switch the prosthesis between different control modes. In addition, contraction of target Muscles, and operation of the prosthesis, occurs in reponse to attempts to move the missing limb, making control easier and more intuitive. TMR has been performed extensively in individuals with high-level upper limb amputations and has been shown to improve functional prosthesis control. The benefits of TMR are being studied in individuals with transradial amputations and lower limb amputations. TMR is also being investigated in an ongoing clinical trial as a method to prevent or treat painful amputation neuromas.
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Targeted Muscle Reinnervation and advanced prosthetic arms.
Seminars in plastic surgery, 2015Co-Authors: Jennifer E. Cheesborough, Todd A. Kuiken, Lauren H. Smith, Gregory A. DumanianAbstract:Targeted Muscle Reinnervation (TMR) is a surgical procedure used to improve the control of upper limb prostheses. Residual nerves from the amputated limb are transferred to reinnervate new Muscle targets that have otherwise lost their function. These reinnervated Muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of advanced prosthetic arms. Here the authors provide a review of surgical techniques for TMR in patients with either transhumeral or shoulder disarticulation amputations. They also discuss how TMR may act synergistically with recent advances in prosthetic arm technologies to improve prosthesis controllability. Discussion of TMR and prosthesis control is presented in the context of a 41-year-old man with a left-side shoulder disarticulation and a right-side transhumeral amputation. This patient underwent bilateral TMR surgery and was fit with advanced pattern-recognition myoelectric prostheses.
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Targeted Muscle Reinnervation: A Novel Approach to Postamputation Neuroma Pain
Clinical Orthopaedics and Related Research®, 2014Co-Authors: Jason M Souza, Todd A. Kuiken, Jennifer E. Cheesborough, Mickey S. Cho, Gregory A. DumanianAbstract:Background Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted Muscle Reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. Questions/purposes We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. Methods We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. Results Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient’s pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. Conclusions None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Gregory A. Dumanian - One of the best experts on this subject based on the ideXlab platform.
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Targeted Muscle Reinnervation as a Solution for Nerve Pain.
Plastic and reconstructive surgery, 2020Co-Authors: Steven T. Lanier, Sumanas W. Jordan, Gregory A. DumanianAbstract:LEARNING OBJECTIVES After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted Muscle Reinnervation. 3. Develop an operative plan for targeted Muscle Reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted Muscle Reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in Muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted Muscle Reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fashion to treat existing pain. SUMMARY Symptomatic injured nerves resulting from amputations, extremity trauma, or prior surgery are common and can decrease patient quality of life, thus necessitating an effective strategy for management. Targeted Muscle Reinnervation is a modern surgical strategy for prevention and treatment of neuroma pain that promotes nerve regeneration and healing rather than neuroma formation. Targeted Muscle Reinnervation involves the transfer of cut peripheral nerves to small motor nerves of adjacent, newly denervated segments of Muscle and can be easily performed without specialized equipment. Targeted Muscle Reinnervation strategies exist for both upper and lower extremity amputations and for symptomatic neuromas of intact limbs. Targeted Muscle Reinnervation has been shown in a prospective, randomized, controlled trial to result in lower neuroma and phantom pain when compared to the historical gold standard of burying cut nerves in Muscle.
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Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.
Clinical orthopaedics and related research, 2020Co-Authors: Lauren M. Mioton, Jason M Souza, Gregory A. Dumanian, Nikita Shah, Cecil S. Qiu, William J.j. Ertl, Benjamin K. Potter, Ian L. Valerio, Sumanas W. JordanAbstract:BACKGROUND Targeted Muscle Reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted Muscle Reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and Muscle burying. QUESTIONS/PURPOSES (1) Does targeted Muscle Reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted Muscle Reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted Muscle Reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted Muscle Reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS By 1 year after targeted Muscle Reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS Targeted Muscle Reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Targeted Muscle Reinnervation for Treatment of Neuropathic Pain.
Clinics in plastic surgery, 2020Co-Authors: Ava G. Chappell, Sumanas W. Jordan, Gregory A. DumanianAbstract:Targeted Muscle Reinnervation (TMR) is a reproducible procedure for effective prevention and treatment of neuropathic pain. Recent studies have demonstrated that TMR is more successful in treating neuroma pain than the standard method of neuroma excision and burying into Muscle. The fundamental concept of TMR is that providing severed nerve endings a place to go and something to do facilitates normal healing. Future studies will continue to support the use of TMR for any region of the body where an injured nerve may develop a painful neuroma.
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Management of Sural Nerve Neuromas with Targeted Muscle Reinnervation.
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Megan Fracol, Gregory A. Dumanian, Lindsay E. Janes, Jennifer BaiAbstract:Neuromas are a debilitating peripheral nerve problem due to aberrant axon sprouting and inflammation after nerve injury. The surgical management of neuromas has for a long time been up for debate, largely due to lack of consistent, reliable outcomes with any one technique. We have found success utilizing targeted Muscle Reinnervation, a technique originally described in amputees that re-routes the proximal ends of cut sensory nerve stumps into the distal ends of motor nerves to nearby Muscles. In doing so, the sensory nerve ending can regenerate along the length of the motor nerve, giving it a place to go and something to do. In this report, we describe our technique specifically for targeted Muscle Reinnervation of sural nerve neuromas that is applicable to both amputees and to patients with intact limbs. Sural nerve neuromas can occur after sural nerve harvest for reconstructive procedures and particularly after lateral malleolar incisions for orthopedic access to the calcaneus. By re-routing the sural nerve into a motor nerve of the lateral gastrocnemius Muscle, we are able to manage a variety of sural nerve neuromas presenting anywhere along the course of the sural nerve and in a variety of clinical settings.
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management of unreconstructable saphenous nerve injury with targeted Muscle Reinnervation
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Lindsay E. Janes, Megan Fracol, Jason H Ko, Gregory A. DumanianAbstract:Targeted Muscle Reinnervation (TMR) is a surgical technique that coapts the proximal ends of cut nerves to small motor nerve branches of nearby Muscles. Initially developed for intuitive myoelectric prosthesis control, the technique has subsequently been found to improve neuroma pain and phantom limb pain in the amputee population.1,2 Given its origins, most early descriptions have focused on the major mixed nerves of the upper extremity. Prior cadaver studies have described the anatomy of motor entry points in the upper and lower leg but with relatively few clinical examples of the treatment of specific nerves using TMR for neuroma pain.3,4 Although the treatment of injured nerves, conceptually, is best with the restoration of continuity either with direct coaptation, nerve grafts, and, more recently, nerve allografts, there are many situations (especially in amputees) where repair is not possible. In these situations of unreconstructable nerve injury, TMR is a helpful adjunct. We present the surgical anatomy of the saphenous nerve and treatment of unreconstructable saphenous neuromas at various levels with TMR.
Ian L. Valerio - One of the best experts on this subject based on the ideXlab platform.
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targeted Muscle Reinnervation following external hemipelvectomy or hip disarticulation an anatomic description of technique and clinical case correlates
Journal of Surgical Oncology, 2020Co-Authors: Spencer R Anderson, Margaret S. Roubaud, Sunishka M Wimalawansa, Alexander F Mericli, Brandon R Horne, Ian L. ValerioAbstract:BACKGROUND Targeted Muscle Reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. METHODS Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. RESULTS A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. CONCLUSIONS This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.
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Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.
Clinical orthopaedics and related research, 2020Co-Authors: Lauren M. Mioton, Jason M Souza, Gregory A. Dumanian, Nikita Shah, Cecil S. Qiu, William J.j. Ertl, Benjamin K. Potter, Ian L. Valerio, Sumanas W. JordanAbstract:BACKGROUND Targeted Muscle Reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted Muscle Reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and Muscle burying. QUESTIONS/PURPOSES (1) Does targeted Muscle Reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted Muscle Reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted Muscle Reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted Muscle Reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS By 1 year after targeted Muscle Reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS Targeted Muscle Reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Targeted Muscle Reinnervation following Breast Surgery: A Novel Technique.
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Andrew L. O'brien, Ian L. Valerio, Casey T. Kraft, Juan L. Rendon, Jamie A. Spitz, Roman J. SkorackiAbstract:Post-mastectomy pain syndrome is a prevalent chronic pain condition that affects numerous patients following breast surgery. The mechanism of this pain has been proposed to be neurogenic in nature. As such, we propose a novel surgical method for the prophylactic management of postsurgical breast pain: targeted Muscle Reinnervation of the breast. This article serves to review the relevant current literature of post-mastectomy pain syndrome and targeted Muscle Reinnervation, describe our current surgical technique for this operation, and present an initial cohort of patients to undergo this procedure.
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A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Michael C. Daly, Ian L. Valerio, Ryan P. Ponton, Kyle R. EberlinAbstract:Targeted Muscle Reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.
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Targeted Muscle Reinnervation Combined with a Vascularized Pedicled Regenerative Peripheral Nerve Interface.
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Ian L. Valerio, Julie M. West, Steven Schulz, Ritsaart F. Westenberg, Kyle R. EberlinAbstract:Symptomatic neuromas and pain caused by nerve transection injuries can adversely impact a patient's recovery, while also contributing to increased dependence on opioid and other pharmacotherapy. These sources of pain are magnified following amputation surgeries, inhibiting optimal prosthetic wear and function. Targeted Muscle Reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) represent modern advances in addressing amputated peripheral nerves. These techniques offer solutions by essentially providing neuromuscular targets for transected peripheral nerves "to grow into and reinnervate." Recent described benefits of these techniques include reports on pain reduction or ablation (eg, phantom limb pain, residual limb pain, and/or neuroma pain).1-6 We describe a technical adaptation combining TMR with a "pedicled vascularized RPNI (vRPNI)." The TMR with the vRPNI surgical technique described offers the advantage of having a distal target nerve and a target Muscle possessing deinnervated motor end plates which may potentially enhance nerve regeneration and Muscle Reinnervation, while also decreasing amputated nerve-related pain.
Jason M Souza - One of the best experts on this subject based on the ideXlab platform.
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Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.
Clinical orthopaedics and related research, 2020Co-Authors: Lauren M. Mioton, Jason M Souza, Gregory A. Dumanian, Nikita Shah, Cecil S. Qiu, William J.j. Ertl, Benjamin K. Potter, Ian L. Valerio, Sumanas W. JordanAbstract:BACKGROUND Targeted Muscle Reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted Muscle Reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and Muscle burying. QUESTIONS/PURPOSES (1) Does targeted Muscle Reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted Muscle Reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted Muscle Reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted Muscle Reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS By 1 year after targeted Muscle Reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS Targeted Muscle Reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE Level IV, therapeutic study.
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targeted Muscle Reinnervation treats neuroma and phantom pain in major limb amputees a randomized clinical trial
Annals of Surgery, 2019Co-Authors: Gregory A. Dumanian, George P. Nanos, Jason M Souza, Lauren M. Mioton, William J.j. Ertl, Benjamin K. Potter, Ian L. Valerio, Jennifer E. Cheesborough, Scott M Tintle, Todd A. KuikenAbstract:Objective:To compare targeted Muscle Reinnervation (TMR) to “standard treatment” of neuroma excision and burying into Muscle for postamputation pain.Summary Background Data:To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve
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Targeted Muscle Reinnervation for transradial amputation: Description of operative technique
Techniques in Hand and Upper Extremity Surgery, 2016Co-Authors: Emily N. Morgan, Benjamin Kyle Potter, Jason M Souza, S M Tintle, George P. NanosAbstract:Targeted Muscle Reinnervation (TMR) is a revolutionary surgical technique that, together with advances in upper extremity prostheses and advanced neuromuscular pattern recognition, allows intuitive and coordinated control in multiple planes of motion for shoulder disarticulation and transhumeral amputees. TMR also may provide improvement in neuroma-related pain and may represent an opportunity for sensory Reinnervation as advances in prostheses and haptic feedback progress. Although most commonly utilized following shoulder disarticulation and transhumeral amputations, TMR techni- ques also represent an exciting opportunity for improvement in inte- grated prosthesis control and neuroma-related pain improvement in patients with transradial amputations. As there are no detailed descriptions of this technique in the literature to date, we provide our surgical technique for TMR in transradial amputations
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targeted Muscle Reinnervation in the upper extremity amputee a technical roadmap
Journal of Hand Surgery (European Volume), 2015Co-Authors: Michael S Gart, Jason M Souza, Gregory A. DumanianAbstract:Targeted Muscle Reinnervation (TMR) offers the potential for improved prosthetic function by reclaiming the neural control information that is lost as a result of upper extremity amputation. In addition to the prosthetic control benefits, TMR is a potential treatment for postamputation neuroma pain. Here, we present our surgical technique for TMR nerve transfers in transhumeral and shoulder disarticulation patients.
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Targeted Muscle Reinnervation: A Novel Approach to Postamputation Neuroma Pain
Clinical Orthopaedics and Related Research®, 2014Co-Authors: Jason M Souza, Todd A. Kuiken, Jennifer E. Cheesborough, Mickey S. Cho, Gregory A. DumanianAbstract:Background Postamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted Muscle Reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied. Questions/purposes We evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees. Methods We conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (> 6 months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR. Results Of the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient’s pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis. Conclusions None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Kyle R. Eberlin - One of the best experts on this subject based on the ideXlab platform.
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A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Michael C. Daly, Ian L. Valerio, Ryan P. Ponton, Kyle R. EberlinAbstract:Targeted Muscle Reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.
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Targeted Muscle Reinnervation Combined with a Vascularized Pedicled Regenerative Peripheral Nerve Interface.
Plastic and reconstructive surgery. Global open, 2020Co-Authors: Ian L. Valerio, Julie M. West, Steven Schulz, Ritsaart F. Westenberg, Kyle R. EberlinAbstract:Symptomatic neuromas and pain caused by nerve transection injuries can adversely impact a patient's recovery, while also contributing to increased dependence on opioid and other pharmacotherapy. These sources of pain are magnified following amputation surgeries, inhibiting optimal prosthetic wear and function. Targeted Muscle Reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) represent modern advances in addressing amputated peripheral nerves. These techniques offer solutions by essentially providing neuromuscular targets for transected peripheral nerves "to grow into and reinnervate." Recent described benefits of these techniques include reports on pain reduction or ablation (eg, phantom limb pain, residual limb pain, and/or neuroma pain).1-6 We describe a technical adaptation combining TMR with a "pedicled vascularized RPNI (vRPNI)." The TMR with the vRPNI surgical technique described offers the advantage of having a distal target nerve and a target Muscle possessing deinnervated motor end plates which may potentially enhance nerve regeneration and Muscle Reinnervation, while also decreasing amputated nerve-related pain.
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contralateral heterotopic thumb to thumb replantation with free ulnar forearm fasciocutaneous flap and targeted Muscle Reinnervation
Journal of Hand Surgery (European Volume), 2020Co-Authors: Rick Tosti, Matthew D Treiser, Kyle R. EberlinAbstract:: Mangling hand injuries can be difficult to manage owing to the severity and heterogeneity of the injuries. Outcomes after reconstruction of unique injuries are less well-known but provide valuable insight. We present an unusual spare parts reconstruction of a bilateral upper-extremity mangling injury treated with a heterotopic thumb-to-thumb replantation, an acute forearm fasciocutaneous free flap, and targeted Muscle Reinnervation. This report highlights the utility of microsurgical reconstruction with available autogenous tissue in the acute setting.
