Targeted Muscle Reinnervation Combined with a Vascularized Pedicled Regenerative Peripheral Nerve Interface

Abstract

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.

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

Figures

Fig. 1.

A clinical example of the TMR with vRPNI technique. A, Immediate TMR nerve coaptation illustrating the size mismatch of the larger proximal mixed nerve and smaller distal motor target nerve within surrounding target muscle. Clinical intraoperative example. B, Illustrated rending of TMR concept for the clinical example provided in (A).

Fig. 2.

A clinical example of the TMR with vRPNI technique. A, The transferred nerve coaptation is seen wrapped with a surrounding vascularized but freshly deinnervated muscle cuff (vRPNI) to completely cover the prior performed nerve coaptation illustrated in Figure 1A. Clinical intraoperative example. B and C, Illustrated rending of TMR vRPNI concept for the clinical example provided in (A).