Abstract
Lower extremity amputation is increasingly prevalent in the United States, with growing numbers of patients suffering from diabetes and peripheral vascular disease. Amputation has significant functional sequelae as more than half of patients are unable to ambulate at one year postoperatively. Improving mobility and decreasing chronic post-amputation pain can significantly improve the quality of life for these patients and reduce the cost burden on the healthcare system. Plastic and reconstructive surgery has been at the forefront of “reconstructive amputation”, in which nerve pedicles can be surgically guided to decrease painful neuroma formation as well as provide targets for myoelectric prosthesis use. We herein review post-amputation outcomes, epidemiology of chronic, post-amputation pain, and current treatments, including total muscle reinnervation and regenerative peripheral nerve interface, which are at the forefront of multidisciplinary treatment of lower extremity amputees.
Highlights
Amputation continues to be prevalent in the present day, with approximately 1.6 million people with major limb amputations in the United States in 2005 and 185,000 major limb amputations every year[2,3]
No appropriate literature on the indirect or total cost of amputation currently exists, but it is estimated to be significant as studies have found that after a major lower extremity amputation, up to 53.9% of patients were still nonambulatory at 6-month follow-up after the operation[4]
Identification of the significant individual and systems burden of amputation, advances in microsurgery, as well as collaborative efforts with medicine-adjunct fields such as mechanical and bioengineering for prosthetics as well as neuromodulation are what birthed total muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI). These techniques to treat and, increasingly, prevent post-amputation pain are newer additions to the plastic surgeons’ armamentarium, which have allowed further evolution of the top rungs of the reconstructive ladder in an often challenging patient population[60]. These techniques were developed in the realm of plastic surgery, plastic surgery has a collaborative history in which many surgical interventions developed by plastic surgeons are adopted by other specialties
Summary
Extremity amputation is one of the oldest procedures known to man, with archeological records suggesting purposeful amputations as far back as 45,000 years since Neolithic times[1]. During these endeavors to treat upper extremity amputees, a retrospective review of fifteen patients who underwent either shoulder disarticulation or transhumeral amputation and had neuroma pain who received TMR for myoelectric control demonstrated an unexpected finding of fourteen of these patients having complete resolution of pain in the transferred nerves[52] These results were corroborated in a rabbit forelimb amputation model by Kim et al.[53]. Twenty-eight major upper and lower limb amputees with neuroma pain were randomized to these two groups They conducted pain measures with two patient-reported scales, including the numerical rating scale (NRS) and PROMIS pain behavior, intensity, and interference short surveys. Patient-reported outcomes measures with both NRS and PROMIS pain behavior, intensity, and
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