Wednesday, May 25, 2022

Responses: TMR for Neuroma Treatment

Julia Fry

Hello,

Reponses below for the question:

“Would you share your experience with TMR surgery as a form of treatment of a patient’s neuroma(s)? 
Please specify level of amputation. ”

Best,

Julia

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35 years of doing this I have never heard of that or seen that as a treatment. Has the patient had the neuroma removed? That is the most drastic treatment I’ve been involved with and haven’t worked with any patients that the removal didn’t eliminate the symptoms, it’s just the last form of treatment due to down time for the patient. Kinda sounds like you have a doc like the one that was ran out of town where l live due to him maiming patients with the surgery he did. I you have time with this patient have you tried a neuroma finger coming off the met pad? Good luck

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UcDavis is doing it in their plastic department.

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Yes, I have especially for transhumeral and shoulder disarticulation.
I don’t know if it is true TMR where the original innervation is cut however. It seems more like a muscle pocket.

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I don’t have clinical experience with TMR clientele but I do see this approach to system control engineering and other forms of mechanical neurobiological engineering very promising so I hope you will post other more informed extracorporeal OPR clinical opinions.

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Here in California (Visalia) I was able to find an Orthopedic surgeon to fix many neuroma issues on a BK amputee. It is a simple 6 minute surgery. I was patient number 1, and a handful more have had the same surgery. There was one sentence in the Atlas of prosthetics on it, but this was the only reference I could find.
It makes a lot of sense. The peroneal nerve does not innervate anything on a BK limb below the knee, since the limb is amputated. Thus, why isn’t the nerve transected outside of the prosthetic socket, so there is no ectopic stimulation of the peroneal nerve during ambulation.
The surgeon perfected this, and moves the hamstring, cuts the peroneal nerve above the level of the socket, and sews back up. Walk in and walk out. I am very bony, and cut at fibula head, so having a correct patient is also necessary. It worked for me, but I cannot say it works for everyone. I can only say it works for me. Not enough people have had the surgery and nobody has written up a study on it, yet. I am too busy.
Not sure if you patient wants to evaluate this and come to Visalia. I should say that walking is important afterwards, or therapy, because there is a tendency to tighten the knee by moving the hamstring, and I would want to avoid the possibility of a knee contracture. I would also say we have seen some delayed healing, because at week 2, people get too active because of less pain and wanting to go live life, but the stitches have not healed yet. So, there also is a need for compliance and going slowly until the stitches are healed, even though the pain is much less during walking.

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I had few patients done All levels
It works well, but sometimes there is a little flare up of phantom pain after!
All patients are satisfied

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I’ve been hearing more and more about this and I’m super intrigued. Sadly I have no direct experience with this (yet) to report to you, I’d be most appreciative if you could post the replies you get.

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I have seen below elbow, bk and several of AK patients. 100% of the time there’s been improvement but not 100% reduction of pain

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I have not had any patients that have had this procedure, but I did watch the Academy symposium on this topic. A doctor from I believe the Boston area has been a big advocate of this procedure and made a nice presentation about it. It seems to have very successful outcomes. You can probably find the course on the Academy website in the On-Line Learning Center… it is titled “Addressing Residual Limb Pain.”

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Back in the olden, golden days when Blockbuster was king and Facebook’s Mark Zuckerberg was still in high school… In the bright, pre-pandemic bliss of my days at NUPOC before RAC audits were a thing… I came across this journal article in their library: https://urldefense.proofpoint.com/v2/url?u=https-3A__pubmed.ncbi.nlm.nih.gov_8360727_&d=DwIF-g&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=2hejPeSIN5ws3WTaW7E92TTyse_SlwUuUcvOaDfZNUg&s=jv13xETMBGi3XahQiYx8tKQiXqGnBZLzhBmbU9_gVnQ&e=

While TMR is nifty and cool, your patient is simply looking for the right solution. The centro central anastomosis exceeded their expectations when it came to resolving painful neuromas for amputees.

If your medical center is seeing a higher than normal number of neuromas which can be responsible for consuming an inordinate amount of your time, you might consider having the hospital run a regression analysis to determine if correlations exist between painful neuromas and one particular surgeon.

Patients should be the focus of clinical healthcare, not the fodder of a clinician’s hubris. You can also tell the clinical team that since the bone marrow in a longbone is so rich in stem cells, leaving the medullary canal unsealed can also contribute to these types of complications. Something about a plank in one eye… and a speck in another’s…

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I saw your post in the listserv regarding experiences with TMR for neuroma treatment. I am a current resident in prosthetics University of Oklahoma Orthotics & Prosthetics Clinic and work closely with Dr. William Ertl. He is now performing prophylactic TMRs with all of his BK/AK/KD amputation surgeries as part of the primary surgery. He often performs revisions to BK/AK/KD with TMRs for patients with symptomatic neuromas as well.

From my brief experience, patient’s almost never have recurrence of the neuromas and the vast majority report improved comfort both within and without their prosthetic sockets. This is anecdotal from my experience with his patients but I have also attached some articles for your reference as well.

Please let me know if you have additional questions I can answer or pass on to Dr. Ertl on your behalf.

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