TMR in amputations
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The document discusses targeted muscle reinnervation (TMR) as a surgical intervention aimed at improving the control and function of prosthetic limbs while reducing post-amputation pain, including phantom limb pain (PLP) and neuropathic pain. It outlines the clinical pathway for implementing TMR in candidates for limb amputation, including inclusion and exclusion criteria, as well as outcome measures to assess pain and quality of life. The document also emphasizes the importance of informed consent and the potential benefits and risks of the procedure.
TMR in amputations
- 1. Innovating limb amputations in Singapore Targeted muscle reinnervation
- 2. Background Riandini, Tet al 2022. 6 656 diabetic lower limb minor amputations 4 724 diabetic major lower limb amputations 571 non-diabetes associated toe/ray amputations 582 non-diabetes associated major amputation
- 3. Challenges Pain Sensory feedback Precise control of myoelectric prosthesis
- 4. Pain phantom limb pain (PLP) ,neuropathic pain (NP), post amputation pain (PAP) and residual limb pain (RLP) •PLP reported as 25% (Sin et al., 2013) • 61% post op pain and 53% PLP with RLP at 32% (Schwinger et al., 2021)
- 5. Targeted Muscle reinnervation in limb amputation •improving control and function of prosthesis (Kuiken et al., 2017) •potential to reduce phantom limb •neuropathic pain by providing more normal sensations (Peters et al., 2020).
- 6. Mechanism • identifying the nerves that controlled the limb • rerouting them to new locations in residual limb • central sensitization and maladaptive neuronal remodelling
- 7. BKA TMR
- 8. Tibial Nerve Nerve to soleus Post Tibial Artery
- 9. Deep Peroneal Br to tibialis anterior
- 10. Evidence TMR at amputation to prevent post amputation pain • primary intervention (Chappell et al., 2020; Dumanian et al., 2019; O’Brien et al., 2021; Valerio et al., 2019). • performed at time of amputation -prophylactic intervention (McNamara and Iorio, 2020) • reduce pathologic PLP and symptomatic neuroma-related RLP (Valerio et al., 2019)
- 13. Clinical Pathway for Targeted Muscle Reinnervation (TMR) an Intervention for Reducing Post-Operative Limb Pain in Limb Amputations Clinically Indicated Limb amputation Fulfils inclusion criteria Recruited into pathway Primary surgeon schedules surgery Nerve surgeon assists with nerve identification and transfer Followed up regularly (0w, 6w,3m,6m,12m)
- 14. Inclusion criteria 1. Candidates for limb amputation 2. Risk of developing post-operative pain and phantom limb pain. 3. Willing and able to participate in post-operative rehabilitation and physical therapy. 4. Informed consent for the procedure and understand the potential risks and benefits. 5. Adequate muscle function to allow for TMR surgery to be performed. 6. Suitable for TMR surgery as per a surgeon's assessment.
- 15. Exclusion criteria 1. Unable or unwilling to participate in post-operative rehabilitation and physical therapy. 2. No informed consent for the procedure or do not understand the potential risks and benefits. 3. Insufficient muscle function to allow for TMR surgery to be performed. 4. Contraindication for TMR surgery as per nerve surgeon's assessment. 5. History of severe mental illness, which may affect their ability to comply with the rehabilitation process. 6. Presence of active infection at the amputation site 7. History of poor wound healing, which may increase the risk of complications during and after the surgery.
- 16. Outcome measures Visual analogue scale (VAS) DN4 for neuropathic pain Phantom limb pain Phantom Limb Pain Scale (PLPS) Quality of life: EQ5D Medical Research Council (MRC) scale. Patient satisfaction questionnaire
- 17. Next steps • Consensus • Team members • DSRB application • Commencement date