Targeted muscle reinnervation: considerations for future implementation in adolescents and younger children

Summary: Prosthetic options for patients with proximal upper limb absence are limited. Current above elbow prostheses may restore basic motor functions for crucial activities, but they are cumbersome to operate, lack sensory feedback, and are often abandoned. Targeted muscle reinnervation (TMR) is a novel surgical procedure that enhances the ability of patients with above elbow amputations to intuitively control a myoelectric prosthesis. By transferring multiple severed peripheral nerves to a robust target muscle, TMR restores physiologic continuity and enables more intuitive prosthetic control. Although reports have been limited to adults, TMR has great potential for application in a pediatric population with congenital or acquired proximal upper limb absence. In this review, we describe the rehabilitative challenges of proximal upper limb amputees and outline the objectives, techniques, and outcomes of TMR. We then discuss important considerations for adapting TMR to pediatric patients, including etiology of upper limb absence, central plasticity, timing of prosthesis fitting, role of the family, surgical feasibility, and bioethical aspects. We believe that carefully screened school-aged children and adolescents with bilateral proximal upper limb absence, as well as adolescents with unilateral proximal upper limb absence, should be seriously considered for TMR by an experienced surgical and rehabilitation team. Financial Disclosure Statement: The authors have nothing to disclose. Corresponding Author: Dr. Gregory Borschel, MD, FACS, FAAP , Associate Professor, Division of Plastic & Reconstructive Surgery, Assistant Professor, Institute of Biomaterials and Biomedical Engineering, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Room 5547, Hill Wing, Toronto, ON M5G 1X8, Tel: (416) 813-7654, ext. 228197, Fax: (416) 813-6637, Email: gregory.borschel@sickkids.ca ©2018American Society of Plastic Surgeons