This paper describes the first published surgical technique for targeted muscle reinnervation (TMR) specifically in below-knee amputation. It reports outcomes in 22 patients who underwent TMR either concurrently with amputation (primary) or as a delayed procedure (secondary). The central question: can TMR prevent symptomatic neuromas and phantom limb pain at the transtibial level?
Standard traction neurectomy leaves peripheral nerves without a distal target, and up to 25% of amputees develop painful end-neuromas as a result. Phantom limb pain affects 9–67% of amputees — a range reflecting how poorly the problem was controlled before techniques like TMR.
When your patient is heading to the OR for a below-knee amputation, coordinate with plastic surgery to perform TMR concurrently. Primary TMR gives every major nerve a motor target at the time of division, converting a neuroma-prone stump into a reinnervated one.
The key technical point: you must cut the recipient motor nerve branch first to denervate the target muscle before coaptation. This creates the reinnervation stimulus. A nerve stimulator after tourniquet release identifies motor branches with minimal extra dissection.
For patients presenting years after amputation with stump neuroma pain, secondary TMR remains an option and is supported by the broader TMR literature this paper builds on.
This paper describes the first published surgical technique for targeted muscle reinnervation (TMR) specifically in below-knee amputation. It reports outcomes in 22 patients who underwent TMR either concurrently with amputation (primary) or as a delayed procedure (secondary). The central question: can TMR prevent symptomatic neuromas and phantom limb pain at the transtibial level?
Standard traction neurectomy leaves peripheral nerves without a distal target, and up to 25% of amputees develop painful end-neuromas as a result. Phantom limb pain affects 9–67% of amputees — a range reflecting how poorly the problem was controlled before techniques like TMR.
When your patient is heading to the OR for a below-knee amputation, coordinate with plastic surgery to perform TMR concurrently. Primary TMR gives every major nerve a motor target at the time of division, converting a neuroma-prone stump into a reinnervated one.
The key technical point: you must cut the recipient motor nerve branch first to denervate the target muscle before coaptation. This creates the reinnervation stimulus. A nerve stimulator after tourniquet release identifies motor branches with minimal extra dissection.
For patients presenting years after amputation with stump neuroma pain, secondary TMR remains an option and is supported by the broader TMR literature this paper builds on.