Below-the-knee Amputation with Targeted Muscle Reinnervation: Operative Technique and Technical Pearls

Area of Science:

• Surgical innovation in lower extremity amputation.
• Neuropathic pain management strategies.
• Regenerative peripheral nerve interface applications.

Background:

• Postamputation pain, including neuroma and phantom limb pain, significantly impairs quality of life after major lower extremity amputation.
• Physiologic nerve stabilization techniques are crucial for preventing pathological neuropathic pain.
• Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces are leading methods for nerve stabilization.

Purpose of the Study:

• To detail a specific institutional technique for physiologic nerve stabilization using TMR.
• To present the approach and rationale for managing major nerves in lower extremity amputations.
• To describe a modified TMR protocol for below-the-knee amputations.

Main Methods:

• The described technique involves targeted muscle reinnervation (TMR) at the time of below-the-knee amputation.
• Unlike other methods, this protocol selectively targets major nerves, balancing neuroma/phantom limb pain rates with surgical morbidity.
• A key modification includes superficial peroneal nerve transposition to move the neurorrhaphy away from the weight-bearing stump.

Main Results:

• The institutional technique has been safely and effectively performed on over 100 patients.
• The modified TMR approach avoids operating on all five major nerves, reducing surgical time and morbidity.
• Superficial peroneal nerve transposition effectively repositions the neurorrhaphy site.

Conclusions:

• This article presents a refined institutional approach to physiologic nerve stabilization via TMR for below-the-knee amputations.
• The described technique aims to prevent postamputation neuropathic pain effectively.
• This method offers a safe and efficient alternative for managing nerve complications after amputation.