IC47-R: Upper Extremity Amputations: Lessons Learned from Combat

IC47-R: Upper Extremity Amputations:

Lessons Learned from Combat Injuries Moderator(s): Peter C. Rhee, DO, MS

Faculty: Mark R. Bagg, MD, Jason A. Nydick, DO, Kenneth F. Taylor, MD, and Scott M. Tintle, MD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

8/24/2020

Jason A. Nydick, DO

Consulting Fees: Axogen, Trimed, Checkpoint Surgical, Conmed Contracted Research: Axogen

Factors in Determining Limb Salvage Versus Amputation IC47-R Program Jason Nydick, DO

Factors in Determining Limb Salvage Versus Amputation

• Injury mechanism / Type of injury / Level of injury • Timing of injury • Age • Tobacco • Medical hx • Associated injuries

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Factors in Determining Limb Salvage Versus Amputation

CONTRAINDICATIONS • Severely crushed or mangled parts • Multiple-level amputations • Patients with multiple trauma or severe medical problems (relative contraindication) • Completely degloved (avulsions) • Self inflicted

Factors in Determining Limb Salvage Versus Amputation SURGICAL GOALS • Successful restoration of function. • Simply returning circulation to an amputated part does not in itself define success. • Replantation of a part that will not perform useful activity should be avoided

Factors in Determining Limb Salvage Versus Amputation • Single fingers distal to the FDS insertion usually function well

• Hands proximal to the mid-palm also usually function well

• Replanted thumb is almost always useful, even if it functions as a post for opposition

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Factors in Determining Limb Salvage Versus Amputation • Single fingers distal to the FDS insertion usually function well

• Hands proximal to the mid-palm also usually function well

• Replanted thumb is almost always useful, even if it functions as a post for opposition

Factors in Determining Limb Salvage Versus Amputation

• 57% success rate • Radial sided injury, no tobacco use predictors of success • Team approach • Need to evaluate current benchmarks and clinical settings for replants

Factors in Determining Limb Salvage Versus Amputation

• 15 yr old table saw

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Factors in Determining Limb Salvage Versus Amputation • Replantation performed

• Success

• Enrolled in Military

Factors in Determining Limb Salvage Versus Amputation • 80 yr old female • Dog leash avulsion

Factors in Determining Limb Salvage Versus Amputation • Vein graft artery repair • 2 veins • FPL, EPL • Nerves with severe avulsion too distal to repair

Functional Thumb…. Success

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Factors in Determining Limb Salvage Versus Amputation • Forearm amputation • Crush injury

• Revision amputation & TMR

Factors in Determining Limb Salvage Versus Amputation • Limb salvage • - Nerves intact / good chance to recovery & function

• Amputation (Reconstruction / TMR) • -myoelectric

• Future directions in prosthetics / TMR/ RPNI although slow, may lead to better reconstruction outcomes

THANK YOU

Factors in Determining Limb Salvage Versus Amputation IC47-R Program Jason Nydick, DO

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SURGICAL TECHNIQUE FOR DIGITAL AND METACARPAL AMPUTATIONS: TIPS AND PEARLS

MARK R. BAGG, MD HAND CENTER OF SAN ANTONIO

DISCLOSURES

Mark R. Bagg, MD

Speakers Bureau: ExsoMed

WHEN REPLANTATION IS NOT AN OPTION

INITIAL MANAGEMENT OF BATTLEFIELD AMPUTATIONS OF THE FINGERS AND HAND DEBRIDEMENT LEAVE WOUNDS OPEN LOOSE DRESSING PREVENT WOUND RETRACTION

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WHEN REPLANTATION IS NOT AN OPTION

INITIAL MANAGEMENT OF BATTLEFIELD AMPUTATIONS OF THE FINGERS AND HAND DEBRIDEMENT LEAVE WOUNDS OPEN LOOSE DRESSING PREVENT WOUND RETRACTION PRESERVE “SPARE PARTS” TO FACILITATE COVERAGE

GOALS OF TREATMENT

• Non-tender stump • Short period of disability • Good cosmesis

FINGERTIP AMPUTATIONS

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FINGERTIP AMPUTATIONS

• PRIMARY CLOSURE Best way…… if you have the tissue to close Trim dog ears

FINGERTIP AMPUTATIONS

• STSG/ FTSG Poor choice Bad color match Doesn’t add bulk Usually tender

FINGERTIP AMPUTATIONS

• LOCAL Flaps V-Y flaps/other local flaps Hypersensitivity

Kutler -- 1947 Atasoy et al -- 1970

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FINGERTIP AMPUTATIONS

• Cross-finger flap Adds bulk to finger tip PIPJ contractures Donor scar

FINGERTIP AMPUTATIONS

• Thenar Flap Few indications PIPJ contractures Bulk to fingertip

FINGERTIP AMPUTATIONS

• Moberg Flap Best reserved for THUMB Coverage of less than 2cm defect

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FINGERTIP AMPUTATIONS

• Microsurgical reconstruction Rarely indicated Best restoration of the pulp

FINGERTIP AMPUTATIONS

SECONDARY INTENTION BEFORE AFTER “THE BEST WAY”

TREATMENT IN ER

• Digital block • Minimal debridement--trim ragged edges • Trim the bone to just below the level of the soft tissue

• Bulky dressing MB1 • Pain medication

Six weeks later

5 Slide 15

MB1 Mark Bagg, 8/22/2020 8/24/2020

IN THE OFFICE 48 HR. LATER

• Remove the dressing • Xeroform/ Coban • Instructions to air-dry wound as much as possible

BEFORE

AFTER

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THE PROBLEM: NAILHORNS

Excise all visible nail bed tissue

Curette dorsal cortex vigorously

Don’t forget the matrix on the underneath side of the proximal nail fold

AT OR NEAR PIP LEVEL

PIP & DIP DISARTICULATIONS

• Round off the volar and lateral flares of the phalanx • May add some grip strength but poor cosmesis

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MP OR SHORT PROXIMAL PHALANX

Poor cosmesis Functional impairment Consider Ray Amputation

RAY AMPUTATION

• All remaining fingers work in the same plane of motion

• Excellent cosmesis

• Good function

• Probably slight loss of grip strength

RAY AMPUTATION

• MOST SERIOUS COMPLICATION • Amputation neuroma • JF Murray et al • J.Hand Surgery • 2:471, 1977

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PREVENTION OF NERVE PROBLEMS

• Avoid excessive tension on the digital nerves • Leave them long (PIP level) • Bury the nerves within the periosteal tube under NO TENSION

RAY AMPUTATIONS

• SPECIAL CONSIDERATIONS OF THE MIDDLE FINGER AND RING FINGER

MORE DIFFICULT THAN THE BORDER INDEX AND SMALL FINGER

TRANSPOSITION RARELY INDICATED HIGH COMPLICATION RATE COSMESIS NOT ANY BETTER

LONG/RING RAY WITHOUT TRANSPOSITION

• MUCH BETTER WAY • LESS COMPLICATIONS • THREE KEYS TO GOOD COSMESIS OSTEOTOMY AT THE FLARE OF MC PRECISE WEB DESIGN SUTURE DTML

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Leave one web intact

EXCISE the other

Digital nerve

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THUMB: SPECIAL CONSIDERATIONS

• SAVE ALL LENGTH MP joint is the critical point • PARTICULARLY THE PROXIMAL PHALANX

Save every mm of proximal phalanx

THUMB: SPECIAL CONSIDERATIONS

Functional Thumb

No reconstruction needed 32

THUMB: SPECIAL CONSIDERATIONS

No thumb

Needs reconstruction

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Peter C. Rhee, DO, MS

Consulting Fees: TriMed Inc., Integra LifeSciences

45M – Auger Injury

Surgical Techniques: Tips and Pearls for Trans-Radial Amputation

Peter Charles Rhee, DO, MS Program Director, Hand Surgery Fellowship Associate Professor of Orthopedic Surgery Department of Orthopedic Surgery Mayo Clinic, Rochester, MN

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Factors to Consider in Determining Amputation Level

Pain-free, sensate, and stable hand/residual limb is more functional than a textbook amputation.

An amputee will utilize the residual limb with or without a prosthesis.

With increased length and preservation of each joint, the person becomes exponentially more capable in interacting with the environment. (Tintle et al. JBJS Am, 2010)

Amputation Goals

• Preserve as much length as possible • Even free-tissue transfer (Baccarani et al. Plast Reconstr Surg, 2007) • Functional outcome • Cosmesis

Preserve length while taking into account: Size, shape, durability, and appearance of the residual limb.

Affects ultimate patient satisfaction

UE Prosthesis

Function • Cosmetic (passive) • Functional

Components Body Powered (cable controlled) • Socket with suspension • Joint (if applicable) • Terminal device

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Socket Suspension

• Requires robust soft tissue envelope • Able to acquire stable suspension • Soft tissue • Bone (Branemark et al. JBJS Br, 2014)

Adaptive Terminal Devices

Transradial Amputation

Advantages • Preserved ability to rotate the forearm • Stable lever arm for prosthetic • Able to weight bear through the stump (especially if crutches/walker) • Most variety in prosthetics while maintaining equal limb length Disadvantages • Radio-ulnar impingement • Elbow flexion contracture (if proximal amputation)

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Surgical Technique: Trans-Radial Amputation

Transradial Amputation: Technical Pearls

Volar Dorsal

How Much Length is Needed/Ideal? - Proximal = ~6 cm of proximal ulna - At most = ~3-5 inches of distal radius

Enagage a Prosthetist Early Pre-op

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Expected Supination/Pronation

Engage Prosthetists Pre-op

Transradial Amputation Pronator Quadratus Flap

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Transradial Amputation Osteotomy

Distal radius/ulna osteotomy based on prosthetist recommendations

Transradial Amputation Pronator Quadratus Interposition

Pedicled PQ inserted between ulna/radius as soft tissue interposition

Transradial Amputation Myodesis and Myoplasty

Myodesis to Ulna/Radius Layered Myoplasty

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Final Stump Appearance

Transradial Amputation Final Outcome due to Length Preservation

Case Example Preserve Length (if possible)

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Enterococcus Infection

Stage 1

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6 Months Post-Operative

Prosthesis Rejection Rates

• Reported at >30% (21% to 38%) (Tintle et al. JBJS 2010)

Reasons for Rejection (Tooms RE. Orthop Clin North Am, 1972) • Poor prosthetic training • Delayed Fitting • Proximal levels of amputation • Limited usefulness of the prosthesis • Excessive weight of the prosthesis • Residual limb/socket discomfort

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Factors Associated with Increased Prosthetic Acceptance

• Loss of the dominant extremity (Wright et al. JHS Am,1995)

• Absence of pain in the residual limb (Pinzur et al. JHS Am, 1994) • Prosthetic fitting within 30 days after amputation • More distal level of amputation

Acceptance Rates Per Level (Tintle et al. JBJS Am, 2010) • Transradial = 80% to 94% • Transhumeral = 43% to 83%

• 100 combat related UE amputation • 42% of cases required revision surgery • Prosthesis usage increased from 19% to 87% after revision • Reasons for revision • HO • Infection • Contracture • Symptomatic scars • Painful neuroma Whatever Amputation You Do, Do it Well

Neuroma Prevention

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Neuroma Prevention TMR or “Graft to Nowhere”

Allograft Median

Allograft SBRN

Ulnar

DSUN

“Graft to Nowhere” Technique

Case Example- Neuroma Prevention Nerve to Allograft to Nerve Coaptation

19M

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Median to Ulnar DSUN to LABC SBRN - GTN

Case Example- Neuroma Prevention Direct Nerve to Nerve Coaptation

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55F

Direct Coaptation

Median to SBRN LABC to ulnar

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Intra-Neural Nerve Catheter Radial Nerve

Take Home Points

• Preserve length

• Create a robust, stable soft tissue envelope

• Optimize prosthetic use and function • Engage prosthetist early

• Prevent nerve related complications

Thank You

16 1

IC47-R: Upper Extremity Amputations: Lessons Learned from Combat Injuries (VAM20) Surgical Techniques: Tips and Pearls for Elbow Disarticulations and Transhumeral Amputations Kenneth F. Taylor, M.D., FAOA, COL (Ret), MC, USA Benjamin Kyle Potter, M.D., FACS, COL, MC, USA

Elbow disarticulation - Potential advantages over transhumeral level amputation o Increased strength – greater bone length, retained muscle units o Active rotational control – due to presence of humeral condylar flare o Easier suspension of prosthetic device - Disadvantages include o In traumatic amputations, soft tissue injury often precludes acceptable wound closure o Addition of prosthetic elbow creates unacceptable limb asymmetry - Current indications are limited o Shoulder or nerve issues preventing use prosthesis o Long helper limb - Otherwise, a shortening osteotomy is indicted o Beltran 2010 ▪ Case report – BUE blast amputation contralat transhumeral amp., shortened elbow disarticulation amputation through ipsilateral fractured diaphysis to facilitate distal wound closure and fit body-powered elbow prosthesis. This also avoided increased risk of heterotopic ossification when revising amputation through zone of blast injury. (Potter 2007) o de Luccia 2000 ▪ Case report – revised a through elbow amputation by 3cm shortening just proximal to metaphyseal flare to address neuroma, excise skin graft and maintain advantage for prosthetic fit

Transhumeral amputation - Distal Transhumeral Amputation o If humeral condyles are not preserved, ideal amputation is 3-5cm proximal to the elbow joint. ▪ Allows fitting of standard prosthetic components while retaining length to suspend/control the prosthesis o Prosthetic suspension for transhumeral amputation typically includes the shoulder ▪ Restricts shoulder motion ▪ Prosthesis cannot be stabilized against rotation o Angular osteotomy – Marquardt 1974 potential option in long transhumeral amputation to improve prosthetic suspension (lacks anatomic condylar flare) ▪ Marquardt’s angular osteotomy • Indicated in distal transhumeral amputations, especially bilateral, and in children at risk for terminal osseous overgrowth and subsequent protrusion (increased remodeling of bone prevents further protrusion. • Angular osteotomy 70-110°, 6 cm proximal to distal end 2

• Facilitates prosthetic suspension distally, frees shoulder, facilitates rotational stability and bioelectronic control of prosthesis • Neusel 1997 – risk of subsequent straightening is not related to regularity of prosthetic wear. Is age-related (<16yo). Not related to underlying cause (trauma vs dysmelia) - Proximal Transhumeral Amputations (Tintle 2010) o 5-7cm residual humerus needed to suspend prosthesis ▪ May need to employ skin grafting or free tissue transfer (latissimus dorsi, parascapular, others) to preserve bone length ▪ Preserve deltoid, even with more proximal, to actively control shoulder joint ▪ Failure to maintain/reconstruct insertions of pectoralis major, latissimus dorsi and deltoid will have results similar to shoulder disarticulation with regard to prosthetic fitting ▪ Consider staged glenohumeral arthrodesis to maintain cosmesis, aid in force transmission and prevent painful abduction contracture or subluxation (unopposed forces of rotator cuff - Soft Tissue o Soft tissue debridement ▪ Combat wounds resulting from a bast mechanism present with a wide and evolving zone of injury; delayed determination of tissue viability requiring serial debridements ▪ Aggressive sharp debridement of nonviable tissue ▪ VAC and vessel loops in lieu of skin traction to preserve length ▪ Atypical myofascial/fasciocutaneous flaps are useful ▪ Nerves are debrided but maintained as long as possible o Soft tissue stabilization – bone ends padded to avoid painful prominences and discomfort with prosthetic wear ▪ Myodesis – residual muscle and fascia stured directly to bone (most stable) ▪ Myoplasty – suturing residual muscle agonist to antagonist to create physiologic tension. Mobile muscle sling may result in painful bursal formation. Myoplasty of antagonists may result in spread of signal and involuntary co-contraction resulting in interference with myoelectric prosthesis ▪ Myofascial closure – suture residual muscle to its associated fascia. (least stable).

Acceptance of prosthesis - Acceptance rate transhumeral 43-83% (Millstein 1986, Stȕrup 1988, Pinzur 1994, Wright 1995) - Wright 1995 o Rejection rates related to poor training, delayed fitting (>30 days) and proximal amputations o Reasons for rejection – limited usefulness, weight, residual limb/socket discomfort - Rates demonstrate: prefer to function one-handed than use burdensome/nonintuitive prosthesis. If bilateral – will universally use at least one prosthesis. If ipsilateral brachial plexus palsy = routinely reject prosthesis 3

- Pinzur 1994 – retrospective review of outcomes following early prosthetic fitting after traumatic amputation o Phantom limb sensation common but pain not sufficient to limit functional prosthetic utilization o High early success with transradial – proceed with early myoelectric limb fitting o Transhumeral – initial body-powered prostheses until demonstrate functional proficiency to warrant myoelectric or hybrid limb - McFarland – survey of Vietnam and OIF/OEF era veterans who sustained single limb upper extremity loss. o OIF/OEF veterans had significantly higher rates of: ▪ PTSD (68% vs 27%) ▪ TBI (32% vs 6%) ▪ Hearing loss (62% vs 34%) ▪ Residual limb pain (68% vs 32%) o Rates for transhumeral prosthetics currently used ▪ Myoelectric/Hybrid: Vietnam 40%; OIF/OEF 34% ▪ Mechanical: Vietnam 34%; OIF/OEF 23% ▪ Cosmetic: Vietnam 33%; OIF/OEF 0% o Reasons for rejecting transhumeral level prosthetics: heavier device requiring increased energy expenditure

Future (and Current) Directions - Prosthetic design o Current myoelectric prosthesis terminal device – tripod forceps grip with one degree of freedom o Newer designs - improved materials, ultrasonic motors, lighter batteries, pneumatically/hydraulically controlled finger joints with multiple degrees of freedom o Future designs – improved neural-prosthesis interfaces (will markedly improve quality of life, providing near-physiologic control without requiring visual attention) ▪ Improved EMG sensors ▪ Implanted electrodes ▪ Sensory interface

- Osseointegrated prosthesis – Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) Program o Direct skeletal fixation of a prosthesis through an osseointegrated implant; Introduced in 1990 in Sweden by Rickard Brånemark (son of Per-Ingvar Brånemark – pioneer of osseointegrated dental implants in the 1960’s) o Lower extremity application available through FDA Humanitarian Device Exemption since 2015; Unavailable for upper limb application though clinical trials are ongoing. o Indications (transhumeral): amputations resulting from trauma or tumor (not vascular disease), inability to wear conventional socket prosthesis (very short residual limb), patient compliant with postoperative protocol o Two-stage surgery: (Jönsson 2011) 4

▪ Stage 1 • Threaded titanium implant fixed to intramedullary bone. • Countersunk 2cm and backfilled with autograft bone held in place by a graft screw • Kept unloaded for 6 months until ingrowth is evident ▪ Stage 2 • Healed bone graft is over-drilled • Additional titanium abutment implant connected to the fixture and penetrates skin. • Skin is thinned and stabilized to the distal bone. ▪ After three weeks, a training prosthesis is eventually suspended from this abutment o Advantages ▪ Decreased effect of residual limb atrophy on socket fit ▪ Decreased skin issues – excessive sweating and irritation ▪ Decreased effect of weight of prosthesis and residual bone length on suspension of prosthesis o Disadvantages ▪ Risk of infection – thought to be reduced by decreasing mobility of soft tissue around metal stem o Outcomes - retrospective of 16 transhumeral amputees available for ≥ 2 year follow-up (median 8 years; range, 2-19 years) (Tsikandylakis 2014) ▪ Survival rates: 2 year – 83%; 5 year – 80% ▪ Incomplete fracture at first surgery (8) ▪ Defective bony canal at second surgery (3) ▪ Superficial skin infections treated non-operatively (15 infections in 5 patients) ▪ Skin reactions at penetration site (8) ▪ Avascular skin flap necrosis (3) ▪ Early loosening requiring removal (3) ▪ Deep implant infection (1) ▪ 1 partially removed due to ipsilateral shoulder arthrodesis secondary to osteoarthritis ▪ Common radiographic findings • Proximal trabecular buttressing • Endosteal bone resorption and cancellization • Cortical thinning • Distal bone resorption o Kang 2010 – In addition to thinning the skin, inserted a porous intraosseous transcutaneous amputation prosthesis (ITAP) implant to integrate with bone and skin (osseocutaneous integration). This is similar in effect to skin at interface with deer antlers to ensure skin remains immobile in relation to the antler. o Current and Future Directions (Li 2017) ▪ Osseointegrated human-machine gateway 5

• Percutaneously placed electrodes to facilitate sensory feedback and motor control ▪ Integration of Targeted Muscle Reinnervation (TMR) surgery to provide even greater functional control of the prosthesis (Ortiz-Catalan 2020)

- Targeted Muscle Reinnervation (TMR) o Designed to improve function of myoelectric prosthesis by providing intuitive control. o Transected nerves are transferred to new motor endpoints which act as transducers of the transferred nerves’ original function. (Dumanian 2009) ▪ Transhumeral amputation – 4 independent nerve/muscle units • Hand open/close - distal radial nerve to motor branch lateral triceps; median nerve to motor branch medial head biceps • Elbow flex/extend – long head triceps and lateral head biceps retain native innervation • Potential fifth control in long transhumeral – Ulnar nerve to brachialis o Treatment/prophylaxis for symptomatic neuromas (Souza 2014) o Sensory reinnervation – restored hand maps of median and ulnar nerves to provide sensory and force feedback (Hebert 2014) o Outcomes in above elbow/shoulder disarticulation – Improved functional outcomes, but still high abandonment rate (32%) suggesting need for continued improvement in prosthetic designs (Salminger 2019)

- Regenerative Peripheral Nerve Interface (RPNI) o Transected peripheral nerve implanted into autologous free muscle graft ▪ Treatment/prophylaxis for symptomatic neuroma (Kubiak 2019) ▪ Potential for improved myoelectric control of prosthesis (Kubiak 2018) ▪ Can be combined with TMR to address size mismatch of donor nerve to target muscle

- Agonist-Antagonist Myoneural Interfaces (Srinivasan 2019) o Surgically connected agonist and antagonist o Preserves proprioceptive feedback from mechanoreceptors within each muscle to communicate with central nervous system o Preliminary human data suggests ▪ Increased control of prosthesis, force feedback and proprioception

Rehabilitation – keeping pace with advances in surgical and prosthetic innovation - Recent efforts to measure and estimate loads transmitted across the prosthesis to the residual limb - Characteristics of successful prosthetic utilization - Effect of unilateral transhumeral arm swing on decreased stride length, cadence and other gait characteristics - Role of virtual reality in prosthetic rehabilitation

Outcomes 6

- Systematic review regarding body-powered versus myoelectric prosthesis selection (Carey 2015) o Body-powered advantages – durability/maintenance, training time, frequency of adjustments o Myoelectric advantages – cosmesis, phantom limb pain, light-intensity work o Ultimate selection based upon individual needs - personal preference, prosthetic experience, functional needs - Retrospective 5-year health outcome after unilateral amputation versus serious upper extremity injury following combat wound (Melcer 2019) o Across three groups, prevalence of most physical and psychological diagnoses decreased after post-injury year 1, except PTSD which increased substantially o Transhumeral amputation – higher odds DVT/PE, cervical pain, osteoarthritis, obesity and mood disorders o Below elbow amputation – lower odds for osteomyelitis o Serious injury other than amputation – increased odds joint disorders and nonunions

Key Points - Elbow disarticulation o Limited indications ▪ long helper limb if not employing a prosthesis • Brachial plexopathy • Shoulder issues - Long transhumeral o Rotational control facilitated by distal osteotomy o Osseointegrated prosthetic suspension in clinical trials - Short transhumeral o Preserve or reconstruct muscle insertions to control shoulder - Nerve transfers o Improve myoelectric control o Address symptomatic neuromas

References Amputation Levels Beltran MJ, Kirk KL, Hsu JR. Minimally invasive shortening humeral osteotomy to salvage a through- elbow amputation. Mil Med. 2010;175:693-696.

Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski DA. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am. 2007;89:476-486. de Luccia N, Marino HL. Fitting of electronic elbow on an elbow disarticulated patient by means of a new surgical technique. Prosthet Orthot Int. 2000;24:247-251.

Fitzgibbons P, Medvedev G. Functional and clinical outcomes of upper extremity amputation. J Am Acad Orthop Surg. 2015;23:751-760.

Salminger S, Gradischar A, Skiera R, Roche AD, Sturma A, Hofer C, Aszmann OC. Attachment of upper arm prostheses with a subcutaneous osseointegrated implant in transhumeral amputees. Prosthet Orthot Int. 2018;42:93-100.

Marquardt E, Neff G. The angulation osteotomy of above-elbow stumps. Clin Orthop Relat Res. 1974;104:232-238.

Neusel E, Traub M, Bläsius K, Marquardt E. Results of humeral stump angulation osteotomy. Arch Orthop Trauma Surg. 1997;116;263-265.

Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. Traumatic and trauma-related amputations part II: Upper extremity and future directions. J Bone Joint Surg Am. 2010;92:2934-2945.

Acceptance of Prosthesis Millstein SG, Heger H, Hunter GA. Prosthetic use in adult upper limb amputees: comparison of the body powered and electrically powered prosthesis. Prosthet Orthot Int. 1986;10:27-34.

Stȕrup J, Thyregod HC, Jensen JS, Retpen JB, Boberg G, Rasmussen E, Jensen S. Traumatic amputation of the upper limb: the use of body-powered prostheses and employment consequences. Prosthet Orthot Int. 1988;12:5-52.

Pinzur MS, Angelats J, Light TR, Izulerdo R, Pluth T. Functional outcomes following traumatic upper limb amputation and prosthetic limb fitting. J Hand Surg Am. 1994;19:836-839.

Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg Am. 1995;20:619-622.

McFarland LV, Hubbard Winkler SL, Heinemann AW, Jones M, Esquenazi A. Unilateral upper-limb loss: Satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev. 2010;47:299-316.

Osseointegrated Prosthesis Jönsson S, Caine-Winterberger K, Brånemark R. Osseointegration amputation prostheses on the upper limbs: Methods, prosthetics and rehabilitation. Prosthet Orthot Int. 2011;35:190-200.

Tsikandylakis G, Berlin Ö, Brånemark R. Implant survival, adverse events, and bone remodeling of osseointegrated percutaneous implants for transhumeral amputees. Clin Orthop Rel Res. 2014;472:2947-2956.

Kang NV, Pendegrass C, Marks L, Blunn G. Osseocutaneous integration of an intraosseous transcutaneous amputation prosthesis implant used for reconstruction of a transhumeral amputee: Case report. J Hand Surg Am. 2010;35:1130-1134.

Li Y, Brånemark R. Osseointegrated prostheses for rehabilitation following amputation. The pioneering Swedish model. Unfallchirurg. 2017;120:285-292.

Ortiz-Catalan M, Mastinu E, Sassu P, Aszmann O, Brånemark R. Self-contained neuromusculoskeletal arm prostheses. N Engl J Med. 2020;1732-1738.

Targeted Muscle Reinervation Dumanian GA, Ko JH, O’Shaughnessy KD, Kim PS, Wilson CJ, Kuiken TA. Targeted reinnervation for transhumeral amputees: Current surgical technique and update on results. Plast Reconstr Surg. 2009;124:863-869.

Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: A novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472:2984-2990.

Hebert JS, Olson JL, Morhart MJ, Dawson MR, Marasco PD, Kuiken TA, Chan KM. Novel targeted sensory reinnervation technique to restore functional hand sensation after transhumeral amputation. IEEE Trans Neural Syst Rehabil Eng. 2014;22:765-773.

Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, challenges, and pitfalls after targeted muscle reinnervation in high-level amputees: Is it worth the effort? Plast Reconstr Surg. 2019;144:1037e.

Regenerative Peripheral Nerve Interface Kubiak CA, Kemp SWP, Cederna PS. Regenerative peripheral nerve interface for management of postamputation neuroma. JAMA Surg. 2018;153:681-682.

Kubiak CA, Kemp SWP, Cederna PS, Kung TA. Prophylactic regenerative peripheral nerve interfaces to prevent postamputation pain. Plast Reconstr Surg. 2019;144:421e.

Agonist-Antagonist Srinivasan SS, Diaz M, Carty M, Herr HM. Towards functional restoration for persons with limb amputation: A duel-stage implementation of regenerative agonist-antagonist myoneural interfaces. Sci Rep. 2019;9:1981.

Rehabilitation Drew AJ, Izykowski MT, Bachus KN, Henninger HB, Foreman KB. Transhumeral loading during advanced upper extremity activities of daily living. PLoS One. 2017;12:e0189418.

Resnik LJ, Borgia ML, Acluche F. Perceptions of satisfaction, usability and desirability of the DEKA Arm before and after a trial of home use. PLoS One. 2017;12:e0178640.

Lafo J, Correia S, Borgia M, Acluche F, Resnik L. Cognitive characteristics associated with device adoption, skill retentions, and early withdrawal from a study of an advances upper limb prosthesis. Am J Phys Med Rehabil. 2019;98:879-887.

Topuz S, Kirdi E, Yalcin AI, Ulger O, Keklicek H, Sener G. Effects of arm swing on spatiotemporal characteristics of gait in unilateral transhumeral amputees. Gait Posture. 2019;68:95-100. doi: 10.1016/j.gaitpost.2018.11.010.

Blana D, Kyriacou T, Lambrecht JM, Chadwick EK. Feasibility of using combined EMG and kinematic signals for prosthesis control: A simulation study using a virtual reality environment. J Electromyogr Kinesiol. 2016;29:21-27.

Prahm C, Kayali F, Sturma A, Aszmann O. PlayBionic: Game-based interventions to encourage patient engagement and performance in prosthetic motor rehabilitation. P MR. 2018;10:1252-1260.

Hargrove L, Miller L, Turner K, Kuiken T. Control within a virtual environment is correlated to functional outcomes when using a physical prosthesis. J Neuroeng Rehabil. 2018;15,60. https://doi.org/10.1186/s12985-018-0402-y.

Outcomes Carey SL, Lura DJ, Highsmith MJ. Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review. J Rehabil Res Dev. 2015;52:247-62. doi: 10.1682/JRRD.2014.08.0192.

Melcer T, Walker J, Sechriest VF 2nd, Bhatnagar V, Richard E, Perez K, Galarneau M. A retrospective comparison of five-year health outcomes following upper limb amputation and serious upper limb injury in the Iraq and Afghanistan conflicts. PM R. 2019;11:577-589. doi: 10.1002/pmrj.12047.

8/24/2020

Scott M. Tintle, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

THE ROLE OF TARGETED MUSCLE REINNERVATION IN TRANS‐RADIAL AND TRANS‐HUMERAL AMPUTATIONS TO ENHANCE PROSTHETICFUNCTION

Scott M. Tintle MD CDR, MC, USN Chief of Hand Surgery Fellowship Director Walter Reed National Military Medical Center

Associate Professor Uniformed Services University

MANDATORY DISCLAIMER

The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of Walter Reed National Military Medical Center, the Department of the Navy, Department of the Army, Department of Defense, nor the U.S. Government

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WITH THANKS TO THE FOLLOWING PEOPLE

• COL Kyle Potter • LCDR Jason Souza • CAPT George Nanos

• Dr Todd Kuiken • Dr. Gregory Dumanian

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• What is TMR ?

• Why Do you do TMR?

• How Do I Do TMR?

• Do I need to do TMR?

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WHAT IS TMR?

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MOTIVATION‐ LACK OF ELECTRICAL SIGNALS TO PROSTHESIS

• Major limitation of upper extremity prosthetics • THA, Shoulder disarticulation‐ poor prosthetic acceptance rates • Transhumeral Level Amputee—3 options • Biceps/Brachialis‐ (Musculocutaneous nerve) • Triceps (Radial Nerve) • Co‐contraction • Anything else is PASSIVE or requires switch

Radial N.

Median N.

Ulnar N.

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CONVENTIONAL TREATMENT OF ABOVE-ELBOW AMPUTATION

Elbow Up/ Hand Close Biceps Electrodes (antennas) Musculocutaneous nerve

Elbow Down/ Triceps Hand Open Radial nerve

TRANSHUMERAL TARGETED MUSCLE REINNERVATION

Lateral Biceps Medial Biceps Musculocutaneous Median Nerve nerve Hand Close Elbow Up

Medial and Long Triceps Lateral Triceps Triceps branch of Distal Radial Radial nerve nerve Elbow Down Hand Open

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SHOULDER DISARTICULATION

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TRANS RADIAL AMPUTATION

• Advanced Prosthetics capable of thumb abduction, opposition, grasp, digital extension, wrist flexion and extension, and forearm rotation.

• Standard Forearm level amputees cannot control this many functions

• Targeted muscle reinnervation can allow for improved prosthetic control and allow for increased number of myoelectric functions.

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PATTERN RECOGNITION VS DIRECT CONTROL

• Pattern recognition‐ Advanced EMG signal and computer learning to allow a prosthesis to perform advanced movements. Minimal nerve transfers necessary

• Direct Control‐ each muscle‐ one function

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WHY PERFORM TMR

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FUNCTIONAL IMPROVEMENT

• Simultaneous control of a two degree of freedom experimental prosthesis

• Doubling of Box and Blocks test

• 26% increase in speed of clothes pin moving test

• Subjectively pt liked it more, it was easier, faster, and felt more natural

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• Return to prior 1 Month with TMR prosthesis prosthetic use after initial post‐operative recovery

• Predictable reinnervation in 5‐6 month

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ADVANCED PATTERN RECOGNITION PROSTHETIC

PAIN CONTROL MY NUMBER 1 REASON

THE NEUROMA

Neuroma Definition: Uncontrolled axonal growth entwined with myofibroblasts, Schwann cells, and endothelial cells

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NERVE MANAGEMENT‐ (HISTORIC SLIDE) • Identify, isolate, dissect proximally, place under tension, transect proximally or bury ALL named nerves – Neuromas may be inevitable…symptoms are not – 13‐33% symptomatic neuroma rate in civilian series – Cut, bovie, ligate… – Do not dennervate proximal muscle groups (esp. UE)

PAINFUL NEUROMA

• Over 150 various treatments described in the literature

• No single treatment has proven superior to any other

• Difficult Problem!!

FRAUGHT WITH COMPLICATIONS

• Neuromas –2nd most common reason

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100 UE AMPUTATIONS Complication Data Complication Data Percent of Total Number of 42 amputations patients with Heterotopic 19% complications Ossification Excision Wound infection 13% Neuroma Excision 9% Total Number of 56 Complications Wound dehiscence 6% Scar Revision 5%

Total number of 103 Contracture Release 4% surgeries

300 LOWER EXTREMITY AMPUTATIONS

Complication Complication Data Percent of Data amputations Total Number of 156 (53%) Heterotopic 24% patients with Ossification Excision complications Wound infection 27% Neuroma Excision 11% Total Number of 261 Wound dehiscence 4% Complications Scar Revision 8% Total number of 465 Myodesis Revision 6% surgeries

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PAINFUL NEUROMA AND TMR

Effects of Targeted Reinnervation (TR) on Neuroma Pain. No. of Pre‐TR Post‐TR Amputation level Patients neuroma pain neuroma pain Transhumeral 18 10 1 Shoulder disarticulation 10 5 0 Total (%) 28 15 (54%) 1 (3.5%)

Conclusions: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy.

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Conclusions Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain.

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Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma‐related residual limb pain. (J Am Coll Surg 2019;228:217e226. ! 2019)

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WHY DOES IT WORK?... THE HYPOTHESIS Typical TMR Neuroma Thinner Distal nerve Collateral axon sprouting forms thicker nerve Normal muscle tissue for nerve fiber distribution. Many nerve fibers form Smaller Neuroma Axons end in functional connections. tangled ball of x x x x fibrous tissue x x x x x x x x x x

Normal Neuroma After TMR nerve

Cross section of a rabbit single median nerve before transection (left), 6 weeks after neuroma formation (center), and 10 weeks post‐TMR (right). Peter Kim et al, JBP&PNI, 2010

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HOW TO DO TMR? ‐ TRANSHUMERAL

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SPECIAL EQUIPMENT

• Nerve stimulator

• Loupes/Microscope

TRANSHUMERAL SURGICAL GOALS

• Median nerve to medial head of Biceps • Radial nerve to lateral head of Triceps • Ulnar nerve to Brachialis muscle • Maximize EMG signals – remove adipofascial flap over muscles and interpose between muscle groups.

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MARKING INCISION

• **Preop hold with patient awake‐ carefully outline and mark biceps and triceps muscles • Mark incision over biceps (cheat slightly medial from deltoid insertion distal • Mark incision between long and lateral heads of triceps muscles same length • Tumesce with 1% lidocaine with epinephrine

Anterior Posterior

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MEDIAN NERVE TO BICEPS

• Elevate 3cm skin flaps preserving adipofascial flap

• Raise adipofascial flap with needle tipped bovie for proximally based flap

• Open raphe between medial and lateral head of biceps exposing musculocutaneous nerve (MCN), dissect out branches to heads of biceps and continuation to brachialis muscle

MCN branch to lateral biceps MCN branch to medial biceps

• Dissect median nerve medial to biceps

• Mobilized median nerve distally and excise neuroma

• Pass Median nerve under biceps between muscles

• Transect MCN branch to medial head of biceps at insertion to muscle but cephalad to any branching pattern to muscle

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Median Nerve

• Bury proximal cut MCN branch into lateral head of biceps

• Coapt median nerve to MCN branch to medial biceps and epimysium with 5‐0 Prolene suture

• PROTECT MCN to lateral biceps!!!

• Interpose adipofascial flap

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RADIAL NERVE TO LONG HEAD TRICEPS

• Incise over raphe of Triceps. • Raise skin flaps and adiofascial flap as before • Bluntly dissect between long and lateral head of triceps to identify radial nerve branches to the lateral head • Dissect the radial nerve distally and transect/resect neuroma • Cut radial nerve branch to lateral head of triceps at insertion, resect segment back to radial nerve also • Coapt radial nerve to lateral head triceps nerve branch and epymisium • Interpose adipofascial flap

Radial nerve branch to lateral head triceps

Radial Nerve

RN coapted to lateral head triceps

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ULNAR NERVE TO BRACHIALIS

• Identify radial nerve to brachialis muscle

• Dissect ulnar nerve medially

• Pass ulnar nerve laterally under biceps muscles

• Coapt ulnar nerve to brachialis muscle nerve branch

• No additional adipofascial flap required.

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MCN branch to Brachialis

Ulnar Nerve to Brachialis

TRANSRADIAL TECHNIQUE

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MEDIAN AND ULNAR NERVES

• Ulnar Nerve to FPL

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MEDIAN TO AIN NERVE

FCU TO ULNAR NERVE

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DO I NEED TO DO TMR?

• TMR improves functional control for the Transhumeral/ Shoulder Disarticulation and transradial Level Amputees

• Prospective Randomized Evidence to support improvement in pain due to neuromas

• Evidence to suggest early intervention and TMR in acute amputees is optimal!

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THANK YOU

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