Early Targeted Muscle Reinnervation Does Not Increase Complications After Upper Extremity Amputation
Sarah Pierrie, MD1; Glenn Gaston, MD2; Bryan Loeffler, MD2
1Atrium Health, Charlotte, NC, 2OrthoCarolina Hand Center, Charlotte, NC
Introduction: Early transition to a prosthesis is associated with increased independence and prosthetic use among patients with upper extremity amputations. Historically, targeted muscle reinnervation (TMR) has been performed in delayed fashion—once a patient has developed painful neuromas or is seeking additional function in a myoelectric prosthesis. The theoretical benefits of early TMR include earlier prosthetic fitting/use, fewer surgical procedures, less neuroma pain, and fewer psychologic symptoms associated with delayed upper extremity function. However, limited clinical data about early TMR is available to guide surgeons.
Materials & Methods: Adult patients who underwent TMR concurrent with or following transradial or transhumeral amputation were identified from our institution's upper extremity amputation registry. Demographic and technical data were extracted from the medical record while patient-reported functional and psychosocial metrics were collected prospectively.
Results: Twenty-five patients with transradial (15 patients, 16 limbs) or transhumeral (10 patients) amputations underwent forearm or above-elbow TMR. Twelve patients had 13 TMR procedures performed within 31 days of primary amputation ("early TMR") while the remainder underwent TMR remote from amputation ("delayed TMR"). The two groups did not differ significantly in regard to gender, age, race, ethnicity, tobacco use, injury mechanism, amputation side, loss of dominant hand, or TMR level. Injured limbs associated with Workers' Compensation claims were more likely to undergo delayed TMR (p=0.04). Neuromas were identified at the time of TMR in 9 limbs undergoing delayed TMR (69.2%). Limbs in the early TMR group tended to undergo concurrent procedures under the same anesthetic (e.g. wound debridement, intentional shortening, or skin grafting; p=0.10), though the median number of surgeries performed after definitive amputation did not differ (p=0.94). Complications including wound dehiscence, postoperative hematoma formation requiring debridement, superficial or deep infection, and persistent tenderness at nerve coaptation sites occurred at the same rate (38.5%) in both groups. TMR targets exhibited palpable contraction at a mean of 2.0 months postoperatively for both groups (p=0.92). DASH scores, VAS scores, PTSD scale scores, and depression indices did not differ between the two groups at 6 and 12 months postoperatively.
Conclusions: In select patients, TMR concurrent with or closely following transradial or transhumeral amputation does not increase the incidence of postoperative complications such as wound dehiscence or infection. Early TMR may improve prosthesis use, function, and self-efficacy if patients with major upper extremity amputations are fitted with prostheses earlier.
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