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Functional Amputation Techniques and Survival Following Below-Knee Amputation: Association of Targeted Muscle Reinnervation with Long-Term Mortality
Hannah Soltani
*, Rachel N. Rohrich, Christopher M. Ply, Karen K. Evans, Richard C. Youn, Christopher E. Attinger, Grant Kleiber, Stephen Baker
Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington,
Background: Below-knee amputation (BKA) carries high morbidity and mortality, often compounded by chronic postamputation pain and limited ambulation. Targeted muscle reinnervation (TMR) reduces pain and may improve functional outcomes, yet its impact on survival following BKA has not been evaluated.
Methods: A retrospective review was conducted of all patients undergoing BKA at a single institution from 2013-2023. Patients were stratified by receipt of TMR or standard traction neurectomy. Demographics, comorbidities, operative details, prior limb interventions, outcomes, and mortality were compared.
Results: A total of 568 patients were identified, of whom 338 (59.5%) underwent TMR. Median age (59 years), sex distribution (67.4% male), and median BMI (28.7 kg/m
2) were similar between groups. The TMR cohort demonstrated a higher comorbidity burden, including diabetes mellitus (81.7% vs 62.6%, p=0.001), peripheral vascular disease (84.6% vs 60.9%, p=0.001), and end-stage renal disease (26.9% vs 18.3%, p=0.017). Operative time was significantly longer in the TMR group (median 245 vs 141 minutes, p<0.001). Postoperative upgrade to AKA occurred more frequently in the non-TMR group (10.0% vs 1.8%, p<0.001). TMR was associated with significantly lower overall mortality (28.7% vs 47.0%, p<0.001), and decreased mortality at 3 years (21.6% vs 30.0%, p=0.023), 4 years (24.9% vs 35.2%, p=0.008), and 5 years (27.8% vs 39.1%, p=0.005). On multivariable analysis, TMR remained independently associated with reduced mortality (OR 0.31, 95% CI 0.21-0.46, p<0.001). Kaplan-Meier survival analysis demonstrated significantly improved long-term survival among patients with TMR (log-rank p<0.001)
(Figure 1). Conclusions: TMR is independently associated with improved long-term survival for BKAs despite higher baseline comorbidity and longer operative time. This survival advantage is likely explained by established improvements in mobility, pain, and prosthetic use with TMR. These findings support adoption of TMR as a standard component of functional BKA reconstruction.
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