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Journal of Hand Surgery (Eur) 49(6)
brachial plexus reconstruction (Narakas, 1984). After
an amputation, the proximal muscles to the distally
amputated parts remain with their innervation. In
TMR, the major nerves innervating the hand and
arm are selectively transferred onto these separate
remnant muscles of the residual limb (Figure 1).
Through these new reinnervation pathways, these
target muscles essentially act as amplifiers of the
action potentials from the transferred nerve, yielding
electromyography (EMG) signals that can be registered
via transcutaneous pickup (Hijjawi et al., 2006).
In their original publication, Kuiken and colleagues
(2004) provided a proof of concept in a
patient with bilateral shoulder disarticulation.
Successful creation of novel neuromuscular units,
cognitively related to the musculature of the lost
hand and arm, allowed the patient to simultaneously
control 2 degrees of freedom including an active
elbow. Furthermore, clinical examination revealed
sensory reinnervation of the skin overlying the targeted
muscles, indicating regrowth of sensory fibres
from the transferred mixed nerves through the
muscles into the dermis.
In the last 20 years, TMR has received increasing
attention as a novel surgical method in the treatment
of limb amputation. Aside from the initially devised
use for augmenting the number and quality of EMG
signals for prosthetic control (Kuiken et al., 2009;
Myers et al., 2020; Salminger et al., 2019), TMR is
now widely investigated (and applied) as a means to
treat and even prevent phantom limb and neuroma
pain (Dumanian et al., 2019; Souza et al., 2014;
Valerio et al., 2019). Combining these different indications,
surgical techniques have been described for
multiple amputation levels in the upper and lower
extremity (Bowen et al., 2019; Dumanian et al.,
2009; Gart et al., 2015; Kuiken et al., 2017; Morgan
et al., 2016; Salminger et al., 2015) and specific
instructions for the cognitively demanding rehabilitation
process in upper limb amputees have been
published (Sturma et al., 2022).
Indications and outcomes of TMR
TMR in upper limb prostheses
TMR can be performed to improve prosthetic control
and/or to address amputation-related pain. From a
prosthetic-control perspective, TMR is particularly
useful where there is a mismatch between available
EMG signals and degrees of freedom needed to
replace when fitted with a myoelectric device. Thus,
it was initially conceived for above-elbow amputation
levels (i.e. transhumeral and glenohumeral), where
an active elbow joint necessitates additional degrees
of freedom (Kuiken et al., 2004, 2009). In contrast, a
transradial amputation generally does not require
augmentation of myosignals, as most of the extrinsic
hand musculature is still available and a direct control
approach can be used. However, a recent publication
(Simon et al., 2023) has demonstrated
functional outcome improvements after TMR in a
series of transradial amputees, when combining
the surgical technique with a pattern-recognition-
based control approach. Pattern recognition employs
a higher number of electrodes for collecting surface
myoelectric activity across the muscles of the residual
limb, in contrast to conventional direct control where
each electrode is placed over an area with cognitively
independent myoelectric activity (Scheme and
Englehart, 2011). Patients employing pattern recognition
for prosthetic control, however, need to regularly
calibrate the device software to match their EMG
patterns to the intended prosthetic movement.
It has been established that reinnervation after
Figure 1. The concept of TMR describes surgical rerouting
of the major nerves of the arm onto the musculature of the
residual limb.
TMR: target muscle reinnervation.
nerve transfers leads to reliable EMG signals for
prosthetic control (Dumanian et al., 2009; Kuiken
et al., 2009). We have recently published our experience
with patients who received TMR after aboveelbow
amputation (Salminger et al., 2019). While
the surgery succeeded in all cases and prosthetic
outcomes after rehabilitation were generally favourable,
still close to one-third of our patients
JHS 49.6 - June 2024
Table of Contents for the Digital Edition of JHS 49.6 - June 2024
Contents
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