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Di Valerio et al. Plast Aesthet Res 2022;9:62 https://dx.doi.org/10.20517/2347-9264.2022.50 Page 3 of 10

section as part of the systematic screening process to identify articles that may have been missed by the
original search query. Articles were chosen based on the following criteria: (1) studies were clinical studies
on TMR; (2) studies included greater than one subject; (3) studies were either case-controls, comparative
cohort analyses, controlled trials, or randomized controlled trials; and (4) studies included one or more
outcomes of interest. Outcomes of interest included: prosthetic use and functionality, improvement or
persistence of pain, indications, complications, donor nerves, and technical aspects of TMR. Case reports
and letters to the editor were excluded. There were no restrictions on the year of publication. After the
articles identified through the original query through the PubMed database were screened, the full-text
articles were assessed for eligibility and inclusion in qualitative synthesis. Twenty-seven additional articles
were surveyed from “Similar Articles”; of the 615 total studies, 9 studies met the final inclusion criteria
[Figure 1]. In accordance with PRISMA guidelines, 2 reviewers independently assessed the quality and
methodology of each study .
[14]
RESULTS
As part of the systematic review, nerve transfer type, amputation location, and specific neurotizations were
reported [Table 1]. Overall, 101 upper extremity nerve transfers were analyzed (with 11 of these specifically
reported as primary TMR for the upper extremity and 8 reported as secondary TMR for the upper
extremity). Specified amputation locations included trans-radial (19), trans-humeral (38), shoulder
disarticulation/glenohumeral (32), above-elbow (8), below-elbow (5), elbow disarticulation (1), and CMC
joint (1) amputations. Neurotizations for the upper extremity primarily involved the ulnar, median, radial,
and musculocutaneous nerves, although additional nerves (including the medial cord, lateral cord, posterior
cord, radial, intercostal, and intercostal brachial cutaneous) were also involved in nerve transfer. A variety
of muscle targets for the upper extremity were identified, and selected based on amputation level, patient-
specific anatomy, zone of injury, mechanism of injury, and nerve length [7,8,15-21] .

For lower extremity amputations, 252 were reported, with specific amputation sites including below-knee
(48), above-knee (50), hip disarticulation (1), trans-tibial (82), trans-femoral (15), and knee disarticulation
(1). Neurotizations for the lower extremity primarily involved the tibial, saphenous, sciatic, and peroneal
nerves, although additional nerves including the posterior femoral cutaneous nerve, femoral, and sural
nerve (among others) were used as well [7,8,15-20] .

A total of four studies assessed the possible benefits of TMR in PLP and RLP via PROMIS (Patient Reported
Outcome Measurement Information System) [Table 2] [7,8,20,21] . PROMIS is a self-reporting tool to capture
respondents’ perception of pain through its impact on multiple components of daily life including physical,
social, and emotional pillars. It utilizes three aspects-intensity, behavior, and interference. Intensity is
represented by standardized pain rating scales (verbal, numerical, visual analog). Pain Interference applies a
numerical rating score for degree of impedance in professional, familial, emotional, and recreational life.
Pain behavior applies a similar numerical rating in the context of how one specifically acts or reacts through
observable displays or phonation. All these studies, with the exception of Dumanian et al., reported
[7]
significant improvements in PROMIS parameters in TMR subjects compared to controls . PROMIS
analysis was also performed for the subcategory of worst pain, as outlined in Table 3.

Several studies included in the systematic analysis did not analyze PROMIS scores, however, still reported
patient subjective improvements in pain outcomes including neuroma pain [Table 4]. Janes et al reported
that of the 10 patients who underwent TMR for chronic neuroma pain, 7 patients (those not lost to follow-
up) were seen an average of 4 months postoperatively, with 2 reporting reduced neuroma pain and 5
reporting complete resolution of pain . Of the 7 patients who underwent acute TMR at the time of
[15]