Surgeon Preferences on Timing and Application of Postamputation Peripheral Nerve Interventions: A Nationwide Survey

Symptomatic neuroma develops in 5%-25% of individuals receiving an amputation. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) have emerged as effective interventions for neuroma treatment, and interest in prophylactic use is growing. However, no national consensus exists on implementation. This study aimed to identify surgeon characteristics associated with peripheral nerve intervention, referral patterns, and barriers to broader adoption of prophylactic TMR/RPNI.

A REDCap survey was administered to 3628 physicians; 303 responded. Participants were members of the American Society for Surgery of the Hand (ASSH) or the Musculoskeletal Tumor Society (MSTS). Physicians were queried on training background, procedural utilization, timing of intervention, and perceived barriers to performance or referral.

Surgeons performing peripheral nerve surgery were more likely to be in practice for 10 years or less ( P  < 0.001), work as an academic surgeon ( P  < 0.001), and be trained in plastic surgery ( P  < 0.001). Among the 142 physicians performing peripheral nerve surgery, 86% perform either TMR or RPNI for prophylaxis and 51% stated the effect was comparable for treatment or prophylaxis. There were no differences in utilization of prophylactic procedures based on time in practice ( P  = 0.42), practice setting ( P  = 0.14), or surgical specialty ( P  = 0.36). Forty-two percent of nerve surgeons stated that not being consulted by the primary team was a consistent barrier. Of 89 amputation-only surgeons, 38% refer to TMR/RPNI, with higher referral rates in the academic setting ( P  < 0.001).

TMR and RPNI are increasingly adopted for treatment and prophylaxis of neuroma. However, referral rates remain low and are limited by coordination challenges and inconsistent consultation pathways. There appears to be a growing proportion of surgeons strategically employing these techniques prophylactically regardless of years in practice or practice setting, possibly due to the increasing body of evidence at single-site studies. These findings highlight the need for broader interdisciplinary awareness, streamlined referral pathways, and continued efforts to translate emerging evidence into clinical practice.