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What I want to do is talk initially about the general management of the military amputee. And I'm talking about surgical management rather than prosthetic management. And then to move on to talk about targeted muscle re innovation being a very new technique to add to our surgical armamentarium. So in the UK military, our patient's coming back from Afghanistan are probably our biggest group of amputees and I want to talk you through their patient pathway. So initially at the time of injury, the patient is taken from the scene to the hospital where the focus is on debride mint, cleaning up the wounds themselves and then subsequently worrying about bone length and soft tissue cover. So our patient's out in Afghanistan were debrided and made safe. We didn't perform soft tissue cover. We simply made safe, removed the contamination and then evacuated by our intensive care aircraft to the Birmingham Queen Elizabeth Hospital, Birmingham. The patient's received treatment for their overall physiology. Many of them were very unwell and soft tissue cover was established by a simplest technique as was possible because they were also physiologically unwell and then they moved on to the rehabilitation unit at Headley court's where we focused on both physical and mental health and the prosthetic rehabilitation. And then once the patient's had stabilized, there was sometimes reasons why we needed to do a further surgical approach. And here at the bottom, right hand corner of my slide is the Queen Victoria Hospital in East Grinstead where I work and this hospital has been associated with the military since the time of the guinea pigs in World War Two. So we would only embark upon further surgery if the patient's were unable to rehabilitate, or there was a factor that was really bothering them from the point of view, perhaps of the limb length decision they had made earlier in their treatment. So he sprinted did I started managing military amputees in approximately 2009. And what I want to share with you is some of my experiences over the last 10 years and what I have learned. So initially my first five years, the majority of the patient's were military amputees. Many of them bilateral. I did manage a number of civilian amputees as it became known that I was someone who would operate and was happy to operate on the problems of amputees and the number of civilians increased. The military patient's with high energy transfer and some of the civilian patient's from road traffic accidents had a lot of problems with excess bone growth over time. We were no longer seeing as many amputees coming back from Afghanistan and by 2016, the majority of my patient's were civilian. So if we now look at what we learned during that, about 10 years, some of them were functional decisions. Some patient's came to me because they wanted to have an amputation. But others because they're functional needs had changed. So this is a patient who elected for a through knee amputation for the high functional benefit. But at a later stage, she was worried by the fact that she could not ride on a bus or an airplane because her femoral length was too long in a prosthesis. And so she was sh opened down to an above knee and accepted the greater energy she would need for every day working. So there are easy reasons why you might wish to do an operation. There may be bone spikes that are clearly causing a problem with the tissue envelope. There were also many patient's who had had skin grafts early on when the limb was very swollen, that when the swelling was all settled, actually had enough soft tissue to allow that skin graft to be removed by a simple cereal excision technique. Many of the patient's however, came to see me because they were in pain and it was important to work out why they were in pain. Sometimes a bone spike is like having a stone in your shoe. There's no point taking medicine, you should take the stone out to make it better there were other things that I found we're not very helpful in the long term. So you can take a floppy stump and tighten it up. But over time they get floppy again. An interesting group are the neuroma patient's because initially there was no management strategy for neuroma other than to cut them away and then wherever you left them, they still came back and we would end up with recurrent neuroma at about 18 months to two years. So with the increasing experience, I decided that really you need to know what it is you're operating on. This is no surprise to those of you that are surgeons. But sometimes we think that if we go in and have a look, we may be able to make the patient better. After 10 years, I can tell you unless you know what you're operating on, you don't make the patient better. And the important thing here was many of these patient's would come to my clinic in a, a lot of pain and want something to be done. And it's very difficult to not be able to do something for a patient in pain. And therefore one is quite tempted to go in and see whether there is a bone spike, whether there is a neuroma that didn't show very well on the investigations. But therefore, it wasn't that I was actively trying to go without an indication. But these patient's are so desperate that we wanted to try and help them at that point. So that was where we were before 2018 in my world when I came across or was introduced by one of my American Navy colleagues, Jason Souza about targeted muscle re innovation and how that would allow us to manage both residual limb pain and phantom limb pain surgically. And this has totally revolutionized my practice over the last few years. So targeted muscle innovation was developed to control myoelectric prostheses. And this was a technique that was brought in initially in America and then um in Vienna in order to allow more effective signaling to a myoelectric prosthesis. So what they found was not only were we able to re innovate muscles but actually doing so improved post amputation pain. So the problem for many of our patient's was both phantom limb pain and also pain in the stump itself often caused by a neuroma, the painful end of the cut nerve. So the technique of targeted muscle re innovation was to take the nerve that is the sensory nerve to divide the nerve and to attach the nerve end to the stump of the motor nerve. And the original um study that was done by the Americans was to compare just putting the end of the nerve in the muscle by itself, but also to do a new, the new technique which was to take that nerve and physically attach it to the stump of the motor nerve. So this nerve therefore would re innovate the muscle using the same motor in plates as the original muscle. So the principle is it gives the nerve somewhere to go and something to do. So there were many studies uh produced. And then the theme in America did a randomized controlled trial to compare just burying the neuroma and the targeted muscle re innovation approach. So they did a randomized control trial and what they found was that targeted muscle re innovation improved the outcome for both phantom pain and residual limb pain in these patient's. What is interesting is this is a very small group. And the reason for that is that the amputees all talked to each other. And after they saw the results, nobody wanted to volunteer to be in the old treatment group. So I started doing a targeted muscle re innovation. TMR in 2019. And I have gradually moved from feeling it was a little bit good to now feeling it's very good. And I offer this now to a considerable number of patient's. I have now done this operation in about 75 or 80 patient's and many of them um just under local anesthetic. So I have been able to offer them to a wide range of patient's. I'm doing the operation with surgical loops rather than a microscope, but still using a nerve stimulator, just a handheld nerve stimulator. And from a pain relief perspective, I put a directly placed peripheral nerve catheter into the main nerve at the end of the operation for postoperative pain relief. What I have found is it takes a lot longer for the patient's to renovate than the American study would suggest. But this is because my patient's are a lot older and a lot less fit. They have many co morbidities. So I find that the patient's are painful for a day or two. Then they have two or three weeks where the pain is much better. And then the renovation will start some patient's. The re innovation lasts for a few weeks. The pain of re innovation. Other patient's it might take six months. I have had patient's who have got considerable improvement as long as two years after their TMR. So the surgery, this is a bologna amputee and this is the popliteal fossa. We start by um dissecting out all the main nerves. And then we confirm the with the nerve stimulator. And so you can see here the different um nerves. So the deeper soleus and the more twitchy superficial, medial and lateral gas stroke. And then what I do is to divide the sensory nerves. The common peroneal is divided at this point and then attached to the lateral gas drop. And then similarly, the main tibial nerve is divided at this point and then attached to the medial gastropathy. And the sural nerve is attached to soleus so that the distal end of the muscle is attached to the proximal end of the sensory nerve. Okay. So to work out whether this technique has been effective, we used the standard pain score. So how painful is your, is it out of 10, the best pain this week and the worst pain this week? But the difficulty with this is if you have one very bad episode of pain, but the rest of the time you're really comfortable, it scores the same as if you have really bad pain all the time and just a few minutes without pain. So we needed a better way. And so we are looking at the total pain burden. So we asked the patient to consider all their pain. So preoperatively, how bad was the pain, both the residual pain and your phantom limb pain added altogether, thinking about the severity, frequency and duration and this is your total pain burden. So then you ask the patient to consider what their pain is now after the surgery compared to what it was when they start. And so this is reported as for instants, I have 75% better. So 25% of the improvement of the pain I used to have or indeed, I only have 10% better and I'm still 90% as bad as I used to be. And that gives us a better feel for the patient's pain. So for all the patient's that had chronic pain in their limbs and had a lot of phantom symptoms and equally the patient's who have a neuroma. We are now doing the targeted muscle re innovation procedure because that manages both neuroma and phantom symptoms. It is helpful to think about the comments of the patient's because although they aren't uh statistically important, it gives you a feel for changing somebody for from their pain being unworkable to their pain, being manageable. So it's important to see that some people get good days and bad days. Some people get short episodes of very bad pain, but overall they are improved, but it's very changeable between patient's. So for many patient's, it is possible to do a stump provisions. For instance, this lady had a big skin graft that I was able to remove by a simple excision and advancement technique and targeted muscle re innovation posteriorly at the same surgery. And this patient had really excruciating phantom pain. And now she only reports 10% of the pain she had pre operatively. So the thing that I have really enjoyed is I can offer an operation that for many of the patient's can manage their pain. Something that in the past has not been possible. We don't know whether it will last. Well, in the long term, the studies that I looked at were only for a few years and I don't know how long my patient's will see the benefit and whether there will be a recurrent neuroma situation and complex regional pain syndrome. I have done a small number of patient's with complex regional pain syndrome. They really suffer during the re innovation. But it does look as if at about 12 months, they do seem to be getting benefit, but it's a very long journey. So does it work for other areas of the body? Well, very much. So, I have had some really good results using this technique and another muscle re innovation technique for bad allodynia in other sites and very good results from those areas too. And as far as complications are concerned, we have had a very small number of complications, mainly hematoma and a skin infection. I've also more recently had one patient who has had some ulceration associated with the numbness that they get after the TMR. But it's not as complete numbness as you would expect and most patient's still have protective um sensation, although I have no idea why they do seem to have it. So I was asked by my commissioners who pay the bill to try this technique in 15 patient's 15. Unfortunately, when I had done the 15 patient's many other patient's wanted the treatment. So I went against my recommendation and did not wait for the few years to see how they did and carried on operating on the next group of patient's and the next group of patient's because when you can see something works, it's very difficult to say no to the next patient. So at the moment, my patient's are doing well. And with the very large cohort now of nearly 100 patient's, I can tell you that the majority feel that it was absolutely worth doing. Most patient's are 50% better or more. And overall, I can't but recommend this fairly straightforward surgery to you for the management of the pain of our patient's. I think the difficulty with doing targeted muscle re innovation as a pain relief for upper limb is that you really should be using it functionally to power your Meyer electorate prosthetic because the difference between two movements and a whole range of movements is very functional. So generally, I would refer my patient to the team that are doing the Meyer electric work. We don't have that option at the queen vic. I haven't done um I haven't done any work on fingers since I've been doing TMR. But certainly my experience at the level of the ankle or in the foot is that I would actually use the technique R P N I regenerative peripheral nerve interface. So putting a small piece of muscle on the end rather than obviously in the finger, there isn't any space. So you can just put a very small piece of dina veetids muscle on the end of a nerve. And I would go with that technique. I think if someone asked me to deal with, with a finger, I would take the nerve, bring it back into the, into the hand and put a small, small free muscle graph probably. But that's theoretical. I've never tried it. I think our P N I is going to be the way forward. But I think there's a difference, there's a huge difference between putting it randomly into a piece of muscle belly as a cushion and actually taking a properly innovated cube of muscle and using the R P N I technique. Um I will never now do a primary amputation without doing TMR. At the same time, I think it's such a good operation and it has a low extra complications. So for every patient that I now do an amputation, I do TMR at the same time as the primary amputation, it gives not only prevention for neuroma, it also gives excellent pain relief post operatively for the amputee. My, the patient's I'm referring to um currently in my practice are not acute amputees. Their patients' for whom a limb salvage has failed. And after many months and years, um they've come to me for a secondary amputation. So for those patients', TMR at the time is absolutely the right thing. It would not be appropriate to do at the time of a the last type amputation. And I think in that situation, it would be sensible to wait for the situation to settle down an infection risk to go down. And that would be probably a number of months before the inflammatory process is settled enough for you to want to go and do a primary, sorry to do A T M R. At that stage. I was talking about secondary amputations for chronic pain rather than primary amputations for trauma. Um I would agree that conventionally, yes, the neuromas do recur and that's why we need a better option. I have not seen any recurrence with TMR. I have seen a number of, well, a couple of patient's where I've had to go back and redo one of the neurorrhaphy is because it hasn't functioned properly. So what we do if the pain is still present is a dynamic, ultrasound, very high quality ultrasound. And you can ask the patient to move their toes or pretend they can move their toes. And you can see if there is transmission and fasciculation in, in the muscle. And then if there is no fasciculation in the muscle, and you can see a neuroma in continuity at your nerve repair, then I've taken down the nerve repair again and reconnected it. And I have done that in three patient's and I'm waiting to see whether it is effective, but I hope it will be the thing I have learned most is it takes a long time for particularly older patient's. And we've seen some patient's who had COVID who's re innovation completely stopped because the nerve growth stopped when they were poorly with COVID. Uh And so some of those patients', people who were unstable diabetes, bad diabetes stop in re innovation in exactly the same way as you would see with a nerve injury generally. Um So sometimes it's wait longer, uh sometimes it's, if it's completely stopped, um, take it down and do it again, I think just that just to clarify my last statement, if the ultrasound showed there was no transmission through that neuroma and no fasciculation, I would do it again. But if my ultrasound shows that there is some movement through it, then I would probably wait and see for a little longer before taking it down.