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Bilateral Targeted Muscle Reinnervation for Upper Extremity Myoelectric Control
Jason M. Souza, MD1, Jennifer E. Cheesborough, MD2, Todd A. Kuiken, MD, PhD3 and Gregory A. Dumanian, MD, FACS1
1Division of Plastic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, 2Division of Plastic Surgery, Northwestern University, Chicago, IL, 3Department of Physical Medicine & Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago, IL
Background: Targeted muscle reinnervation (TMR) has become an established technique for providing intuitive control of upper extremity prostheses, with over 80 cases having been performed worldwide. However, the technique has only been described as a unilateral procedure, even when performed in the setting of bilateral upper extremity amputations. We present the first report of bilateral TMR, performed in combination with tissue expansion and free tissue transfer for management of traumatic upper extremity amputations stemming from a high-energy electrical injury. Case Report/Technique: A 41 year-old male presented with a left shoulder disarticulation and a right transhumeral amputation performed acutely following high-voltage electrical burns to both arms. One year after the initial injury, the patient complained of left-sided surgical site pain, soft tissue breakdown, poor socket suspension, and inability to control his right arm myoelectric prosthesis. For management of the left shoulder disarticulation site, the patient underwent tissue expansion of the left chest wall and shoulder girdle followed 4 months later by TMR and coverage of the left shoulder with a pedicled myocutaneous latissimus flap. After 4 months of convalescence, the patient returned to the operating room for TMR of the right transhumeral amputation. In this case, the native biceps brachii muscle had been severely damaged and could not serve as a usable target for reinnervation. Therefore, a free gracilis muscle flap was transferred to the anterior residual arm to provide improved soft tissue coverage and serve as a muscle target for reinnervation. Separate proximal and distal motor branches of the gracilis muscle served as targets for median and musculocutaneous nerve transfers, respectively. The patient recovered uneventfully from both procedures. Prosthetic/Therapy Outcomes/Results: Five months after his second surgery, the patient has five distinct EMG recording sites on his left chest and four distinct sites on his right residual limb. In the patient's first postoperative visit with the prosthetics team, he doubled his efficiency on box and blocks testing. With the assistance of virtual reality training and novel pattern recognition software, the patient has now achieved seamless prosthetic control with three degrees of freedom (elbow, wrist, and hand). Conclusions: This case demonstrates the feasibility and functional benefits of targeted muscle reinnervation in a bilateral amputee, and highlights some of the latest surgical and prosthetic advances in the field of TMR.
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