Targeted Muscle Reinnervation in the Hand for the Management of Symptomatic Neuroma Following Digit and Hand Amputations – A Case Series

Abstract

<b>Background:</b> Targeted muscle reinnervation (TMR) is an emerging surgical technique that reroutes severed peripheral nerves to nearby motor targets to prevent symptomatic neuroma formation and reduce amputation-related pain. This case series evaluates the effectiveness of TMR in managing symptomatic neuromas following digit and hand amputations and reports postoperative outcomes and complications. <b>Methods:</b> Seventeen patients with traumatic or surgical digit/hand amputations distal to the wrist crease presenting with symptomatic neuromas were prospectively enrolled between August 2021 and August 2023. Patients underwent either primary TMR at the time of amputation or secondary TMR following neuroma formation. Surgical technique involved microsurgical coaptation of transected sensory nerves to adjacent motor entry points under loupe or microscopic magnification. Outcomes assessed included operative time, pain recurrence, phantom limb pain (PLP), narcotic usage and upper limb function measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. <b>Results:</b> Primary TMR was performed in 13 patients and secondary TMR in 4 patients. The mean operative time was approximately 90 minutes. All nerve transfers maintained a sensory-to-motor diameter ratio of less than 2:1. Postoperative neuroma-related pain occurred in only one patient due to a slipped suture, which was successfully revised. PLP was reported in three patients, resolving within 2 months in all cases. Narcotic and neuromodulator medication use was required transiently in three patients, with complete cessation achieved by 2 months postoperatively. The mean DASH score was 21 ± 8, indicating mild overall disability and good overall hand function. <b>Conclusions:</b> TMR demonstrates significant promise as an effective intervention to reduce symptomatic neuroma formation and associated pain following digit and hand amputation. Successful implementation requires detailed knowledge of hand microsurgical anatomy and expertise in nerve coaptation techniques. Further studies with larger cohorts and longer follow-up are warranted to validate these findings and optimise patient selection. <b>Level of Evidence:</b> Level IV (Therapeutic).