TMR surgery

Targeted Muscle Reinnervation (TMR) for neuroma and phantom limb pain / An innovative surgical technique with proven long-term results for reducing the pain you experience.

Quick facts

  • Osseointegration (OI) surgery involves the insertion of a metal implant into the bone of your residual limb. Following a rehabilitation process, you will be able to attach a prosthesis directly to the implant.
  • OI, while innovative, is a well-established surgical technique that goes back decades.
  • OI provides many advantages, including greater control over your prosthesis and greater convenience for donning and doffing.

OI is a surgical procedure that involves inserting a metal implant into the bone of your residual limb. Following the procedure and a period of rehabilitation, you will find it easier to attach your prosthesis directly to this implant than to use a socket.

Although OI technology is advanced, it is not new. In fact, it is a highly trusted and well-understood process. The scientific discoveries underpinning this type of surgery were first made in the 1950s and the first procedures using OI for amputees took place in Sweden in the 1990s.

Advances in OI technology are rapidly changing the game for amputees worldwide. At Relimb™, we are proud to offer the procedure to people who have suffered an upper or lower limb amputation.

Benefits of OI

  • Eliminates the problems associated with a standard socket-fitted prosthesis such as rubbing and chafing, sweating, painful skin ulcers, neuroma pain and changes in stump volume.
  • Greater control over your prosthesis, with improved stability and increased range of movement of the residual limb.
  • Reduced energy requirements when walking.
  • Easier to put on and remove your prosthesis.
  • Better overall quality of life with osseoperception through the implant. Osseoperception is the feedback patients get from their prosthesis when they walk. In some cases, experienced users are even able to distinguish between walking on grass versus carpet!

Why Relimb?

As a patient, you are at the heart of everything we do and why we do it. You will receive a plan of treatment, tailored to your specific needs, from the Relimb team, who are experienced leaders in the field of OI and TMR surgery. In addition, you will benefit from having a holistic approach to your care, since Relimb can provide you with all your surgery and prosthetic/rehabilitation support in one seamless package. Our aim is to help you reach the outcomes you have been dreaming of.

Procedure

OI surgery can be performed in 1 or 2 stages, depending on the implant system and the part of the body requiring treatment. Read our OI surgery pages for more details.

My experience

Jeff’s story*

38 years ago, I was involved in a motorcycle accident and lost my left arm above the elbow. In the same accident, I also suffered a severe brachial plexus injury, which left me suffering from intense PLP. Over the years, I tried everything you can think of for the pain: pregabalin, opiates, mirror therapy, hypnosis, you name it. Nothing worked. Eventually, I just learnt to live with the pain.

Unfortunately, I then developed increasing problems with severe back pain. The rehabilitation doctors said that the loss of my left arm meant that the weight across my shoulders was uneven and I had developed a significant scoliosis (twisting) of the spine. To address this, I needed to wear a heavier socket-fitted prosthesis on my left side. To make things worse, the brachial plexus injury meant that my residual limb was very sensitive when touched. So, wearing a heavier prosthesis would also mean having to suffer more pain.

I was sure that there must be a better solution and did some internet research. I discovered that a better solution to my problem might be to undergo a combined TMR and osseointegration (OI) procedure. The OI surgery would allow me to wear a heavier prosthesis and the TMR procedure would help to deal with my phantom limb pain. Surgery was not available on the NHS, so I approached the team at Relimb. They felt that I was a suitable candidate for the surgery, and we went ahead with this at the Royal Free in April 2018.

It has been 3 years since I underwent the surgery, and I am so grateful for what the team at Relimb have been able to do for me. Having the bone-anchor in place in my left arm means that I can now wear a prosthesis that is the right weight for me, without having to disturb the soft-tissues of my residual limb. As a result, my scoliosis has gone and my back pain with it.

The TMR surgery did result in significant worsening of my phantom limb pain for a few months. However, eventually, the nerves grew through and, with a lot of help from the team at Dorset Orthopaedic, I was able to regain voluntary control over the reinnervated muscles. As this happened, it suddenly felt as though my amputated left arm was back again. Over a few weeks, I suddenly noticed that the PLP was also beginning to occur less frequently and at lower intensity.

Nowadays, I don’t have any PLP at all. Since I have undergone the TMR surgery, it has also been possible to increase the number of activation sites that I can use to control my myoelectric prosthetic limb. This has improved my ability to use the prosthesis, and this has allowed me to return to the hobbies I enjoy most – like riding my motorcycle!

*Name changed to respect our patient’s privacy.

Aftercare and pain control FAQs

Do I need to stay in overnight for TMR?

If you choose TMR only (i.e. not in combination with osseointegration), you will generally be able to go home on the same day as your surgery. Some patients with more complex needs, such as TMR for a through-shoulder amputation, may need to stay overnight to receive support with pain control.

What type of medications should I be taking to manage my pain?

We advise you to continue taking your normal anti-neuroma or anti-phantom pain medications before surgery.

We may also advise you to begin increasing your dose of these medications a few days before your surgery is performed. This is because you may experience a temporary, but significant, increase in PLP. This may last for around 3-6 months after the procedure.

The wound pain after this surgery is usually minimal and easily controlled with standard pain medication, which you will only need to take for a few days.

Can I shower after surgery?

After TMR surgery, your incision will be closed (typically) with absorbable sutures, which do not need to be removed. You may wash and shower with running water immediately after surgery.

How long until I can start using my prosthesis again?

We recommend that you avoid any heavy use of your limb for 2-3 weeks. You should not use your prosthesis until your wound has healed (3-6 weeks – longer for lower limb TMR) and any associated soft-tissue swelling has resolved.

What kind of rehabilitation do I need?

If you are having TMR surgery to improve your control over a bionic limb, you must undergo rehabilitation with a specialist that is experienced in the use of computerised feedback techniques, such as Dorset Orthopaedic.

If you are undergoing TMR surgery to deal with neuroma pain only, you do not need specialised rehabilitation. However, many of our patients who engage in specialist rehabilitation after surgery also learn to use their reinnervated muscles more quickly and observe more rapid resolution of their pain.

Are you experiencing nerve pain?

Get in touch and find out how we can help. Our dedicated enquiries team are available to answer your questions or book you in for a consultation. Contact us Monday – Friday from 8am – 6pm on 020 7317 7751 or rf-tr.privateenquiries@nhs.net.