Background: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures have been shown to improve patient-reported outcomes for the treatment of symptomatic neuromas after amputation; however, the specific indications and comparative outcomes of each are unclear. The primary research questions were what complement of nerves most frequently requires secondary pain intervention after conventional amputation, whether this information can guide the focused application of TMR and RPNI to the primary amputation setting, and how the outcomes compare in both settings. Methods: We performed a retrospective review of records for patients who had undergone lower-extremity TMR and/or RPNI at our institution. Eighty-seven procedures were performed: 59 for the secondary treatment of symptomatic neuroma pain after amputation and 28 for primary prophylaxis during amputation. We reviewed records for the amputation level, TMR and/or RPNI timing, pain scores, patient-reported resolution of nerve-related symptoms, and complications or revisions. We evaluated the relationship between the amputation level and the frequency with which each transected nerve required neurologic intervention for pain symptoms. Results: The mean pain score decreased after delayed TMR or RPNI procedures from 4.3 points to 1.7 points (p < 0.001), and the mean final pain score (and standard deviation) was 1.0 ± 1.9 points at the time of follow-up for acute procedures. Symptom resolution was achieved in 92% of patients. The sciatic nerve most commonly required intervention for symptomatic neuroma above the knee, and the tibial nerve and common or superficial peroneal nerve were most problematic following transtibial amputation. None of our patients required a revision pain treatment procedure after primary TMR targeting these commonly symptomatic nerves. Failure to address the tibial nerve during a delayed procedure was associated with an increased risk of unsuccessful TMR, resulting in a revision surgical procedure (odds ratio, 26 [95% confidence interval, 1.8 to 368]; p = 0.02). Conclusions: There is a consistent pattern of symptomatic nerves that require secondary surgical intervention for the management of pain after amputation. TMR and RPNI were translated to the primary amputation setting by using this predictable pattern to devise a surgical strategy that prevents symptomatic neuroma pain. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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The rehabilitation of individuals with lower extremity injury is a common but complex problem for the surgical and rehabilitative teams. Basic science tenets of fracture and soft tissue reconstruction and healing guide postoperative weight-bearing and range of motion protocols. In addition to the physiological complications associated with the injury severity, patient outcomes are often influenced by other factors such as patient compliance, pain, depression, and the negative effects of immobility. As a result, novel rehabilitative protocols to include early weight bearing, continuous passive motion, psychosocial intervention, and multimodal pain management are becoming more popular to facilitate rehabilitation and improved patient outcomes. Further supporting the need for this shift in paradigm thinking are outcome studies of both civilian and military trauma patients that demonstrate the negative impact that psychological, social, and economical factors have on outcomes. This report highlights the experience that our team has had in instituting comprehensive rehabilitation strategies to treat injured service members with complex lower extremity trauma from combat.

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Objectives: To determine whether there is a patient-reported functional difference between combat-related knee disarticulations (KDs) and transfemoral amputations (TFAs). Setting: Role 3 Military Trauma Centers. Patients: We identified and contacted all KDs and TFAs performed at the Walter Reed National Military Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center from January 2003 until July 2012 to participate in a retrospective functional cohort analysis. Ten KD patients were available for study completion and were matched against 18 patients in the TFA group. Intervention: Knee disarticulation versus transfemoral amputation. Main Outcome Measurements: The following surveys were obtained from the participants—AAOS Lower Limb Outcome Questionnaire (LLQ), Tegner Activity Scale, SF-36, and Prosthetic Evaluation Questionnaires (PEQs). Results: Ten KD patients agreed to participate in the study, and 18 TFA matched controls were interviewed. Patients were followed up at an average of 66 months (interquartile range 50–79 months) after injury. There were no significant differences with regard to the SF-36, PEQ, LLQ, and Tegner Activity Scale scores. Conclusions: We detected no functional differences measured on the PEQ, LLQ, SF-36, and Tegner Activity Scale scores between KDs and TFAs. In the absence of a proven functional difference, we advocate performing trauma-related amputations at the most distal level the osseous and soft tissue injuries permit. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.