Rees Andrew B, Mastracci Julia C, Posey Samuel L, Loeffler Bryan J, Gaston R Glenn
Atrium Health Musculoskeletal Institute, Charlotte, NC, USA.
OrthoCarolina Hand Center, Charlotte, NC, USA.
Hand (N Y). 2024 Sep 12:15589447241277842. doi: 10.1177/15589447241277842.
Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) prevent symptomatic neuroma formation in amputees. Forearm-level amputations present multiple muscular targets, making it challenging to determine the ideal treatment. The purpose of this study was to evaluate the best TMR targets, role of RPNI, and appropriate patient-selection criteria in forearm-level amputations. We hypothesized that deep and distal TMR targets would best prevent symptomatic neuromas, RPNI would prove a success adjunct, and patients with poorly controlled diabetes would not develop symptomatic neuromas regardless of nerve management.
We retrospectively identified forearm-level amputations performed between 2017 and 2022. Patients with TMR by outside providers, follow-up <6 months, or insufficient documentation were excluded. Demographics, surgical nerve management, and postoperative complications were collected. The primary outcome was development of a painful neuroma determined by the Eberlin criteria. Patients undergoing TMR were divided a priori into two groups, superficial and proximal versus deep and distal TMR targets, and were compared.
Thirty-nine patients met inclusion criteria, and 16 developed a symptomatic neuroma. No patients with a deep or distal TMR target developed a symptomatic neuroma. One nerve out of 12 treated with RPNI developed a symptomatic neuroma. No patient with poorly controlled diabetes developed a symptomatic neuroma, despite no advanced nerve management.
In a case series of forearm amputations, deep and distal TMR targets prevented symptomatic neuroma formation more than superficial and proximal targets. Regenerative peripheral nerve interface is a useful adjunct for neuroma control, especially for the radial sensory nerve. Patients with poorly controlled diabetes may not require advanced nerve management.
Level IV retrospective case series.
靶向肌肉再支配（TMR）和再生周围神经接口（RPNI）可预防截肢患者出现有症状的神经瘤形成。前臂水平截肢存在多个肌肉靶点，这使得确定理想的治疗方法具有挑战性。本研究的目的是评估前臂水平截肢中最佳的TMR靶点、RPNI的作用以及合适的患者选择标准。我们假设深部和远端TMR靶点能最好地预防有症状的神经瘤形成，RPNI将被证明是一种成功的辅助手段，并且无论神经处理方式如何，糖尿病控制不佳的患者不会出现有症状的神经瘤。
我们回顾性地确定了2017年至2022年间进行的前臂水平截肢病例。排除由外部机构进行TMR治疗、随访时间<6个月或记录不充分的患者。收集患者的人口统计学资料、手术神经处理情况和术后并发症。主要结局是根据埃伯林标准确定的疼痛性神经瘤的发生情况。接受TMR治疗的患者被预先分为两组，即浅部和近端TMR靶点组与深部和远端TMR靶点组，并进行比较。
39例患者符合纳入标准，其中16例出现了有症状的神经瘤。深部或远端TMR靶点组的患者均未出现有症状的神经瘤。接受RPNI治疗的12条神经中有1条出现了有症状的神经瘤。尽管没有采用先进的神经处理方法，但糖尿病控制不佳的患者均未出现有症状的神经瘤。
在一组前臂截肢病例中，深部和远端TMR靶点比浅部和近端靶点更能预防有症状的神经瘤形成。再生周围神经接口是控制神经瘤的一种有用辅助手段，尤其是对于桡神经感觉支。糖尿病控制不佳的患者可能不需要先进的神经处理方法。
IV级回顾性病例系列。
