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Cut Nerves, Divided Opinions: National Trends in Surgeon Preferences for Timing and Referral of TMR and RPNI
Aidan S. Weitzner
*, William Padovano, Jeffrey Khong, Arushi Biswas, Zachary Zamore, Sami Tuffaha
Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
Introduction: Symptomatic neuromas develop in 5-25% following amputation and can be treated with peripheral nerve interventions like targeted muscle reinnervation (TMR) or regenerative peripheral nerve interface (RPNI). These interventions are increasingly performed prophylactically, yet no national consensus exists regarding their use. This study aimed to identify physician populations that may benefit from additional education and to define barriers that limit broader adoption of these procedures to prevent post-amputation pain.
Methods: A REDCap survey was distributed to 3628 physicians, with 303 responses collected. Participants were members of American Society for Surgery of the Hand (ASSH) or Musculoskeletal Tumor Society (MSTS). The survey assessed surgical techniques, timing of interventions, and perceived barriers to performing or referring for peripheral nerve procedures.
Results: Physicians performing peripheral nerve surgery were more likely to be in practice for 10 years or less (p<0.001), work in academic settings (p<0.001), and be trained in plastic surgery (p<0.001). Among these surgeons, 86% reported performing TMR or RPNI prophylactically (Table 1). There were no differences in utilization of prophylactic procedures based on time in practice (p=0.55) and surgical specialty (p=0.56). Half (51%) stated the effectiveness of TMR/RPNI was independent of timing. 42% identified lack of consultation by the primary surgical team as a barrier. Among amputation-only surgeons, 38% referred patients for TMR/RPNI and were more often affiliated with academic centers (p<0.001) compared to those who do not refer.
Conclusions: Despite growing awareness and utilization of TMR/RPNI amongst both resident physicians and attendings, perspectives on prophylaxis versus treatment remain divided. Key barriers, including limited interdisciplinary coordination, highlight the need for targeted education and institutional strategies to support broader implementation and research into prophylactic nerve interventions.
