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J Reconstr Microsurg 2023; 39(03): 238-244
DOI: 10.1055/s-0042-1755262
Original Article

The Current State of Targeted Muscle Reinnervation: A Systematic Review

Amanda R. Walsh 
1   Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
,
Jocelyn Lu
1   Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
,
Esdras Rodriguez
2   Division of Plastic Hand and Microsurgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Shawn Diamond
2   Division of Plastic Hand and Microsurgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
,
Steven M. Sultan
1   Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract

Background Targeted muscle reinnervation (TMR) is growing in popularity; however, literature evaluating patient characteristics and outcomes is limited.

Methods The EMBASE database was queried with the search terms “targeted muscle reinnervation” OR “TMR” AND “outcomes” OR “patient outcomes.” Clinical human studies in English were eligible for inclusion, yielding 89 articles. After rigorous exclusion criteria, a total of 13 articles were included in this review. Study data including geographic location, patient demographics, TMR indication, amputation level, number of nerve transfers performed, length of follow-up, and reported outcomes were extracted and analyzed.

Results The included articles represent 338 patients (341 limbs). Average patient age was 47.4 years. Indication for amputation included trauma (n = 125), infection (n = 76) cancer/tumor resection (n = 71), ischemia (n = 18), failed Charcot reconstruction (n = 15), failed hardware (n = 9), burn (n = 4), and CRPS (n = 4). Five studies included upper extremity TMR only, two included lower extremity TMR only, and six included both upper and lower extremity TMR. TMR was performed in an immediate or delayed fashion, with an average of 2.2 nerve transfers performed per limb overall. Average length of follow-up was 22.3 months. In three studies, patients with phantom limb pain undergoing delayed TMR were found to have significant or trending toward significant reduction in pain after TMR using numeric rating scale and patient-reported outcomes measurement information system scales. One article reported 9/10 patients with improved or complete resolution of phantom limb pain after delayed TMR. Three studies found that patients undergoing immediate TMR had lower pain scores compared with non-TMR controls.

Conclusion While there is evidence that TMR reduces neuroma-related pain and improves the quality of life for amputees, further outcomes studies are needed to study the patient experience with TMR on a larger scale. Establishing standardized, validated patient-reported outcomes assessment tools is critical to future investigation in this field.

Keywords

targeted muscle reinnervation - TMR - TMR outcomes - patient outcomes - upper extremity surgery - lower extremity surgery - peripheral nerve surgery


Publication History

Received: 31 January 2022

Accepted: 29 May 2022

Article published online:
21 August 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Cheesborough JE, Smith LH, Kuiken TA. et al. Targeted muscle reinnervation and advanced prosthetic arms. Sem in Plast Surg 2015; 29 (01) 62-72
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Valerio IL, Larsen M, Eberlin KR. Application of spare parts in combination with targeted muscle reinnervation surgery. Plast Reconstr Surg 2021; 147 (02) 279e-283e
    CrossrefPubMedGoogle Scholar
  • 3 Alexander JH, Jordan SW, West JM. et al. Targeted muscle reinnervation in oncologic amputees: early experience of a novel institutional protocol. J Surg Oncol 2019; 120 (03) 348-358
    CrossrefPubMedGoogle Scholar
  • 4 Dumanian GA, Potter BK, Mioton LM. et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: a randomized clinical trial. Ann Surg 2019; 270 (02) 238-246
    CrossrefPubMedGoogle Scholar
  • 5 Hebert JS, Chan KM, Dawson MR. Cutaneous sensory outcomes from three transhumeral targeted reinnervation cases. Prosthet Orthot Int 2016; 40 (03) 303-310
    CrossrefPubMedGoogle Scholar
  • 6 Hoffer JA, Loeb GE. Implantable electrical and mechanical interfaces with nerve and muscle. Ann Biomed Eng 1980; 8 (4-6): 351-360
    CrossrefPubMedGoogle Scholar
  • 7 Michno DA, Woollard ACS, Kang NV. Clinical outcomes of delayed targeted muscle reinnervation for neuroma pain reduction in longstanding amputees. J Plast Reconstr Aesthet Surg 2019; 72 (09) 1576-1606
    CrossrefPubMedGoogle Scholar
  • 8 Mioton LM, Dumanian GA, Shah N. et al. Targeted muscle reinnervation improves residual limb pain, phantom limb pain, and limb function: a prospective study of 33 major limb amputees. Clin Orthop Relat Res 2020; 478 (09) 2161-2167
    CrossrefPubMedGoogle Scholar
  • 9 Myers H, Lu D, Gray SJ, Bruscino-Raiola F. Targeted muscle reinnervation to improve electromyography signals for advanced myoelectric prosthetic limbs: a series of seven patients. ANZ J Surg 2020; 90 (04) 591-596
    CrossrefPubMedGoogle Scholar
  • 10 O'Brien AL, Jordan SW, West JM, Mioton LM, Dumanian GA, Valerio IL. Targeted muscle reinnervation at the time of upper-extremity amputation for the treatment of pain severity and symptoms. J Hand Surg Am 2021; 46 (01) 72.e1-72.e10
    CrossrefPubMedGoogle Scholar
  • 11 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; 144 (06) 1037e-1043e
    CrossrefPubMedGoogle Scholar
  • 12 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
    CrossrefPubMedGoogle Scholar
  • 13 Stoehr JR, Sood R, Jordan SW, Dumanian GA. Targeted muscle reinnervation at the time of amputation in the management of complex regional pain syndrome of the lower extremity. Microsurgery 2020; 40 (08) 852-858
    CrossrefPubMedGoogle Scholar
  • 14 Valerio IL, Dumanian GA, Jordan SW. et al. Preemptive treatment of phantom and residual limb pain with targeted muscle reinnervation at the time of major limb amputation. J Am Coll Surg 2019; 228 (03) 217-226
    CrossrefPubMedGoogle Scholar
  • 15 Chang BL, Mondshine J, Attinger CE, Kleiber GM. Targeted muscle reinnervation improves pain and ambulation outcomes in highly comorbid amputees. Plast Reconstr Surg 2021; 148 (02) 376-386
    CrossrefPubMedGoogle Scholar
  • 16 McNamara CT, Iorio ML. Targeted muscle reinnervation: outcomes in treating chronic pain secondary to extremity amputation and phantom limb syndrome. J Reconstr Microsurg 2020; 36 (04) 235-240
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 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
    CrossrefPubMedGoogle Scholar
  • 18 Kuiken TA, Childress DS, Rymer WZ. The hyper-reinnervation of rat skeletal muscle. Brain Res 1995; 676 (01) 113-123
    CrossrefPubMedGoogle Scholar
  • 19 Kuiken TA, Stoykov NS, Popović M, Lowery M, Taflove A. Finite element modeling of electromagnetic signal propagation in a phantom arm. IEEE Trans Neural Syst Rehabil Eng 2001; 9 (04) 346-354
    CrossrefPubMedGoogle Scholar
  • 20 Kelly DA, Pedersen S, Tosenovsky P, Sieunarine K. Major lower limb amputation: outcomes are improving. Ann Vasc Surg 2017; 45: 29-34
    CrossrefPubMedGoogle Scholar