Gregory Dumanian - Profile on Academia.edu (original) (raw)
Papers by Gregory Dumanian
Neurosurgery, Sep 1, 2018
INTRODUCTION: Trigeminal neuralgia (TN) is a complex neuropathic pain condition. Neurosurgical do... more INTRODUCTION: Trigeminal neuralgia (TN) is a complex neuropathic pain condition. Neurosurgical dogma has stressed the role of vascular compression of the trigeminal ganglion or nerve root in the pathogenesis of TN, reinforcing the use of invasive microvascular decompression (MVD) for treatment. However, the symptoms of many patients with TN are recalcitrant to MVD, and other TN patients are disturbingly found to have no vascular compression at the time of surgery, suggesting other factors. It has long been long recognized that familial forms of TN exist, but to date no gene associated with TN has been definitely identified. METHODS: Exome capture was performed on genomic DNA samples isolated from 131 unrelated TN probands, including case-parent trios (total n = 215). Sequencing reads were aligned to the human reference genome and further processed for variant calling. Variants were annotated with ANNOVAR. MetaSVM was used to predict the deleteriousness of missense mutations. Enrichment detection for rare damaging mutations was performed using binomial analysis. RESULTS: Gene burden analysis revealed genome-wide significant enrichment of rare damaging mutations in one member of the calcium voltage-gated channel proteins (n = 6; 4.5%; P-value = 9.21 × 10 -7 ) among patients with MVD-resistant TN. Additionally, a considerably significant rare damaging mutation burden was found in a gene belonging to the basic helix-loop-helix (bHLH) family of transcription factors highly expressed in trigeminal pain pathways (n = 3, Pvalue = 1.72 × 10 -5 ). A novel, damaging de novo mutation was also identified in a GABA receptor subunit in an MVD-resistant patient. CONCLUSION: This work represents the first exome-sequenced TN cohort in the world, and uncovers genetic determinants and molecular mechanisms underlying TN pathogenesis. These findings suggest (1) microvascular compression is an incomplete explanation for TN pathogenesis; (2) some patients with gene mutations may not benefit from MVD; and (3) specific ion transport molecules may be potential pharmacotherapeutic targets.
Kiteboarding Induced Abdominal Wall Pain: Intercostal Neuroma versus Anterior Cutaneous Nerve Entrapment (ACNES)
Plastic and Reconstructive Surgery - Global Open
Summary: Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can hav... more Summary: Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can have similar presentations. Anterior cutaneous nerve entrapment syndrome has been reported to be a significant cause of AWP. Here, we report the case of a patient who was initially diagnosed with anterior cutaneous nerve entrapment syndrome and ultimately found to have intercostal neuromas-in-continuity. The patient was a healthy 36-year-old man who presented with debilitating, chronic abdominal wall pain. The pain began after a time period when the patient was regularly kiteboarding, and it impacted the ability to exercise and perform activities of daily living. The patient had undergone extensive testing and attempted many treatments, including medication, nerve blocks, and anterior cutaneous nerve entrapment syndrome surgery. Examination was significant for 2 near-symmetric areas that were persistently tender to palpation in the subcostal abdomen. The patient underwent excision and recon...
PLOS ONE
Background Despite the growing availability of multifunctional prosthetic hands, users’ control a... more Background Despite the growing availability of multifunctional prosthetic hands, users’ control and overall functional abilities with these hands remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputations (i.e., shoulder disarticulation and transhumeral amputation). Objective The goal of this study was to determine if prosthesis hand grasp control improves following transradial TMR surgery. Methods Eight participants were trained to use a multi-articulating hand prosthesis under myoelectric pattern recognition control. All participated in home usage trials pre- and post-TMR surgery. Upper limb outcome measures were collected following each home trial. Results Three outcome measures (Southampton Hand Assessment Proc...
Transradial amputation is the most common level of major upper limb amputation. Despite the growi... more Transradial amputation is the most common level of major upper limb amputation. Despite the growing availability of multifunctional prosthetic hands, users’ control of these hands and overall functional abilities remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputation levels (i.e., shoulder disarticulation and transhumeral amputation). The goal of this study was to determine if similar prosthesis control improvements could be seen for individuals with amputations at the transradial level. Participants controlled 3-5 grips with a multi-articulating hand prosthesis under myoelectric pattern recognition control for at least 8 weeks at home pre- and post-TMR surgery. Users gained some significant functional control b...
Plastic and Reconstructive Surgery - Global Open, 2021
Background: Neuromas are an under-recognized contributor to chronic abdominal pain. Other than af... more Background: Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature. Methods: All patients who underwent surgical treatment for painful abdominal wall neuromas by the senior author at Northwestern Memorial Hospital were reviewed. Patients were treated with neuroma excision and allograft nerve reconstruction and/or with targeted muscle reinnervation (TMR). Follow-up pain surveys were issued to assess pain levels, activities of daily living, and pain medication usage. Results: Twenty patients met inclusion criteria. Eighteen (90%) patients reported improvement in neuropathic pain postoperatively. Two (10%) patients had TMR following failed nerve allograft reconstruction, which led to complete pain resolution. Twenty-seven nerves were treated surgically, the majority of which were abdominal intercostal (13), followed by ili...
Plastic & Reconstructive Surgery, 2018
Summary: The ultimate tensile strength of newly apposed tissue is the sum of the strength of the ... more Summary: The ultimate tensile strength of newly apposed tissue is the sum of the strength of the physical construct holding the tissues and the strength of biologic healing. For successful incisional hernia repair, the total strength of the repair must remain greater than the forces applied. While much work has been done to understand the science of wound healing—the ability of an open defect to contract and close—far less has been done to understand the healing of 2 newly approximated previously nonwounded surfaces held together with sutures or other implants. In this article, the elements of ultimate tensile strength on laparotomy closure as well as their progression over time will be related to clinical studies of abdominal wall closure.
The American Surgeon, 2009
Massive ventral hernia repairs are sometimes complicated by the “loss of domain.” The separation ... more Massive ventral hernia repairs are sometimes complicated by the “loss of domain.” The separation of parts hernia repair reverses the loss of domain by increasing intra-abdominal volume, but not by elevating the hemidiaphragms into the thoracic cavity. Hernia repair in patients with a “loss of abdominal domain” is thought to be associated with postoperative pulmonary difficulties. A retrospective chart review was performed on 102 patients treated by a single surgeon. The 10 patients with matching preoperative and postoperative abdominal CT scans were computer-analyzed for intra-abdominal volume changes and diaphragm height measurements. Postoperative pulmonary complications in these 102 patients were recorded. Intra-abdominal volume increased after separation of parts hernia repair from 8600 ± 2800 mL to 9700 ± 2700 mL ( P = 0.01). Diaphragm height did not statistically change. Two of the 102 patients had prolonged intubations, and seven other patients were ventilated briefly. The se...
Journal of the American College of Surgeons, 2019
BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chroni... more BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain. STUDY DESIGN: A multi-institutional cohort study was conducted between 2012 and 2018. Fifty-one patients undergoing major limb amputation with immediate TMR were compared with 438 unselected major limb amputees. Primary outcomes included an 11-point Numerical Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behavior, and interference. Patients who underwent TMR had less PLP and residual limb pain compared with untreated amputee controls, across all subgroups and by all measures. Median "worst pain in the past 24 hours" for the TMR cohort was 1 out of 10 compared to 5 (PLP) and 4 (residual) out of 10 in the control population (p ¼ 0.003 and p < 0.001, respectively). Median PROMIS t-scores were lower in TMR patients for both PLP (pain intensity [36.3 vs 48.3], pain behavior [50.1 vs 56.6], and pain interference [40.7 vs 55.8]) and residual limb pain (pain intensity [30.7 vs 46.8], pain behavior [36.7 vs 57.3], and pain interference [40.7 vs 57.3]). Targeted muscle reinnervation was associated with 3.03 (PLP) and 3.92 (residual) times higher odds of decreasing pain severity compared with general amputee participants. CONCLUSIONS: Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain. (
Plastic and Reconstructive Surgery - Global Open, 2018
Background: Excess residual limb fat is a common problem that can impair prosthesis control and n... more Background: Excess residual limb fat is a common problem that can impair prosthesis control and negatively impact gait. In the general population, thighplasty and liposuction are commonly performed for cosmetic reasons but not specifically to improve function in amputees. The objective of this study was to determine if these procedures could enhance prosthesis fit and function in an overweight above-knee amputee. Methods: We evaluated the use of these techniques on a 50-year-old transfemoral amputee who was overweight. The patient underwent presurgical imaging and tests to measure her residual limb tissue distribution, socket-limb interface stiffness, residual femur orientation, lower-extremity function, and prosthesis satisfaction. A medial thighplasty procedure with circumferential liposuction was performed, during which 2,812 g (6.2 lbs.) of subcutaneous fat and skin was removed from her residual limb. Imaging was repeated 5 months postsurgery; functional assessments were repeate...
Surgery, Aug 25, 2018
Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and ... more Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and is associated with high morbidity, decreased quality of life, and high costs. The International Symposium on Incisional Hernia Prevention was held October 19-20, 2017, at the InterContinental Hotel in San Francisco, CA, hosted by the Department of Surgery, University of California, San Francisco. One hundred and three attendees included general and plastic surgeons from 9 countries, including principal participants for several of the seminal studies in the field. Over the course of the 2-day meeting, there were 38 oral presentations, 3 keynote lectures, and 2 panel discussions. The Symposium was a combination of new information but also a comprehensive review of the existing data so as to assess the current state of the field and to set the stage for future research. Further, the Symposium sought to increase awareness and thus emphasize the importance of preventing the formation of incis...
Neurosurgical focus: Video, 2023
In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower... more In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower limb. This results in residual limb pain in up to 85% of cases. Targeted muscle reinnervation (TMR) is a technique that has been shown to prevent symptomatic neuroma formation. In this video, the authors demonstrate their technique utilizing TMR at the time of above-the-knee amputation. Coaptations are made to provide motor targets for branches of the saphenous, tibial, and peroneal sensory nerves. At the featured patient's most recent follow-up visit 3 months postoperatively, she reported no stump pain or phantom limb pain.
427.8: Patient Definitions of Transplant “Success” of Upper Extremity VCA
Transplantation
Within Reach -- A Patient-Centered Website to Foster Informed Decision Making about Upper Extremity Vascularized Composite Allotransplantation: Development and Usability Testing (Preprint)
BACKGROUND Upper extremity (UE) vascularized composite allotransplantation (VCA) (hand transplant... more BACKGROUND Upper extremity (UE) vascularized composite allotransplantation (VCA) (hand transplantation) is a reconstructive treatment option for patients with upper extremity loss. Approximately 37 UE VCAs have been performed in the U.S. to date, thus little is known about long-term psychosocial outcomes and whether benefits outweigh risks. To make an informed treatment decision, patients must understand the procedure, risks, and potential benefits of UE VCA. However, few educational resources are publicly available that provide unbiased, comprehensive information about UE VCA. OBJECTIVE This paper describes the development of a neutral, accessible and ADA-compliant educational website supporting informed decision-making about UE VCA as a treatment option for individuals with UE amputations. METHODS Website content development was informed by 9 focus groups conducted with civilians and military service members with UE amputations at three study sites (Northwestern University, Johns ...
With the increasing availability of more advanced prostheses individuals with a transradial amput... more With the increasing availability of more advanced prostheses individuals with a transradial amputation can now be fit with single to multi-degree of freedom hands. Reliable and accurate control of these multi-grip hands still remains challenging. This is the first multi-user study to investigate at-home control and use of a multi-grip hand prosthesis under pattern recognition and direct control. Individuals with a transradial amputation were fitted with and trained to use an OSSUR i-Limb Ultra Revolution with Coapt COMPLETE CONTROL system. They participated in two 8-week home trials using the hand under myoelectric direct and pattern recognition control in a randomized order. While at home, participants demonstrated broader usage of grips in pattern recognition compared to direct control. After the home trial, they showed significant improvements in the Assessment of Capacity for Myoelectric Control (ACMC) outcome measure while using pattern recognition control compared to direct co...
Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication
Plastic and Reconstructive Surgery - Global Open, 2021
Background: Concerns regarding infection, extrusion, and pain have traditionally precluded the us... more Background: Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. Methods: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last ...
Plastic & Reconstructive Surgery, 2020
Learning Objectives: After reading this article, the participants should be able to: 1. List curr... more Learning Objectives: After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fash...
Discussion: Measuring Success in Complex Abdominal Wall Reconstruction: The Role of Validated Outcome Scales
Plastic & Reconstructive Surgery, 2018
Microsurgery, 2020
Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined b... more Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. Patients and methods: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an aboveknee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). Results: There were no complications related to the TMR procedure. Average followup time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. Conclusion: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function. 1 | INTRODUCTION Complex regional pain syndrome (CRPS) is the descriptive term for a constellation of symptoms and signs that present after trauma to the extremity. CRPS has historically been known by different names, including reflex sympathetic dystrophy (RSD), causalgia, and Sudeck's dystrophy (Ratti, Nordio, Resmini, & Murena, 2015). The most widely accepted criteria for CRPS is the Budapest criteria, which includes pain, the presence of signs and symptoms in four domains (e.g., sensory, vasomotor, edema, and motor), and the lack of another diagnosis that explains the presentation (Veldman, Reynen, Arntz, & Goris, 1993). CRPS is classified into two types: type I (RSD) is not associated with a specific nerve injury, whereas type II (causalgia) has a nerve injury identifiable by diagnostic testing (Duman et al., 2007).
Prosthetics & Orthotics International, 2004
A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient w... more A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient with bilateral amputations at the shoulder disarticulation level. Four independently controlled nerve-muscle units were created by surgically anastomosing residual brachial plexus nerves to dissected and divided aspects of the pectoralis major and minor muscles. The musculocutaneous nerve was anastomosed to the upper pectoralis major; the median nerve was transferred to the middle pectoralis major region; the radial nerve was anastomosed to the lower pectoralis major region; and the ulnar nerve was transferred to the pectoralis minor muscle which was moved out to the lateral chest wall. After five months, three nerve-muscle units were successful (the musculocutaneous, median and radial nerves) in that a contraction could be seen, felt and a surface electromyogram (EMG) could be recorded. Sensory reinnervation also occurred on the chest in an area where the subcutaneous fat was removed. Th...
Plastic & Reconstructive Surgery, 2019
Background: The topographic distribution through histologic analysis of motor and sensory axons w... more Background: The topographic distribution through histologic analysis of motor and sensory axons within peripheral nerves at the brachial plexus level is not clearly defined, as there has previously been little need to appreciate this microanatomy. A desire to better understand the topography of fascicle groups developed with the introduction of targeted muscle reinnervation. Methods: Fourteen bilateral brachial plexus specimens from seven fresh human cadavers were harvested at the time of organ donation, and immunofluorescent staining of motor and sensory nerves with choline acetyltransferase and Neurofilament 200 was performed to determine whether a consistent somatotopic orientation exists at the brachial plexus level. Results: There was significant variability in the number of fascicles at the level of the brachial plexus. Qualitative analysis of choline acetyltransferase staining demonstrated that although motor axons tended to be grouped in clusters, there were high degrees of variability in somatotopic orientation across specimens. The radial nerve demonstrated the highest number of total myelinated axons, whereas the median nerve exhibited the greatest number of motor axons. The ulnar nerve contained only 13 percent motor axons, which was significantly lower than the median, radial, and musculocutaneous nerves. Conclusions: There was no consistent somatotopic organization of motor and sensory axons of the mixed major nerves of the arm just distal to the brachial plexus, but clustering of motor axons may facilitate the splitting of nerves into primarily "motor" and "sensory" fascicles.
Neurosurgery, Sep 1, 2018
INTRODUCTION: Trigeminal neuralgia (TN) is a complex neuropathic pain condition. Neurosurgical do... more INTRODUCTION: Trigeminal neuralgia (TN) is a complex neuropathic pain condition. Neurosurgical dogma has stressed the role of vascular compression of the trigeminal ganglion or nerve root in the pathogenesis of TN, reinforcing the use of invasive microvascular decompression (MVD) for treatment. However, the symptoms of many patients with TN are recalcitrant to MVD, and other TN patients are disturbingly found to have no vascular compression at the time of surgery, suggesting other factors. It has long been long recognized that familial forms of TN exist, but to date no gene associated with TN has been definitely identified. METHODS: Exome capture was performed on genomic DNA samples isolated from 131 unrelated TN probands, including case-parent trios (total n = 215). Sequencing reads were aligned to the human reference genome and further processed for variant calling. Variants were annotated with ANNOVAR. MetaSVM was used to predict the deleteriousness of missense mutations. Enrichment detection for rare damaging mutations was performed using binomial analysis. RESULTS: Gene burden analysis revealed genome-wide significant enrichment of rare damaging mutations in one member of the calcium voltage-gated channel proteins (n = 6; 4.5%; P-value = 9.21 × 10 -7 ) among patients with MVD-resistant TN. Additionally, a considerably significant rare damaging mutation burden was found in a gene belonging to the basic helix-loop-helix (bHLH) family of transcription factors highly expressed in trigeminal pain pathways (n = 3, Pvalue = 1.72 × 10 -5 ). A novel, damaging de novo mutation was also identified in a GABA receptor subunit in an MVD-resistant patient. CONCLUSION: This work represents the first exome-sequenced TN cohort in the world, and uncovers genetic determinants and molecular mechanisms underlying TN pathogenesis. These findings suggest (1) microvascular compression is an incomplete explanation for TN pathogenesis; (2) some patients with gene mutations may not benefit from MVD; and (3) specific ion transport molecules may be potential pharmacotherapeutic targets.
Kiteboarding Induced Abdominal Wall Pain: Intercostal Neuroma versus Anterior Cutaneous Nerve Entrapment (ACNES)
Plastic and Reconstructive Surgery - Global Open
Summary: Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can hav... more Summary: Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can have similar presentations. Anterior cutaneous nerve entrapment syndrome has been reported to be a significant cause of AWP. Here, we report the case of a patient who was initially diagnosed with anterior cutaneous nerve entrapment syndrome and ultimately found to have intercostal neuromas-in-continuity. The patient was a healthy 36-year-old man who presented with debilitating, chronic abdominal wall pain. The pain began after a time period when the patient was regularly kiteboarding, and it impacted the ability to exercise and perform activities of daily living. The patient had undergone extensive testing and attempted many treatments, including medication, nerve blocks, and anterior cutaneous nerve entrapment syndrome surgery. Examination was significant for 2 near-symmetric areas that were persistently tender to palpation in the subcostal abdomen. The patient underwent excision and recon...
PLOS ONE
Background Despite the growing availability of multifunctional prosthetic hands, users’ control a... more Background Despite the growing availability of multifunctional prosthetic hands, users’ control and overall functional abilities with these hands remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputations (i.e., shoulder disarticulation and transhumeral amputation). Objective The goal of this study was to determine if prosthesis hand grasp control improves following transradial TMR surgery. Methods Eight participants were trained to use a multi-articulating hand prosthesis under myoelectric pattern recognition control. All participated in home usage trials pre- and post-TMR surgery. Upper limb outcome measures were collected following each home trial. Results Three outcome measures (Southampton Hand Assessment Proc...
Transradial amputation is the most common level of major upper limb amputation. Despite the growi... more Transradial amputation is the most common level of major upper limb amputation. Despite the growing availability of multifunctional prosthetic hands, users’ control of these hands and overall functional abilities remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputation levels (i.e., shoulder disarticulation and transhumeral amputation). The goal of this study was to determine if similar prosthesis control improvements could be seen for individuals with amputations at the transradial level. Participants controlled 3-5 grips with a multi-articulating hand prosthesis under myoelectric pattern recognition control for at least 8 weeks at home pre- and post-TMR surgery. Users gained some significant functional control b...
Plastic and Reconstructive Surgery - Global Open, 2021
Background: Neuromas are an under-recognized contributor to chronic abdominal pain. Other than af... more Background: Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature. Methods: All patients who underwent surgical treatment for painful abdominal wall neuromas by the senior author at Northwestern Memorial Hospital were reviewed. Patients were treated with neuroma excision and allograft nerve reconstruction and/or with targeted muscle reinnervation (TMR). Follow-up pain surveys were issued to assess pain levels, activities of daily living, and pain medication usage. Results: Twenty patients met inclusion criteria. Eighteen (90%) patients reported improvement in neuropathic pain postoperatively. Two (10%) patients had TMR following failed nerve allograft reconstruction, which led to complete pain resolution. Twenty-seven nerves were treated surgically, the majority of which were abdominal intercostal (13), followed by ili...
Plastic & Reconstructive Surgery, 2018
Summary: The ultimate tensile strength of newly apposed tissue is the sum of the strength of the ... more Summary: The ultimate tensile strength of newly apposed tissue is the sum of the strength of the physical construct holding the tissues and the strength of biologic healing. For successful incisional hernia repair, the total strength of the repair must remain greater than the forces applied. While much work has been done to understand the science of wound healing—the ability of an open defect to contract and close—far less has been done to understand the healing of 2 newly approximated previously nonwounded surfaces held together with sutures or other implants. In this article, the elements of ultimate tensile strength on laparotomy closure as well as their progression over time will be related to clinical studies of abdominal wall closure.
The American Surgeon, 2009
Massive ventral hernia repairs are sometimes complicated by the “loss of domain.” The separation ... more Massive ventral hernia repairs are sometimes complicated by the “loss of domain.” The separation of parts hernia repair reverses the loss of domain by increasing intra-abdominal volume, but not by elevating the hemidiaphragms into the thoracic cavity. Hernia repair in patients with a “loss of abdominal domain” is thought to be associated with postoperative pulmonary difficulties. A retrospective chart review was performed on 102 patients treated by a single surgeon. The 10 patients with matching preoperative and postoperative abdominal CT scans were computer-analyzed for intra-abdominal volume changes and diaphragm height measurements. Postoperative pulmonary complications in these 102 patients were recorded. Intra-abdominal volume increased after separation of parts hernia repair from 8600 ± 2800 mL to 9700 ± 2700 mL ( P = 0.01). Diaphragm height did not statistically change. Two of the 102 patients had prolonged intubations, and seven other patients were ventilated briefly. The se...
Journal of the American College of Surgeons, 2019
BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chroni... more BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain. STUDY DESIGN: A multi-institutional cohort study was conducted between 2012 and 2018. Fifty-one patients undergoing major limb amputation with immediate TMR were compared with 438 unselected major limb amputees. Primary outcomes included an 11-point Numerical Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behavior, and interference. Patients who underwent TMR had less PLP and residual limb pain compared with untreated amputee controls, across all subgroups and by all measures. Median "worst pain in the past 24 hours" for the TMR cohort was 1 out of 10 compared to 5 (PLP) and 4 (residual) out of 10 in the control population (p ¼ 0.003 and p < 0.001, respectively). Median PROMIS t-scores were lower in TMR patients for both PLP (pain intensity [36.3 vs 48.3], pain behavior [50.1 vs 56.6], and pain interference [40.7 vs 55.8]) and residual limb pain (pain intensity [30.7 vs 46.8], pain behavior [36.7 vs 57.3], and pain interference [40.7 vs 57.3]). Targeted muscle reinnervation was associated with 3.03 (PLP) and 3.92 (residual) times higher odds of decreasing pain severity compared with general amputee participants. CONCLUSIONS: Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain. (
Plastic and Reconstructive Surgery - Global Open, 2018
Background: Excess residual limb fat is a common problem that can impair prosthesis control and n... more Background: Excess residual limb fat is a common problem that can impair prosthesis control and negatively impact gait. In the general population, thighplasty and liposuction are commonly performed for cosmetic reasons but not specifically to improve function in amputees. The objective of this study was to determine if these procedures could enhance prosthesis fit and function in an overweight above-knee amputee. Methods: We evaluated the use of these techniques on a 50-year-old transfemoral amputee who was overweight. The patient underwent presurgical imaging and tests to measure her residual limb tissue distribution, socket-limb interface stiffness, residual femur orientation, lower-extremity function, and prosthesis satisfaction. A medial thighplasty procedure with circumferential liposuction was performed, during which 2,812 g (6.2 lbs.) of subcutaneous fat and skin was removed from her residual limb. Imaging was repeated 5 months postsurgery; functional assessments were repeate...
Surgery, Aug 25, 2018
Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and ... more Incisional hernia is a frequent complication of midline laparotomy and enterostomal creation and is associated with high morbidity, decreased quality of life, and high costs. The International Symposium on Incisional Hernia Prevention was held October 19-20, 2017, at the InterContinental Hotel in San Francisco, CA, hosted by the Department of Surgery, University of California, San Francisco. One hundred and three attendees included general and plastic surgeons from 9 countries, including principal participants for several of the seminal studies in the field. Over the course of the 2-day meeting, there were 38 oral presentations, 3 keynote lectures, and 2 panel discussions. The Symposium was a combination of new information but also a comprehensive review of the existing data so as to assess the current state of the field and to set the stage for future research. Further, the Symposium sought to increase awareness and thus emphasize the importance of preventing the formation of incis...
Neurosurgical focus: Video, 2023
In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower... more In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower limb. This results in residual limb pain in up to 85% of cases. Targeted muscle reinnervation (TMR) is a technique that has been shown to prevent symptomatic neuroma formation. In this video, the authors demonstrate their technique utilizing TMR at the time of above-the-knee amputation. Coaptations are made to provide motor targets for branches of the saphenous, tibial, and peroneal sensory nerves. At the featured patient's most recent follow-up visit 3 months postoperatively, she reported no stump pain or phantom limb pain.
427.8: Patient Definitions of Transplant “Success” of Upper Extremity VCA
Transplantation
Within Reach -- A Patient-Centered Website to Foster Informed Decision Making about Upper Extremity Vascularized Composite Allotransplantation: Development and Usability Testing (Preprint)
BACKGROUND Upper extremity (UE) vascularized composite allotransplantation (VCA) (hand transplant... more BACKGROUND Upper extremity (UE) vascularized composite allotransplantation (VCA) (hand transplantation) is a reconstructive treatment option for patients with upper extremity loss. Approximately 37 UE VCAs have been performed in the U.S. to date, thus little is known about long-term psychosocial outcomes and whether benefits outweigh risks. To make an informed treatment decision, patients must understand the procedure, risks, and potential benefits of UE VCA. However, few educational resources are publicly available that provide unbiased, comprehensive information about UE VCA. OBJECTIVE This paper describes the development of a neutral, accessible and ADA-compliant educational website supporting informed decision-making about UE VCA as a treatment option for individuals with UE amputations. METHODS Website content development was informed by 9 focus groups conducted with civilians and military service members with UE amputations at three study sites (Northwestern University, Johns ...
With the increasing availability of more advanced prostheses individuals with a transradial amput... more With the increasing availability of more advanced prostheses individuals with a transradial amputation can now be fit with single to multi-degree of freedom hands. Reliable and accurate control of these multi-grip hands still remains challenging. This is the first multi-user study to investigate at-home control and use of a multi-grip hand prosthesis under pattern recognition and direct control. Individuals with a transradial amputation were fitted with and trained to use an OSSUR i-Limb Ultra Revolution with Coapt COMPLETE CONTROL system. They participated in two 8-week home trials using the hand under myoelectric direct and pattern recognition control in a randomized order. While at home, participants demonstrated broader usage of grips in pattern recognition compared to direct control. After the home trial, they showed significant improvements in the Assessment of Capacity for Myoelectric Control (ACMC) outcome measure while using pattern recognition control compared to direct co...
Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication
Plastic and Reconstructive Surgery - Global Open, 2021
Background: Concerns regarding infection, extrusion, and pain have traditionally precluded the us... more Background: Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. Methods: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last ...
Plastic & Reconstructive Surgery, 2020
Learning Objectives: After reading this article, the participants should be able to: 1. List curr... more Learning Objectives: After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fash...
Discussion: Measuring Success in Complex Abdominal Wall Reconstruction: The Role of Validated Outcome Scales
Plastic & Reconstructive Surgery, 2018
Microsurgery, 2020
Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined b... more Background: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. Patients and methods: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an aboveknee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). Results: There were no complications related to the TMR procedure. Average followup time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. Conclusion: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function. 1 | INTRODUCTION Complex regional pain syndrome (CRPS) is the descriptive term for a constellation of symptoms and signs that present after trauma to the extremity. CRPS has historically been known by different names, including reflex sympathetic dystrophy (RSD), causalgia, and Sudeck's dystrophy (Ratti, Nordio, Resmini, & Murena, 2015). The most widely accepted criteria for CRPS is the Budapest criteria, which includes pain, the presence of signs and symptoms in four domains (e.g., sensory, vasomotor, edema, and motor), and the lack of another diagnosis that explains the presentation (Veldman, Reynen, Arntz, & Goris, 1993). CRPS is classified into two types: type I (RSD) is not associated with a specific nerve injury, whereas type II (causalgia) has a nerve injury identifiable by diagnostic testing (Duman et al., 2007).
Prosthetics & Orthotics International, 2004
A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient w... more A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient with bilateral amputations at the shoulder disarticulation level. Four independently controlled nerve-muscle units were created by surgically anastomosing residual brachial plexus nerves to dissected and divided aspects of the pectoralis major and minor muscles. The musculocutaneous nerve was anastomosed to the upper pectoralis major; the median nerve was transferred to the middle pectoralis major region; the radial nerve was anastomosed to the lower pectoralis major region; and the ulnar nerve was transferred to the pectoralis minor muscle which was moved out to the lateral chest wall. After five months, three nerve-muscle units were successful (the musculocutaneous, median and radial nerves) in that a contraction could be seen, felt and a surface electromyogram (EMG) could be recorded. Sensory reinnervation also occurred on the chest in an area where the subcutaneous fat was removed. Th...
Plastic & Reconstructive Surgery, 2019
Background: The topographic distribution through histologic analysis of motor and sensory axons w... more Background: The topographic distribution through histologic analysis of motor and sensory axons within peripheral nerves at the brachial plexus level is not clearly defined, as there has previously been little need to appreciate this microanatomy. A desire to better understand the topography of fascicle groups developed with the introduction of targeted muscle reinnervation. Methods: Fourteen bilateral brachial plexus specimens from seven fresh human cadavers were harvested at the time of organ donation, and immunofluorescent staining of motor and sensory nerves with choline acetyltransferase and Neurofilament 200 was performed to determine whether a consistent somatotopic orientation exists at the brachial plexus level. Results: There was significant variability in the number of fascicles at the level of the brachial plexus. Qualitative analysis of choline acetyltransferase staining demonstrated that although motor axons tended to be grouped in clusters, there were high degrees of variability in somatotopic orientation across specimens. The radial nerve demonstrated the highest number of total myelinated axons, whereas the median nerve exhibited the greatest number of motor axons. The ulnar nerve contained only 13 percent motor axons, which was significantly lower than the median, radial, and musculocutaneous nerves. Conclusions: There was no consistent somatotopic organization of motor and sensory axons of the mixed major nerves of the arm just distal to the brachial plexus, but clustering of motor axons may facilitate the splitting of nerves into primarily "motor" and "sensory" fascicles.