829 - Staying S.T.R.O.N.G. After Shark Attack - Significance of Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interface (RPNI) in Optimizing Neuromuscular Gains in the Pediatric Amputee

Case Diagnosis: 15-year-old with right above-knee and left below-elbow amputations following shark attack

Case Description: A 15-year-old female underwent right above knee and left below-elbow amputations at an outside hospital following shark bites. Targeted Muscle Reinnervation (TMR) was unavailable, so she was transferred to a higher level of care. She underwent revision of amputations with excision of several neuromas and TMR (median nerve into flexor digitorum profundus [2-3], ulnar nerve into flexor carpi ulnaris, common fibular nerve into biceps femoris, tibial nerve into semitendinosus), and regenerative peripheral nerve interface (RPNI) creation for radial sensory and saphenous nerves. She transferred to inpatient rehabilitation after one month. At admission, she required maximal assistance for lower body ADLs and was nonambulatory. She began using upper extremity myoelectric prosthesis shortly after admission, and lower extremity prosthesis with hydraulic knee after three weeks. After eight weeks, she was discharged home, ambulating with supervision and modified-independent for ADLs. One year later, she reported consistent use of prostheses and involvement in athletics.

Discussions: TMR is a surgical procedure in which residual nerves are implanted into muscle tissue at an amputated site, with the benefit of improved pain and prosthetic control. Though TMR/RPNI are becoming increasingly more common, reports of TMR/RPNI are rare in pediatric literature. This patient’s inpatient rehabilitation stay was longer than typical for several reasons. However, this extended rehabilitation stay allowed for continued progression of goals and improved acceptance of her prostheses.

Conclusions: Excellent functional gains can be achieved for pediatric patients with amputation after TMR and RPNI; prolonged inpatient rehabilitation may improve prosthetic acceptance.