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

2021 ◽  
pp. 193864002110027
Author(s):  
Shannon I. Kuruvilla ◽  
Christine V. Schaeffer ◽  
Minton T. Cooper ◽  
Brent R. DeGeorge
Keyword(s):  
Neuropathic Pain ◽  
Phantom Limb ◽  
Branch Points ◽  
Morton’S Neuroma ◽  
The Third ◽  
Targeted Muscle Reinnervation ◽  
Muscle Reinnervation ◽  
Distal Edge ◽  
Morton's Neuroma ◽  
The Mean

Background Despite multiple surgical modalities available for the management of Morton’s neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be explored as an option for the prevention of recurrence of Morton’s neuroma. The purpose of the present investigation was to determine the consistency of the relevant foot neurovascular and muscle anatomy and to demonstrate the feasibility of TMR as an option for Morton’s neuroma. Methods The anatomy of 5 fresh-tissue donor cadaver feet was studied, including the course and location of the medial and lateral plantar nerves (MPNs and LPNs), motor branches to abductor hallucis (AH) and flexor digitorum brevis (FDB), as well as the course of sensory plantar digital nerves. Measurements for the locations of the muscular and sensory branches were taken relative to landmarks including the navicular tuberosity (NT), AH, FDB, and the third metatarsophalangeal joint (third MTPJ). Results The mean number of nerve branches to FDB identified was 2. These branch points occurred at an average of 8.6 cm down the MPN or LPN, 9.0 cm from the third MTPJ, 3.0 cm distal to AH distal edge, and 4.8 cm from the NT. The mean number of nerves to AH was 2.2. These branch points occurred at an average of 6.3 cm down the MPN, 11.9 cm from the third MTPJ, 0.8 cm from the AH distal edge, and 3.8 cm from the NT. Conclusions Recurrent interdigital neuroma, painful scar, and neuropathic pain are common complications of operative management for Morton’s neuroma. Targeted muscle reinnervation is a technique that has demonstrated efficacy for the prevention and treatment of neuroma, neuropathic pain, and phantom limb pain in amputees. Herein, we have described the neuromuscular anatomy for the application of TMR for the management of Morton’s neuroma. Target muscles, including the AH and FDB, have consistent innervation patterns in the foot, and consequently, TMR represents a viable option to consider for the management of recalcitrant Morton’s neuroma. Levels of Evidence: V

Morton’s Neuroma Excision: What Are We Really Doing? Which Retractor Is Superior?

2018 ◽  
Vol 12 (3) ◽  
pp. 272-277
Author(s):  
Zachariah Pinter ◽  
Christopher Odom ◽  
Andrew McGee ◽  
Kyle Paul ◽  
Samuel Huntley ◽  
...  
Keyword(s):  
Cadaver Study ◽  
Common Complication ◽  
Morton’S Neuroma ◽  
Dorsal Approach ◽  
Levels Of Evidence ◽  
The Third ◽  
Significant Difference ◽  
Fresh Frozen ◽  
Morton's Neuroma ◽  
The Mean

Background: When using a dorsal approach for Morton’s neuroma excision, the most common complication is recurrent Morton’s neuroma. The present cadaveric study demonstrates how far proximally the nerve is resected during a dorsal approach and examines both the laminar spreader and Gelpiretractor to determine which instrument facilitates maximal proximal resection of the nerve. Methods: This study involved 12 fresh-frozen cadaver specimens, each of which underwent a dorsal approach to the interdigital nerve with proximal resection. Either a laminar spreader or a Gelpi retractor was used to improve visualization of the intermetatarsal space. The interdigital nerve was then resected, and the lengths of the cut nerves were compared based on the retractor employed. Results: The mean length of proximal resection in the second intermetatarsal space was 2.42 cm when using the laminar spreader and 1.93 cm when using the Gelpi retractor (P = .252). In the third intermetatarsal space, the mean length of proximal resection was 2.14 cm when using the Laminar spreader and 1.48 cm when using the Gelpi retractor (P = .166). Conclusion: This study demonstrates how far proximal the interdigital nerve is resected during a dorsal approach to Morton’s neuroma and shows no statistically significant difference between the Laminar spreader and the Gelpi retractor. Levels of Evidence: Level V: Cadaver study

Revision Targeted Muscle Reinnervation Improves Secondary Pain Insult in an Upper Extremity Amputee: A Case Report

Hand ◽  
2021 ◽  
pp. 155894472199246
Author(s):  
David D. Rivedal ◽  
Meng Guo ◽  
James Sanger ◽  
Aaron Morgan
Keyword(s):  
Neuropathic Pain ◽  
Peripheral Nerves ◽  
Nerve Biopsy ◽  
Sensory Cortex ◽  
Denervated Muscle ◽  
Unique Case ◽  
Targeted Muscle Reinnervation ◽  
Muscle Reinnervation ◽  
And Function ◽  
The Brain

Targeted muscle reinnervation (TMR) has been shown to improve phantom and neuropathic pain in both the acute and chronic amputee population. Through rerouting of major peripheral nerves into a newly denervated muscle, TMR harnesses the plasticity of the brain, helping to revert the sensory cortex back toward the preinsult state, effectively reducing pain. We highlight a unique case of an above-elbow amputee for sarcoma who was initially treated with successful transhumeral TMR. Following inadvertent nerve biopsy of a TMR coaptation site, his pain returned, and he was unable to don his prosthetic. Revision of his TMR to a more proximal level was performed, providing improved pain and function of the amputated arm. This is the first report to highlight the concept of secondary neuroplasticity and successful proximal TMR revision in the setting of multiple insults to the same extremity.

Targeted Muscle Reinnervation for Treatment of Neuropathic Pain

2020 ◽  
Vol 47 (2) ◽  
pp. 285-293
Author(s):  
Ava G. Chappell ◽  
Sumanas W. Jordan ◽  
Gregory A. Dumanian
Keyword(s):  
Neuropathic Pain ◽  
Targeted Muscle Reinnervation ◽  
Muscle Reinnervation

Risk Factors for Neuropathic Pain Following Major Upper Extremity Amputation

2020 ◽  
Author(s):  
Jonathan Lans ◽  
Yannick Hoftiezer ◽  
Santiago A. Lozano-Calderón ◽  
Marilyn Heng ◽  
Ian L. Valerio ◽  
...  
Keyword(s):  
Neuropathic Pain ◽  
Upper Extremity ◽  
Multivariable Analysis ◽  
Phantom Limb Pain ◽  
Phantom Limb ◽  
Limb Pain ◽  
Targeted Muscle Reinnervation ◽  
Medical Chart Review ◽  
Increased Risk ◽  
Extremity Amputation

Abstract Background Active treatment (targeted muscle reinnervation [TMR] or regenerative peripheral nerve interfaces [RPNIs]) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation. Methods Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology (n = 53, 37%) and trauma (n = 45, 32%), with transhumeral amputations (n = 44, 30%) and shoulder amputations (n = 37, 25%) being the most prevalent. Results Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio [OR]: 4.1, p = 0.015), transhumeral amputations (OR: 3.9, p = 0.024), and forequarter amputations (OR: 8.4, p = 0.003) were independently associated with the development of neuropathic pain. Conclusion In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.

A Study of the Communicating Branch between the Medial and Lateral Plantar Nerves

Foot & Ankle ◽  
1984 ◽  
Vol 4 (6) ◽  
pp. 313-315 ◽  
Author(s):  
J. R. Jones ◽  
L. Klenerman
Keyword(s):  
Morton’S Neuroma ◽  
The Third ◽  
Communicating Branch ◽  
Morton's Neuroma

A study of the communicating branch between the medial and lateral plantar nerves was carried out on the feet of 20 cadavers. The nerve was found to be present in all the feet examined, but in two women it was considerably enlarged bilaterally. It is suggested that this enlarged communicating branch may be a factor responsible for the frequent involvement of the nerve to the third interspace by Morton's neuroma.

Long-Term Results of Neurectomy in the Treatment of Morton’s Neuroma

2011 ◽  
Vol 4 (6) ◽  
pp. 349-353 ◽  
Author(s):  
Kyung Tai Lee ◽  
Jun Beom Kim ◽  
Ki Won Young ◽  
Young Uk Park ◽  
Jin Su Kim ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Scoring System ◽  
Long Term Results ◽  
Morton’S Neuroma ◽  
Vas Score ◽  
Significant Difference ◽  
Morton's Neuroma ◽  
The Mean

Purpose. The objective of this retrospective study was to evaluate the long-term follow-up results of neurectomy clinical outcomes and complications in the treatment of Morton’s neuroma. Materials and methods. A total of 19 patients (19 different feet) were treated for Morton’s neuroma by excision of the interdigital nerve at our institute between May 1997 and May 1999. Thirteen (13 feet) of them were followed up. The 13 patients were female and had an average age of 43 years (range 34-54 years) at the time of the operation. The patients were followed-up for a mean of 10.5 years (range 10.0-12.2 years) and scored using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot scoring system and Visual Analogue Scale (VAS) score. Subjective satisfaction was evaluated at the final follow-up. Results. Eight patients scored more than 90 on the AOFAS forefoot scoring system. The VAS score was improved in all patients. The mean preoperative VAS score was 8.6 ± 0.8 cm (7-10) and the mean follow-up VAS score was 2.4 ± 1.8cm (0-6), which indicated no significant difference (P > .05). The final follow-up satisfaction results indicated that 4 patients were completely satisfied with the operation, 4 were satisfied with minor reservations, 5 were satisfied with major reservations, and no patient was unsatisfied. Neurectomy to treat Morton’s neuroma had a good satisfaction rate (61%). Eleven of the patients complained of numbness on the plantar aspect of the foot adjacent to the interspace, and 2 of these 11 patients complained of disability induced by severe numbness. There was a complaint of residual pain by 1 patient. There were no skin problems on the operation lesions. Conclusion. The long-term results of neurectomy clinical outcomes in Morton’s neuroma are slightly worse than the short- and mid-term results. Levels of Evidence: Therapeutic, Level IV, Retrospective case series

scholarly journals Targeted muscle reinnervation in quadruple amputees: self-reported outcomes

2021 ◽  
Vol 4 (2) ◽  
Author(s):  
Emma-Leigh Rudduck ◽  
Frank Bruscino-Raiola ◽  
Margaret Angliss ◽  
Steven J Gray ◽  
David Lee Gow ◽  
...  
Keyword(s):  
Current Literature ◽  
Phantom Limb Pain ◽  
Phantom Limb ◽  
Residual Limb ◽  
Limb Pain ◽  
Targeted Muscle Reinnervation ◽  
Alfred Hospital ◽  
Muscle Reinnervation ◽  
Residual Limb Pain ◽  
Psychological Disabilities

Targeted muscle reinnervation (TMR) reduces pain and physical and psychological disabilities in amputees. We present the first two cases reported globally of quadruple amputees that underwent acute TMR. Each patient completed our novel ‘The Alfred Hospital Osteointegration Survey’ (TAHOS) for each limb at six, 12 and 24 months post amputation which evaluated aspects of prosthesis wear, neuroma-related residual limb pain (RLP), phantom limb pain (PLP) and overall function. Our findings that TMR reduced or eliminated RLP and PLP by 12 months and clinically improved prosthetic function in both quadruple amputees reflects the current literature for single and multiple limb amputees.

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