Management of Unreconstructable Saphenous Nerve Injury with Targeted Muscle Reinnervation

Abstract

Summary: Neuroma pain significantly impacts patient quality of life and is associated with unemployment, chronic opioid dependence, and depression. Targeted muscle reinnervation (TMR), a surgical technique that coapts proximal stumps of cut nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study was to describe the surgical technique for TMR of the saphenous nerve, while providing a retrospective review. Between January 2015 and December 2018, 18 patients underwent TMR of the saphenous nerve: 1 nonamputee patient with chronic pain after ankle surgery and 17 amputee patients (10 for relief of chronic postamputation neuroma pain and phantom pain and 7 at the time of amputation for prevention of these symptoms). Six patients were lost to follow up; 2 patients had recurrent pain; and 10 patients had reduced or no pain after TMR surgery. TMR is a successful technique for the management of traumatic neuroma pain in both the amputee and nonamputee populations, and in this study, we describe the technique for saphenous nerve TMR.

Targeted Muscle Reinnervation for Trauma-Related Amputees: A Systematic Review

“…This left six total studies meeting the criteria for inclusion (Figure 1 ). Two studies were low [ 3 , 18 ], three studies were moderate [ 5 , 6 , 19 ], and one study was considered at high risk of bias [ 20 ] according to the JBI assessment; additional details are available in Tables 2 , 3 .…”

“…Three studies had data exclusively for primary TMR [ 3 , 5 , 6 ], one study examined only secondary TMR [ 18 ], and two studies examined both [ 19 , 20 ]. Study characteristics (including sample size, mean age, and sex) are shown in Table 4 .…”

“…Two studies were low [3,18], three studies were moderate [5,6,19], and one study was considered at high risk of bias [20] according to the JBI assessment; additional details are available in Tables 2, 3. Three studies had data exclusively for primary TMR [3,5,6], one study examined only secondary TMR [18], and two studies examined both [19,20]. Study characteristics (including sample size, mean age, and sex) are shown in Table 4.…”

Contemporary Review: Targeted Muscle Reinnervation for Foot and Ankle Applications

“…30,48 Nevertheless, the literature is relatively sparse for this indication in both the lower and upper extremities. Specific to the lower extremity, studies are currently limited to case reports and technique articles that describe the management of sural 24 and saphenous 38 neuromas in nonamputees with limited but favorable early results. 12 A 2018 metanalysis of neuroma treatment by Poppler et al 61 did not include TMR but demonstrated a 77% overall rate of meaningful reduction in pain for prior surgical techniques such as traction neurectomy and nerve end burial.…”

“The Feasibility of Targeted Muscle Reinnervation for the Management of Morton’s Neuroma”

“…23 Furthermore, it is successful in preventing recurrent stump neuroma after nonamputee symptomatic neuroma excision and has proven superior to simple neurectomy. [24][25][26][27] Recent anatomical studies have defined potential donor nerves and motor nerve targets for TMR for upper and lower extremity amputees as well as nonamputee neuromas proximal to the ankle; however, the data to support the feasibility of TMR for the management of Morton's neuroma has yet to be established. 20 Our primary goals of this investigation are to determine the consistency of the relevant anatomy in the lower extremity distal to the ankle and demonstrate the feasibility of TMR as a practical option for Morton's neuroma, particularly in the setting of recurrence.…”