A Single Incision Anterior Approach for Transhumeral Amputation Targeted Muscle Reinnervation

Abstract

Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.

Fig. 1.

After raising full-thickness skin flaps, distal dissection revealed a large neuroma of the median nerve (A). Dissection of the musculocutaneous nerve revealed a brachialis branch (B) and biceps branch (C), both tagged here with white vessel loops. D, Medial antebrachial cutaneous nerve.

Fig. 2.

Anterior access for posterior nerve transfers. The main trunk of the radial nerve (B, tagged here with a penrose drain) does not stimulate muscular contraction in this transhumeral amputee and, therefore, is considered a suitable sensory donor for transfer to a recipient motor nerve, such as the lateral head of triceps branch of the radial nerve (A) in this case. A, Lateral head of triceps branch of radial nerve. B, Radial nerve main trunk. C, Median nerve. D, Ulnar nerve. E, Medial antebrachial cutaneous nerve.

Fig. 3.

Posterior nerve transfer safely completed from the anterior approach (A). Here, the radial nerve main trunk (sensory nerve donor) has been coapted to the lateral head triceps branch of the radial nerve (motor nerve recipient). Note the size mismatch between donor and recipient nerves in this transfer. B, Median nerve. C, Ulnar nerve.

Fig. 4.

Inset of proximally based local muscle flap (B) for vascularized RPNI coverage of the radial nerve to lateral head triceps branch of radial nerve transfer (A), which may potentially limit axonal escape in the setting of size mismatch between nerve transfer donor and recipient. C, Ulnar nerve. RPNI indicates regenerative peripheral nerve interface implantation.