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Page 2 of 7 Zargaran et al. Plast Aesthet Res 2023;10:10 https://dx.doi.org/10.20517/2347-9264.2022.42

improvement in quality of life, from 68 pre-operatively to 78 post-procedure (P < 0.05).

Conclusion: This is the first quantified evaluation of changes in HRQoL after TMR surgery for upper limb
amputation. There appears to be a significant improvement in both HRQoL and overall perception of pain. This
finding may have important implications for funding and national resource allocation for TMR surgery.

Keywords: Amputation, TMR, targeted muscle reinnervation, quality of life, QALY

INTRODUCTION
[1]
There are an estimated 10,000 upper limb amputations annually in the United Kingdom ; most are digital
amputations, with approximately 300 major limb amputations (e.g., transhumeral or transradial). The
adverse impact of an upper limb amputation on mental health and pain is well established . There are
[2]
additional functional sequelae associated with the loss of the limb, which adversely impact health-related
quality of life (HRQoL) . Functional reconstruction can be achieved through upper limb prosthesis;
[3]
however, their accessibility may be precluded by high upfront and running costs, even in a developed nation
such as the UK. These costs are difficult to determine due to a wide range of available devices and the extent
of prosthesis required, which in turn is dependent on the level of amputation . In the United States, one
[4]
source has estimated the mean cost of a myoelectric prosthesis for partial hand amputations at $18,703,
$20,329 for transradial amputations, $59,664 for Transhumeral amputations, and approximately $62,000 for
[5]
shoulder and forequarter amputations . Overall, prosthesis-related expenses can range between £31,890 to
$117,440, clearly highlighting a significant financial burden on both the patients and the healthcare
system .
[4]
The nerve-related pain experienced after upper limb amputation can be both persistent and debilitating .
[6]
The two main nociceptive sensations after amputation are neuroma pain (NP) and phantom limb pain
(PLP), which can be differentiated based on their character, location and triggers . NP is typically initiated
[7]
by direct pressure over the end of the injured nerve, while PLP is any pain or discomfort that is perceived to
[8]
occur in the now absent limb . The sustained and persistent nature of these two types of pain has been
demonstrated to adversely impact the patient’s HRQoL . Although the introduction of neuropathic agents
[9]
(e.g., gabapentin) has had a transformational effect on the management of both of these types of pain, these
drugs cannot abolish pain and patients often suffer from a variety of debilitating side effects or may be
[10]
completely intolerant of the medication . Chronic use of the medication is also costly for many healthcare
systems.

Targeted muscle reinnervation (TMR) has shown great promise in the treatment of both types of nerve-
[11]
related pain . By providing a muscle target to the regenerating nerve stumps after amputation, TMR
surgery appears to reduce the reformation of painful neuromas while simultaneously providing feedback to
the central nervous system (CNS), which appears to reduce the perception of PLP. However, to date, there
has been no work to quantify the impact of TMR surgery on the quality of life in this population.

METHODS
We performed a retrospective review of all upper limb amputees with NP and/or PLP who underwent TMR
surgery between October 2013 and September 2021 by the Relimb Unit, Royal Free Hospital, London,
United Kingdom. Data were collected from patient records and telephone interviews. Additional baseline
characteristics were also collected from the study participants, including; age, gender, date of procedure and
indication for TMR. Our primary outcome measures evaluated pain and quality of life. Subjects were