SYM02: Jedi Mind Tricks: Targeted Muscle Reinnervation and Advanced Prosthetics Moderator(s): David M. Brogan, MD, MSc. Faculty: Kyle R. Eberlin, MD, Jason H. Ko, MD, MBA, Jason M. Souza, MD, and Scott M. Tintle, MD Session Handouts Friday, October 02, 2020 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. 9/2/2020 Symposium #2: Jedi Mind Tricks: Targeted Muscle Reinnervation and Advanced Prosthetics 1 Symposium Objectives • Explain the principles of Targeted Muscle Reinnervation as well as its indications in neuroma management • Have an appreciation of the variety of myoelectric prosthetics currently available for upper extremity amputees • Understand the post-operative protocols and rehabilitation necessary to maximize functional results. 2 Program & Faculty • Upper Extremity Targeted Muscle Reinnervation: Basic Principles and Technique • Jason Ko, MD, MBA (Northwestern University) • Osseointegration of Upper Extremity Prosthetics • Jason Souza, MD (Walter Reed National Military Medical Center) • Efficacy of TMR in Reducing Neuroma & Phantom Limb Pain • Kyle Eberlin, MD (MGH / Harvard) • Beyond Skywalker’s Hand: Current Prosthetic Options • David M. Brogan, MD, MSc (Washington University in St. Louis) • Future Directions in TMR Research • Scott Tintle, MD (Walter Reed National Military Medical Center) 3 1 9/2/2020 DISCLOSURES Jason H. Ko, MD, MBA Consulting Fee: Integra LifeSciences Corporation EDGe Surgical, Inc. Speakers Bureau: Checkpoint Surgical, Inc. Others: Mesh Suture, Inc. (Scientific Advisory Board) 4 Upper Extremity Targeted Muscle Reinnervation (TMR): Basic Principles and Techniques Jason H. Ko, MD, MBA Associate Professor Division of Plastic and Reconstructive Surgery Department of Orthopedic Surgery Northwestern University Feinberg School of Medicine Chicago, IL USA Jedi Mind Tricks: TMR and Advanced Prosthetics ASSH Annual Meeting October 2, 2020 5 WHY 6 2 9/2/2020 WHY WHO 7 WHY WHO HOW 8 1891 Courtesy of Gregory Dumanian, MD 9 3 9/2/2020 2020? 10 11 Myoelectric prostheses • Major limitations – Can only move one “joint” at a time – Controlled by the “wrong” muscle signals Courtesy of Gregory Dumanian, MD 12 4 9/2/2020 13 14 15 5 9/2/2020 1. NEURAL SIGNALS STILL EXIST TARGETED MUSCLE REINNERVATION 16 The brain still creates signals that go to the nerves. Can we tap into these signals to control an artificial arm? TARGETED MUSCLE REINNERVATION 17 CAN WE RECORD CONTROL SIGNALS FROM THE BRAIN?? TARGETED REINNERVATION 18 6 9/2/2020 CAN WE RECORD CONTROL SIGNALS FROM THE NERVES?? 19 20 1. NEURAL SIGNALS STILL EXIST 2. AVAILABLE MUSCLE SITES TARGETED MUSCLE REINNERVATION 21 7 9/2/2020 1. NEURAL SIGNALS STILL EXIST 2. AVAILABLE MUSCLE SITES 3. INTUITIVE CONTROL TARGETED MUSCLE REINNERVATION 22 TARGETED MUSCLE REINNERVATION (TMR) COMBINES AVAILABLE TECHNOLOGY WITH MODIFICATION OF THE RESIDUAL ANATOMY 23 • 54-year-old electrical utility lineman • May 2001: suffered 7200 volt burns • Immediate bilateral shoulder disarticulation • Split-thickness skin grafts for closure of painful wounds First TMR Patient 24 8 9/2/2020 Gregory Dumanian, MD Todd Kuiken, MD, PhD Feinberg School of Medicine Rehabilitation Institute of Northwestern University Chicago * Surgery performed January 2002 TMR Nerve Transfer Surgery 25 Surgical Considerations • No plexopathy • Good pectoralis function • Tinel’s signs at anterior axillary line We know his nerves work!!! 26 27 9 9/2/2020 Surgical Technique • Mobilize nerve stumps • Divide normal pectoralis major innervation • Create distinct segments of pectoralis muscle • Coapt nerves & muscle segments 28 Surgical Technique • Mobilize nerve stumps medial • Divide normal pectoralis major lateral innervation • Create distinct segments of pectoralis muscle • Coapt nerves & muscle segments 29 Surgical Technique • Mobilize nerve stumps medial 1 • Divide normal 4 pectoralis major 2 lateral innervation • Create distinct segments of 3 pectoralis muscle • Coapt nerves & muscle segments 30 10 9/2/2020 Surgical Technique • Mobilize nerve stumps • Divide normal pectoralis major innervation • Create distinct segments of pectoralis muscle • Coapt nerves & muscle segments 31 Targeted Muscle Reinnervation Pre-Op: 1 myoneurosome Post Op: 4 myoneurosomes 32 33 11 9/2/2020 34 Thumb Abduction Thumb Wrist Supination Adduction PATTERN RECOGNITION 35 Elbow Flexion Elbow Extension Hand Close Hand Open PATTERN RECOGNITION 36 12 9/2/2020 Myoelectric Prosthesis 37 Myoelectric Prosthesis 38 Original Prosthesis Nerve Transfer Prosthesis (Used more than 20 months) (Used about 2 months) 39 13 9/2/2020 Targeted Muscle Reinnervation • Left upper extremity prosthesis created with myoelectric controls “Doc, now I don’t have to think about what I’m doing so much—I just do it.” 40 Who is a candidate? 41 Courtesy of Gregory Dumanian, MD 42 14 9/2/2020 Courtesy of Gregory Dumanian, MD 43 44 45 15 9/2/2020 46 47 48 16 9/2/2020 49 50 51 17 9/2/2020 Targeted Muscle Reinnervation (TMR) Transhumeral amputees 52 53 Transhumeral Targeted Muscle Reinnervation A different amputation... A different surgery! Proximal Radial n. to Triceps (no change) Elbow Down Musculocutaneous n. to Lateral Biceps (no change) Elbow Up Median n. to Medial Biceps Hand Close Distal Radial n. to Brachialis Hand Open 54 18 9/2/2020 55 55 56 57 19 9/2/2020 58 58 Transhumeral Surgical Procedure Median nerve Medial biceps Radial nerve Lateral head triceps Ulnar Brachialis (if long limb) Musculocutaneous nerve Lateral biceps Proximal radial nerve Long head triceps 59 60 20 9/2/2020 Conventional Treatment TMR Post-Op 2 signals 4 to 5 signals Surface Electrode 61 62 63 21 9/2/2020 Transradial TMR 64 Median, ulnar, and radial Transferred to motor nerves in neuromas forearm 1) Median to AIN 2) Ulnar to FCU 3) DSBRN to FDS 65 1 week old crush injury transferred to me 66 22 9/2/2020 67 1) Median to AIN 2) Ulnar to FCU 3) DSBRN to FDS 68 69 23 9/2/2020 1) Median to AIN 2) Ulnar to FCU 3) DSBRN to FDS 70 71 Partial Hand TMR 72 24 9/2/2020 Partial Hand TMR 73 74 Epithelioid sarcoma 75 25 9/2/2020 76 2 years later… recurrence 77 Partial hand TMR 78 26 9/2/2020 TMR nerve transfers: Digital nerves to motor branches of lumbrical muscles 79 Partial hand TMR 80 3 months post-op 81 27 9/2/2020 WHY 82 WHY WHO 83 WHY WHO HOW 84 28 9/2/2020 1891 85 The future is now… 86 Thank you! [email protected] 87 29 9/2/2020 DISCLOSURES Jason M. Souza, MD Speaker has no relevant financial relationships with commercial interest to disclose. 88 SYM02: Jedi Mind Tricks: Targeted Muscle Reinnervation and Advanced Prosthetics (VAM20) Jason M. Souza MD, FACS 89 The views expressed in this presentation are those of the author and do not reflect the official policy of Walter Reed National Military Medical Center, the Uniformed Services University of Health Sciences, Department of the Army, Department of the Navy, the Department of Defense or the United States Government. Faces and Tattoos Are Shown with Permission 90 30 9/2/2020 Jason M. Souza MD, FACS 91 a.Inclusion Criteria • The Patient must be a transhumeral amputee, age 22 -65 • The Patient with a residual humerus ≥ 10 cm in length • Documented difficulty with prosthetic wear due to conditions including (not limited to) inadequate soft tissues, ulceration(s), socket discomfort, excessive perspiration, intolerance to interface materials, or other inadequate methods of suspension. • Cortical thickness of at least 1.5mm • Residual humerus suitable for size 13-25 fixtures by radiographic templating. • The Patient must be suitable for surgery based upon medical history and physical examination. • The Patient must be likely to comply with treatment, rehabilitation and follow- up requirements. 92 93 31 9/2/2020 94 95 96 32 9/2/2020 a.Inclusion Criteria • The Patient must be a transhumeral amputee, age 22 -65 • The Patient with a residual humerus ≥ 10 cm in length • Documented difficulty with prosthetic wear due to conditions including (not limited to) inadequate soft tissues, ulceration(s), socket discomfort, excessive perspiration, intolerance to interface materials, or other inadequate methods of suspension. • Cortical thickness of at least 1.5mm • Residual humerus suitable for size 13-25 fixtures by radiographic templating. • The Patient must be suitable for surgery based upon medical history and physical examination. • The Patient must be likely to comply with treatment, rehabilitation and follow-up requirements. 97 98 99 33 9/2/2020 100 101 102 34 9/2/2020 103 104 105 35 9/2/2020 106 107 108 36 9/2/2020 109 110 111 37 9/2/2020 Artificial Limb Osseointegrated Human-Machine Muscular Gateway Interface (OHMG) Neural Interface Artificial Limb Controller Bio-amplifiers & PatRec 112 X 113 114 38 9/2/2020 The DoD Osseointegration Program Team 115 THANK YOU 116 DISCLOSURES Kyle R. Eberlin, MD Consulting Fees: AxoGen, Integra, Checkpoint, Tissium 117 39 9/2/2020 Efficacy of TMR in Reducing Neuroma and Phantom Limb Pain Kyle R. Eberlin, MD Assistant Professor of Surgery, Harvard Medical School Program Director, Harvard Plastic Surgery Residency Program Associate Program Director, MGH Hand Surgery Fellowship October 2nd, 2020 118 Why has TMR become popular for addressing Neuroma and Phantom Limb Pain? 119 Outline • Definition and Pathophysiology of Neuroma • Diagnosis and Decision for Surgical Intervention • Surgical Options Including TMR 120 40 9/2/2020 Outline • Definition and Pathophysiology of Neuroma • Diagnosis and Decision for Surgical Intervention • Surgical Options Including TMR 121 This problem is more common than surgeons think… 122 What are Neuromas? • Definition: disorganized growth or tumor of nerve tissue following nerve injury • Occurs when a nerve ending is “not connected” to its target organ • Neuroma vs.