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American Association for Hand Surgery

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Targeted motor reinnervation (TMR) for hand and wrist post traumatic neuroma pain, case series and surgical techniques.
Madi El Haj, MD. MSc.1, Shahar Tal, Medical Student2, Sofia Anastasia Vorobeitchik, RA3, Ido Volk, MD4 and Shai Luria, MD4, (1)Hadassah Hebrew University medical school, Jerusalem, Israel, (2)Hebrew University, Jerusalem, Israel, (3)Hadassah Hebrew University Medical Center, Jerusalem, Israel, (4)Orthropaedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Targeted motor reinnervation (TMR) has emerged as a promising technique for prevention of neuroma formation following major limb loss. Treatment of a painful neuroma of the hand was previously reported in one case report. The aim of the study was to present a variety of other surgical techniques for digital, ulnar sensory and radial sensory post traumatic neuromas in the hand and wrist in patients with intractable pain, following failed previous surgical attempts.
Methods:
This is a retrospective review of all patients with symptomatic neuromas treated with different TMR surgical techniques from April 2019 to May 2021. Pain and motor function of donor motor nerves were evaluated using two tailed paired student t-test.

Results: The following table summarizes the patient's data


Patient #


Age/Sex


Injured side


Course of pain (months)


previous surgeries


Injured nerve


Surgical Procedure


1


29/F


Non dominant


13


1


SBRN


SBRN to AIN


2


44/M


Dominant


16


1


RRF UDN, RDN


UDN RDN to 2ND 3RDLumbrical


3


58/M


Dominant


47


3


Thumb RDN, UDN


1st lumbrical


4


54/M


Non dominant


28


1


DCU


DCU to AIN


5


21/M


Non dominant


21


1


LRF RDN


UDN to 3rdlumbrical


6


26/M


Dominant


47


3


LRF UDN


UDN to 4thlumbrical


7


44/M


Non dominant


71


6


SBRN


SBRN to Brachioradialis Branch


8


39/F


Non dominant


4


1


RRF RDN


RDN to 4thLumbrical


9


47/F


Non dominant


27


3


LIF RDN


RDN to 1stlumbrical


10


62/M


Non dominant


100


8


DCU


DCU to AIN


, VAS score improved significantly post-operatively (8.82 vs 6.2; P=0.001). Motor deficits due to the sacrifice of motor branches were undetectable.
Conclusion: TMR is reasonable salvage technique to prevent neuromatic pain following failed attempts of reconstructive procedures.

Figure 1: A previous scar B- (SBRN-1) distal neuroma C- coaptation of SRBN-1 (donor) with the (AIN) (recipient)
Figure -2 : A- volar ulnar incision. B- dorso-ulnar incision C- DCU neuroma. D-coaptation of DCU (donor) with the AIN (recipient)
Figure 3 A - Henry approach B- neuroma of the SBRN. C- motor branch to brachioradialis. D- coaptation of SRBN (donor) with the brachioradialis (recipient).
Figure 4: A- incision, B- UDN neuroma C- motor branch to the 3rd lumbrical D- nerve coaptation of the digital nerve (donor) to the 3rd lumbrical motor branch (recipient)
Figure 5: A- incision, B-UDN and RDN neuroma long finger B- coaptation of the digital nerves (donors) to the 2nd and 3rd lumbrical motor branch (recipients)





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