{"paper_id":"35b28ade-25dd-45e3-b6b7-69fc0b11988f","body_text":"Enhancing sensory perception in upper limb prosthetics through combined Targeted Muscle Re-innervation and osseointegration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Enhancing sensory perception in upper limb prosthetics through combined Targeted Muscle Re-innervation and osseointegration Nupur Shukla, Abby Hutchison, Frank Bruscino-Raiola This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8580524/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Upper limb amputation significantly impairs physical and psychosocial functioning. Many upper limb amputees discontinue prosthesis use due to a multitude of complications. We embarked on a study that merged the surgical techniques of osseointegration and targeted muscle reinnervation (TMR) to explore the potential enhancement of sensory perception in a prosthetic limb. Osseointegration involves skeletal anchorage of an implant and abutment to establish a direct attachment point for a prosthesis. TMR involved transfer of residual peripheral nerves to nearby redundant motor nerves creating biologic amplifiers that convert native neural signals into distant muscle contractions. Both TMR and osseointegration are known to improve sensibility and proprioception, combining these procedures will improve intuitive control. Methods Routine testing on the prosthetic limb for patients enrolled in the Advanced Surgical Amputee Program (ASAP) included two-point discrimination, monofilament assessment and vibration detection. These tests were conducted at numerous time points pre and post osseointegration and were assessed for any improvement. All patients had already undergone TMR. Results Four patients were included in this study. The results showed variable improvement in deep pressure sensation detection, consistent improvement in vibration detection and no improvement in two-point discrimination. We also found an improved ability to correctly identify the location of a stimulus. Conclusion This study provides early evidence supporting a positive correlation between improved sensibility and spatial awareness when combining osseointegration and TMR. We recommend future research with larger cohorts and longer follow-up periods to validate and strengthen these findings. Osseointegration Myoelectric prosthesis Amputation Targeted muscle reinnervation INTRODUCTION Upper limb amputation profoundly affects an individual’s ability to carry out activities of daily living and significantly impacts one’s quality of life. Loss of both motor and sensory function result in significant patient morbidity. Australian studies have shown that only 44% of amputees wear their prosthesis for half or more time [ 1 ]. Major issues with socket prosthesis include skin irritation, residual pain and lack of function use rendering the prosthesis unsatisfactory [ 2 ]. Studies have shown that key patient concerns include weight of prosthesis, difficulty with manipulation, financial burden and loss of sensory feedback [ 3 ]. While considerable progress has been made in enhancing the functionality of prostheses, with advancements in body-powered and externally powered options aimed at improving motor function, a major limitation persists—the absence of conscious sensory feedback and intuitive control [ 4 ]. Proprioception and sensation play a pivotal role in the development of a functional limb. The concept of sensory feedback is intricate and multifaceted, posing considerable challenges when it comes to replicating it in prosthetic limbs [ 5 ]. Prosthetic limb users must maintain constant visual monitoring to compensate for the lack of haptic feedback – an impractical limitation when attempting to carry out basic tasks. In an ideal scenario, a prosthesis should empower users to perceive the device's current configuration and velocity without having to constantly direct their gaze towards it. This advancement would undoubtedly lead to a substantial improvement in the overall functionality of prosthetic limbs [ 5 ]. Osseointegration is a surgical procedure which allows direct skeletal anchorage of a fixture. This involves the insertion of an implant and abutment to establish a direct attachment point for a prosthesis. Originally developed for maxillofacial surgery in 1965, osseointegration has since found applications in various medical fields, including hearing aids, orbital implants, as well as upper and lower limb amputation [ 2 ]. One of the notable advantages of osseointegration is its ability to eliminate a significant number of issues associated with socket-based prostheses. These problems encompass skin discomfort, sweating, and ill-fitting prosthetic devices. Studies have shown promising results including increased prosthetic use, range of movement, reduced energy requirements, faster donning, and doffing with reports of improved quality of life post operatively [ 6 ]. Additional to these benefits, osseointegration improves functionality by creating closed loop feedback to allow for better detection of the physical environment. It has been shown to improve sensory feedback through a process known as osseoperception [ 7 ]. Although full understanding of the neurophysiological mechanism is still being explored, patient satisfaction in dental procedures has been established with improved tactile function and restoration of masticatory function [ 8 ]. Targeted muscle reinnervation (TMR) adds to improvement of intuitive control of upper limb myoelectrical prothesis. It involves transfer of peripheral nerves to redundant target muscle motor nerves. Peripheral nerves are found, neuromas are excised, motor nerves of the target muscles are identified and transected near the muscle creating bioamplifiers. These bioamplifiers effectively increase the number of signal generators to enhance the degrees of freedom for prosthetic motor function outlays, allowing for more definitive and specific signals to enhance bioprosthetic control [ 9 ]. While both procedures have been independently evaluated for their motor and sensory outcomes, their synergistic potential remains largely unexamined. AIMS Both TMR and osseointegration are known to improve sensation and proprioception of prostheses. Limited existing literature evaluates the effect of both procedures combined on sensory awareness and proprioceptive outcomes in patients with traumatic transhumeral amputations. This study aims to directly and quantitively assess sensory and proprioceptive outcomes in patients with TMR and osseointegration vs TMR and socket prosthesis. We included the metric of location accuracy to approach the assessment to spatial perception. Knowledge may inform future clinical decisions when determining the optimal reconstructive options for each individual patient. Ultimately, we aim to improve the quality of life in a cohort of patients who experience significant morbidity. METHOD Study Design We conducted a prospective longitudinal cohort study using a within-subject pre–post design. All participants had undergone TMR prior to the study. Assessments were conducted on TMR patients while using a socket-based prosthesis. The same assessments were conducted after osseointegration. Each participant served as their own control, with pre-intervention testing conducted before osseointegration. Institutional ethics was obtained – the HREA Project ID is 658/19. All participants in this study are enrolled in the ASAP program and attended appointments at a major trauma hospital. They undergo comprehensive medical assessment by medical and allied health practitioners including plastic and reconstructive surgeons, hand therapists and prosthetists. If deemed suitable plans are made for surgical intervention with TMR and osseointegration. Participation All participants were greater than 18 years of age with unilateral trans-humeral amputation referred to ASAP and were appropriate candidates to proceed with TMR and osseointegration. Inclusion criteria included completed TMR with a successful fitting socket-based prosthesis. Exclusion criteria included unhealed residual limb pathology and an inability to comply with rehabilitation to follow up. TMR dates range from 2016 to 2018. Osseointegration range from 2009 to 2021. Data collection The testing required for the research is routine for patients enrolled in ASAP. Both normal and prosthetic limbs were tested. All participants had previously undergone TMR. The pre intervention phase involved standardised clinical assessment while using a conventionally fitted socket prosthesis. Post intervention testing was performed after participants completed osseointegration. No changes were made to the equipment or prosthesis to augment sensory feedback. The patients were blinded. Sensibility was assessed with two-point discrimination and Semmes-Weinstein Monofilament Assessment. Vibration assessment was conducted using a Ragg Gardiner Brown 128Hz tuning fork to determine the ability of subjects to discriminate various vibration intensities. The vibrating tuning fork was placed on various joints in the upper limb including distal interphalangeal joint of digits, ulnar styloid and olecranon process on both prothesis and the native limb. The patient was asked to indicate when they no longer perceive the vibration stimulus. Another data point collected during the study was the concept of \"location accuracy\". This refers to the participants ability to detect and interpret where the vibration stimulus was applied on the tested limb. This was assessed by participants indicating the perceived location using their contralateral limb and scored correct if within 2cm (proximally or distally) of the actual stimulus location. Although this is tool is not yet validated, it provides useful insight into the participant’s capacity to perceive and accurately identify tactile stimuli. Incorporating location accuracy as an evaluative metric offer an opportunity to quantify spatial perception thereby strengthening the assessment and improving detection of subtle perceptual differences. Due to the COVID pandemic limiting face to face reviews these reviews were conducted at six-to-twelve-month intervals post operatively. The duration between clinical assessment is variable due to challenges with follow up during this period. RESULTS Eight patients who had upper limb transhumeral amputation followed by TMR were identified for this study. Among them, three underwent acute TMR, while the remaining five had delayed TMR. Seven of these patients underwent osseointegration, while one patient declined and was thus excluded from analysis. Due to the challenges posed by the pandemic, three patients who live interstate were unable to participate in face-to-face assessment. Ultimately, four patients were included in the study. Regular follow-up and assessment were conducted for these patients, initially with socket/harness prosthesis and subsequently with osseointegration suspension prosthesis. The results for the four patients included in the study are listed in the following tables. Pre-intervention with osseointegration no patients were able to detect deep pressure sensation. Post osseointegration, there was an improvement observed in deep pressure sensation for one patient (Table 1 ). Detection of vibration varied prior to osseointegration, with three out of four patients demonstrating some ability to perceive vibration. All patients showed improvement in vibration detection post osseointegration (Table 2 ). Two-point discrimination was found to be zero in all patients both before and after osseointegration (Table 3 ). Our results also indicated an enhanced ability to accurately identify the location of a stimulus, such as deep pressure or vibration following TMR and osseointegration as depicted in Table 4 . Table 1 Results of pressure sensation detection TMR only OI/TMR (average score) Patient 1 0 0 Patient 2 0 3.5 Patient 3 0 0 Patient 4 0 0 Table 2 Results of pressure vibration detection TMR only OI/TMR (average score) Patient 1 3 5.5 Patient 2 5 8 Patient 3 5 7 Patient 4 0 4 Table 3 Results of 2 point discrimination detection TMR only OI/TMR (average score) Patient 1 0 0 Patient 2 0 0 Patient 3 0 0 Patient 4 0 0 Table 4 Results of location accuracy detection TMR only OI/TMR (average score) Patient 1 1 3 Patient 2 N/A 5.5 Patient 3 N/A 4 Patient 4 0 2 DISCUSSION Upper limb amputation is a life-altering consequence that can stem from various causes, including trauma, malignancy, and systemic illnesses like diabetes mellitus, leaving affected individuals with substantial physical and psychological challenges. Among the many functions of the upper limb, hand function stands out as particularly vital for human beings. While medical and technological advancements have paved the way for the continuous evolution of prosthetic devices, a significant hurdle remains—the lack of sensory feedback. Sensory feedback plays a pivotal role in creating a truly functional prosthesis, yet it is conspicuously absent in the experience of current prosthetic users. Further to this, due to constraints imposed by insurance policies, we are unable to modify prosthetic devices to enhance sensory feedback. Advanced modifications aimed at augmenting sensation do not currently fit within the scope of insurance. In our research, we embarked on a study that sought to merge the surgical techniques of osseointegration and TMR to explore the potential enhancement of sensory perception in a prosthetic limb. This combination of procedures provides a comprehensive approach to enhancing prosthetic functionality and sensory feedback. Osseointegrated prostheses are rigidly anchored to bone resulting in enhanced mechanical stability, improved vibration and load transmission through the skeleton as opposed to a socket prothesis thereby improving sensibility through ‘osseoperception’[ 7 ]. This supports the theory of improved electromyography pick up from TMR muscles. There is also more consistent kinematics – because the interface does not rotate as it would in a socket-based prosthesis, joint angles and forces are more predictable. TMR involves neuroma excision and the creation of biologic amplifiers. Resulting electromyography from these muscles is strong, focal and task specific and neuroma excision improved phantom limb pain [ 10 , 16 ]. Evidence on cortical reorganisation shows that somatosensory map can become maladaptive after limb loss [ 11 ]. TMR may stabilise these changes by improved sensory input or reducing maladaptive signalling which is likely to support better sensory and proprioceptive integration. Combing these surgical procedures offers a synergistic platform for closed loop prosthetic control. Early clinical reports of combined TMR and osseointegration depict improvements in function, reduced pain and increased prosthetic use however detailed data on proprioception and sensation remains limited and requires future research [ 15 ]. Our results support this, with a general improvement post TMR and osseointegration. All patients showed improvement in vibration detection, with the extent of improvement varying. Deep pressure detection was improved in one patient; the others did not show significant change. There is also a consistent lack of two-point discrimination which may suggest that this aspect of sensory perception is not significantly impacted by osseointegration. This variation may be attributed to the impact of the material utilised to create the prosthetic device such as hard plastic (patients 2,3,4) which is more conductive than silicon glove and foam covering over terminal device (patient 1) which can dampen sensation. It also highlights the multifactorial individualised nature of sensory outcomes. The observation of enhanced location accuracy in identifying stimulus post osseointegration suggests a potential positive effect of osseointegration on the spatial perception of sensory stimuli. There is substantial evidence that enhanced sensory feedback improves prosthetic control; however, there is a lack of meaningful outcome measures to quantify this effect [ 13 ]. A major challenge is the absence of validated assessment tools specifically designed to evaluate tactile sensation and proprioception in upper limb prothesis users. Existing measures predominantly rely on subjective patient-reported questionnaires, which provide valuable insight but are susceptible to individual bias. Objective outcome measures offer a quantifiable and reliable evaluation of function, yet very few have been validated in upper limb prosthesis users. A comprehensive review identified 17 outcome measures, only two of which incorporated sensory components – and neither were validated in upper limb prosthesis users [ 14 ]. While existing functional assessments may inadvertently reflect aspects of sensory feedback, they do not account for improvements that may arising from emerging surgical techniques such as TMR and osseointegration. In this study we utilised validated screening assessments designed for the intact limb, however there are notable limitations when applied to a prosthesis user, as discussed below. There is a clear need develop standardised and validated outcome measures in this patient group. Given that such are largely conducted by allied health specialists, interdisciplinary collaboration is essential to ensure clinical utility and validity. Several potential assessment approaches could be explored including tactile location accuracy to evaluate spatial perception, prosthesis-mediated joint position tasks and object recognition without visual or auditory feedback [ 15 ]. Patient-reported outcomes can complement objective measures. Validated tools such as the Patient Specific Functional Scale (PSFS) - in which patients identify and reassess five tasks pre and post intervention - and the modified OPUS Upper Extremity Functional Status (UEFS) survey – which assesses perceived ability to conduct a defined set of activities of daily living - may be incorporated alongside clinical metrics to provide a more comprehensive evaluation of sensory function [ 15 ]. In this pilot pre-post study, participants served as their own controls. For future research we intend to pursue a large-scale study and could adopt a case-controlled design incorporating three comparison groups: a socket based non TMR/osseointegration cohort, a TMR only cohort and a combined TMR and osseointegration group with matched demographics. Several of the proposed tools could be utilised to enable rigorous assessment of sensory and proprioceptive outcomes. LIMITATIONS Interruptions to data collection were experienced due to varying restrictions with face-to-face contact during the COVID-19 pandemic. There are also inconsistencies in when patients were fit with their devices based on differing approval processes and timing across funding models. Limited digit extension of the terminal devices impedes their ability to lay flat on a table in a supinated position like anatomical hands. This may further impact the detection of pressure. Resistance at end range, or slight movement of the terminal device in response to pressure may be noticeable to patients, particularly more experienced prosthetic users, rather than true pressure detection and should be considered when interpreting results. There are several limitations of monofilament utilisation for sensory testing. Inter-rate reliability is already a limitation even in validated populations and this has not been tested for use in the amputee cohort. This is further exacerbated when considering that the testing force of the thickest monofilament is evaluated by visually observing the skin at the testing site – which is not possible on a prosthetic arm. This lack of visual confirmation of force may affect the reliability of this test in prosthesis users. CONCLUSION In summary, the study provides insights into the sensory outcomes of TMR and osseointegration procedures in patients with upper limb amputations, indicating both variability in individual responses and potential positive effects on spatial perception. Further research with larger sample sizes and longer-term follow-up utilising validated assessment tools will help confirm these findings and better understand the underlying mechanisms driving sensory improvements post osseointegration. Declarations Ethics statement Ethical approval to report these cases was obtained from Ethics Committee of Alfred Health – HREA Project ID is 658/19. Consent to participate: Written informed consent was obtained from the patient for their anonymized information to be published in this article. Clinical Trial Number Not applicable Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by F.B.R., N.S. and A.H. The first draft of the manuscript was written by N.S. and all authors read commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Davidson J (2002) A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther 15(1):62–70. https://doi.org/10.1053/hanthe.2002.v15.01562 Hebert JS, Rehani M, Stiegelmar R (2017) Osseointegration for Lower-Limb Amputation: A Systematic Review of Clinical Outcomes. JBJS Rev 5(10):e10. https://doi.org/10.2106/JBJS.RVW.17.00037 Stephens-Fripp B, Jean Walker M, Goddard E, Alici G (2020) A survey on what Australians with upper limb difference want in a prosthesis: justification for using soft robotics and additive manufacturing for customized prosthetic hands. Disabil Rehabil Assist Technol 15(3):342–349. https://doi.org/10.1080/17483107.2019.1580777 Cordella F, Ciancio AL, Sacchetti R et al (2016) Literature Review on Needs of Upper Limb Prosthesis Users. Front Neurosci 12:10:209. https://doi.org/10.3389/fnins.2016.00209 Blank A, Okamura AM, Kuchenbecker KJ (2010) Identifying the role of proprioception in upper-limb prosthesis control: Studies on targeted motion. ACM Trans Appl Percept 7(3):1–23. https://doi.org/10.1145/1773965.1773966 Zaid MB, OʼDonnell RJ, Potter BK, Forsberg JA (2019) Orthopaedic Osseointegration: State of the Art. J Am Acad Orthop Surg 27(22):e977–e985. https://doi.org/10.5435/JAAOS-D-19-00016 Tropf J, Potter B (2023) Osseointegration for amputees: Current state of direct skeletal attachment of prostheses. Orthoplastic Surg 12:20–28. https://doi.org/10.1016/j.orthop.2023.05.004 Bhatnagar VM, Karani JT, Khanna A, Badwaik P, Pai A (2015) Osseoperception: An Implant Mediated Sensory Motor Control- A Review. J Clin Diagn Res 9(9):ZE18–20. https://doi.org/10.7860/JCDR/2015/14349.6532 Bowen JB, Wee CE, Kalik J, Valerio IL (2017) Targeted Muscle Reinnervation to Improve Pain, Prosthetic Tolerance, and Bioprosthetic Outcomes in the Amputee. Adv Wound Care (New Rochelle) 1;6(8):261–267. https://doi.org/10.1089/wound.2016.0717 Cheesborough JE, Smith LH, Kuiken TA, Dumanian GA (2015) Targeted muscle reinnervation and advanced prosthetic arms. Semin Plast Surg 29(1):62–72. https://doi.org/10.1055/s-0035-1544166 Sparling T, Iyer L, Pasquina P, Petrus E (2024) Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery. J Neurosci. 3;44(1):e1051232024. https://doi.org/10.1523/JNEUROSCI.1051-23.2023 Webster J, Heckman J, Borgia M, Delikat J, Resnik L (2025) Outcomes in transhumeral upper limb amputation with osseointegration and targeted muscle reinnervation: A preliminary observational cohort study. PM&R. https://doi.org/10.1002/pmrj.13407 Jabban L, Dupan S, Zhang D, Ainsworth B, Nazarpour K, Metcalfe BW (2022) Sensory Feedback for Upper-Limb Prostheses: Opportunities and Barriers. IEEE Trans Neural Syst Rehabil Eng 30:738–747. https://doi.org/10.1109/TNSRE.2022.3159186 Wang S, Hsu CJ, Trent L, Ryan T, Kearns NT, Civillico EF, Kontson KL (2018) Evaluation of Performance-Based Outcome Measures for the Upper Limb: A Comprehensive Narrative. Rev PM&R 10(9):951–962e3. https://doi.org/10.1016/j.pmrj.2018.02.008 Cuberovic I, Gill A, Resnik LJ, Tyler DJ, Graczyk EL (2019) Learning of Artificial Sensation Through Long-Term Home Use of a Sensory-Enabled Prosthesis. Front Neurosci 21:13:853. https://doi.org/10.3389/fnins.2019.00853 Dumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, Ertl WJ, Tintle SM, Nanos GP, Valerio IL, Kuiken TA, Apkarian AV, Porter K, Jordan SW (2019) Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Ann Surg 270(2):238–246 https // 10.1097/SLA.0000000000003088 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8580524\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Short Report\",\"associatedPublications\":[],\"authors\":[{\"id\":587024172,\"identity\":\"6debddfc-b621-4781-8423-fc1a8a5be986\",\"order_by\":0,\"name\":\"Nupur Shukla\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYPCCAwwS7AyMDyQqgGxm5gYitTAzMBtYnAFpYSReC5tEZRuIQ0CLuUTuMemKP3cSZzYzP5O4Oa82mr8dqOVHxTacWixn5KVJnm17ljibmc3Ycua247kzDjM2MPacuY1Ti8GNHDPJxobDifOYGQxvS247ltsA1MLM2EZAS8MfkBb2D9J/5xzLnU+cFrbDQIfxGElINtTkbiCo5cy7ZMvGtsPGM5t5ig0kjh3I3QjUchCvX47nHrwJdJjsjOPtGx9I1NTlzjt/+OCDHxW4tTAw8KDwDoPJA3jUY2ipw694FIyCUTAKRiQAAEOJX8VY3zj+AAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Alfred Health\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Nupur\",\"middleName\":\"\",\"lastName\":\"Shukla\",\"suffix\":\"\"},{\"id\":587024173,\"identity\":\"ea3967cb-3b65-4f10-a15c-9c6ce4440e6b\",\"order_by\":1,\"name\":\"Abby Hutchison\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Alfred Health\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abby\",\"middleName\":\"\",\"lastName\":\"Hutchison\",\"suffix\":\"\"},{\"id\":587024174,\"identity\":\"1f748bf5-1fe1-4835-ba4d-395803fa7278\",\"order_by\":2,\"name\":\"Frank Bruscino-Raiola\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Alfred Health\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Frank\",\"middleName\":\"\",\"lastName\":\"Bruscino-Raiola\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-12 10:38:14\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8580524/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8580524/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":107480703,\"identity\":\"42ffd03c-bfb7-4d4e-81c1-5b6a47be832d\",\"added_by\":\"auto\",\"created_at\":\"2026-04-22 02:13:10\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":217585,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8580524/v1/04a479b5-2ae3-4ae7-b749-186b8aa21ba0.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Enhancing sensory perception in upper limb prosthetics through combined Targeted Muscle Re-innervation and osseointegration\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eUpper limb amputation profoundly affects an individual\\u0026rsquo;s ability to carry out activities of daily living and significantly impacts one\\u0026rsquo;s quality of life. Loss of both motor and sensory function result in significant patient morbidity. Australian studies have shown that only 44% of amputees wear their prosthesis for half or more time [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Major issues with socket prosthesis include skin irritation, residual pain and lack of function use rendering the prosthesis unsatisfactory [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Studies have shown that key patient concerns include weight of prosthesis, difficulty with manipulation, financial burden and loss of sensory feedback [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. While considerable progress has been made in enhancing the functionality of prostheses, with advancements in body-powered and externally powered options aimed at improving motor function, a major limitation persists\\u0026mdash;the absence of conscious sensory feedback and intuitive control [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eProprioception and sensation play a pivotal role in the development of a functional limb. The concept of sensory feedback is intricate and multifaceted, posing considerable challenges when it comes to replicating it in prosthetic limbs [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Prosthetic limb users must maintain constant visual monitoring to compensate for the lack of haptic feedback \\u0026ndash; an impractical limitation when attempting to carry out basic tasks. In an ideal scenario, a prosthesis should empower users to perceive the device's current configuration and velocity without having to constantly direct their gaze towards it. This advancement would undoubtedly lead to a substantial improvement in the overall functionality of prosthetic limbs [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOsseointegration is a surgical procedure which allows direct skeletal anchorage of a fixture. This involves the insertion of an implant and abutment to establish a direct attachment point for a prosthesis. Originally developed for maxillofacial surgery in 1965, osseointegration has since found applications in various medical fields, including hearing aids, orbital implants, as well as upper and lower limb amputation [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. One of the notable advantages of osseointegration is its ability to eliminate a significant number of issues associated with socket-based prostheses. These problems encompass skin discomfort, sweating, and ill-fitting prosthetic devices. Studies have shown promising results including increased prosthetic use, range of movement, reduced energy requirements, faster donning, and doffing with reports of improved quality of life post operatively [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAdditional to these benefits, osseointegration improves functionality by creating closed loop feedback to allow for better detection of the physical environment. It has been shown to improve sensory feedback through a process known as osseoperception [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Although full understanding of the neurophysiological mechanism is still being explored, patient satisfaction in dental procedures has been established with improved tactile function and restoration of masticatory function [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eTargeted muscle reinnervation (TMR) adds to improvement of intuitive control of upper limb myoelectrical prothesis. It involves transfer of peripheral nerves to redundant target muscle motor nerves. Peripheral nerves are found, neuromas are excised, motor nerves of the target muscles are identified and transected near the muscle creating bioamplifiers. These bioamplifiers effectively increase the number of signal generators to enhance the degrees of freedom for prosthetic motor function outlays, allowing for more definitive and specific signals to enhance bioprosthetic control [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. While both procedures have been independently evaluated for their motor and sensory outcomes, their synergistic potential remains largely unexamined.\\u003c/p\\u003e\"},{\"header\":\"AIMS\",\"content\":\"\\u003cp\\u003eBoth TMR and osseointegration are known to improve sensation and proprioception of prostheses. Limited existing literature evaluates the effect of both procedures combined on sensory awareness and proprioceptive outcomes in patients with traumatic transhumeral amputations. This study aims to directly and quantitively assess sensory and proprioceptive outcomes in patients with TMR and osseointegration vs TMR and socket prosthesis. We included the metric of location accuracy to approach the assessment to spatial perception. Knowledge may inform future clinical decisions when determining the optimal reconstructive options for each individual patient. Ultimately, we aim to improve the quality of life in a cohort of patients who experience significant morbidity.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section3\\\"\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\\n\\n\\n\\n \"},{\"header\":\"METHOD\",\"content\":\"\\u003ch2\\u003eStudy Design\\u003c/h2\\u003e\\u003cp\\u003eWe conducted a prospective longitudinal cohort study using a within-subject pre–post design. All participants had undergone TMR prior to the study. Assessments were conducted on TMR patients while using a socket-based prosthesis. The same assessments were conducted after osseointegration. Each participant served as their own control, with pre-intervention testing conducted before osseointegration. Institutional ethics was obtained – the HREA Project ID is 658/19. All participants in this study are enrolled in the ASAP program and attended appointments at a major trauma hospital. They undergo comprehensive medical assessment by medical and allied health practitioners including plastic and reconstructive surgeons, hand therapists and prosthetists. If deemed suitable plans are made for surgical intervention with TMR and osseointegration.\\u003c/p\\u003e\\u003ch3\\u003eParticipation\\u003c/h3\\u003e\\u003cp\\u003eAll participants were greater than 18 years of age with unilateral trans-humeral amputation referred to ASAP and were appropriate candidates to proceed with TMR and osseointegration. Inclusion criteria included completed TMR with a successful fitting socket-based prosthesis. Exclusion criteria included unhealed residual limb pathology and an inability to comply with rehabilitation to follow up. TMR dates range from 2016 to 2018. Osseointegration range from 2009 to 2021.\\u003c/p\\u003e\\u003ch3\\u003eData collection\\u003c/h3\\u003e\\u003cp\\u003eThe testing required for the research is routine for patients enrolled in ASAP. Both normal and prosthetic limbs were tested. All participants had previously undergone TMR. The pre intervention phase involved standardised clinical assessment while using a conventionally fitted socket prosthesis. Post intervention testing was performed after participants completed osseointegration. No changes were made to the equipment or prosthesis to augment sensory feedback. The patients were blinded.\\u003c/p\\u003e\\u003cp\\u003eSensibility was assessed with two-point discrimination and Semmes-Weinstein Monofilament Assessment. Vibration assessment was conducted using a Ragg Gardiner Brown 128Hz tuning fork to determine the ability of subjects to discriminate various vibration intensities. The vibrating tuning fork was placed on various joints in the upper limb including distal interphalangeal joint of digits, ulnar styloid and olecranon process on both prothesis and the native limb. The patient was asked to indicate when they no longer perceive the vibration stimulus. Another data point collected during the study was the concept of \\\"location accuracy\\\". This refers to the participants ability to detect and interpret where the vibration stimulus was applied on the tested limb. This was assessed by participants indicating the perceived location using their contralateral limb and scored correct if within 2cm (proximally or distally) of the actual stimulus location. Although this is tool is not yet validated, it provides useful insight into the participant’s capacity to perceive and accurately identify tactile stimuli. Incorporating location accuracy as an evaluative metric offer an opportunity to quantify spatial perception thereby strengthening the assessment and improving detection of subtle perceptual differences.\\u003c/p\\u003e\\u003cp\\u003eDue to the COVID pandemic limiting face to face reviews these reviews were conducted at six-to-twelve-month intervals post operatively. The duration between clinical assessment is variable due to challenges with follow up during this period.\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eEight patients who had upper limb transhumeral amputation followed by TMR were identified for this study. Among them, three underwent acute TMR, while the remaining five had delayed TMR. Seven of these patients underwent osseointegration, while one patient declined and was thus excluded from analysis. Due to the challenges posed by the pandemic, three patients who live interstate were unable to participate in face-to-face assessment. Ultimately, four patients were included in the study.\\u003c/p\\u003e \\u003cp\\u003eRegular follow-up and assessment were conducted for these patients, initially with socket/harness prosthesis and subsequently with osseointegration suspension prosthesis. The results for the four patients included in the study are listed in the following tables. Pre-intervention with osseointegration no patients were able to detect deep pressure sensation. Post osseointegration, there was an improvement observed in deep pressure sensation for one patient (Table \\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Detection of vibration varied prior to osseointegration, with three out of four patients demonstrating some ability to perceive vibration. All patients showed improvement in vibration detection post osseointegration (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Two-point discrimination was found to be zero in all patients both before and after osseointegration (Table \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Our results also indicated an enhanced ability to accurately identify the location of a stimulus, such as deep pressure or vibration following TMR and osseointegration as depicted in Table \\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults of pressure sensation detection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTMR only\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOI/TMR (average score)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults of pressure vibration detection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTMR only\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOI/TMR (average score)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults of 2 point discrimination detection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTMR only\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOI/TMR (average score)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eResults of location accuracy detection\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTMR only\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOI/TMR (average score)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient 4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eUpper limb amputation is a life-altering consequence that can stem from various causes, including trauma, malignancy, and systemic illnesses like diabetes mellitus, leaving affected individuals with substantial physical and psychological challenges. Among the many functions of the upper limb, hand function stands out as particularly vital for human beings.\\u003c/p\\u003e \\u003cp\\u003eWhile medical and technological advancements have paved the way for the continuous evolution of prosthetic devices, a significant hurdle remains\\u0026mdash;the lack of sensory feedback. Sensory feedback plays a pivotal role in creating a truly functional prosthesis, yet it is conspicuously absent in the experience of current prosthetic users. Further to this, due to constraints imposed by insurance policies, we are unable to modify prosthetic devices to enhance sensory feedback. Advanced modifications aimed at augmenting sensation do not currently fit within the scope of insurance.\\u003c/p\\u003e \\u003cp\\u003eIn our research, we embarked on a study that sought to merge the surgical techniques of osseointegration and TMR to explore the potential enhancement of sensory perception in a prosthetic limb. This combination of procedures provides a comprehensive approach to enhancing prosthetic functionality and sensory feedback. Osseointegrated prostheses are rigidly anchored to bone resulting in enhanced mechanical stability, improved vibration and load transmission through the skeleton as opposed to a socket prothesis thereby improving sensibility through \\u0026lsquo;osseoperception\\u0026rsquo;[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. This supports the theory of improved electromyography pick up from TMR muscles. There is also more consistent kinematics \\u0026ndash; because the interface does not rotate as it would in a socket-based prosthesis, joint angles and forces are more predictable. TMR involves neuroma excision and the creation of biologic amplifiers. Resulting electromyography from these muscles is strong, focal and task specific and neuroma excision improved phantom limb pain [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. Evidence on cortical reorganisation shows that somatosensory map can become maladaptive after limb loss [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. TMR may stabilise these changes by improved sensory input or reducing maladaptive signalling which is likely to support better sensory and proprioceptive integration. Combing these surgical procedures offers a synergistic platform for closed loop prosthetic control. Early clinical reports of combined TMR and osseointegration depict improvements in function, reduced pain and increased prosthetic use however detailed data on proprioception and sensation remains limited and requires future research [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur results support this, with a general improvement post TMR and osseointegration. All patients showed improvement in vibration detection, with the extent of improvement varying. Deep pressure detection was improved in one patient; the others did not show significant change. There is also a consistent lack of two-point discrimination which may suggest that this aspect of sensory perception is not significantly impacted by osseointegration. This variation may be attributed to the impact of the material utilised to create the prosthetic device such as hard plastic (patients 2,3,4) which is more conductive than silicon glove and foam covering over terminal device (patient 1) which can dampen sensation. It also highlights the multifactorial individualised nature of sensory outcomes. The observation of enhanced location accuracy in identifying stimulus post osseointegration suggests a potential positive effect of osseointegration on the spatial perception of sensory stimuli.\\u003c/p\\u003e \\u003cp\\u003eThere is substantial evidence that enhanced sensory feedback improves prosthetic control; however, there is a lack of meaningful outcome measures to quantify this effect [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. A major challenge is the absence of validated assessment tools specifically designed to evaluate tactile sensation and proprioception in upper limb prothesis users. Existing measures predominantly rely on subjective patient-reported questionnaires, which provide valuable insight but are susceptible to individual bias. Objective outcome measures offer a quantifiable and reliable evaluation of function, yet very few have been validated in upper limb prosthesis users.\\u003c/p\\u003e \\u003cp\\u003eA comprehensive review identified 17 outcome measures, only two of which incorporated sensory components \\u0026ndash; and neither were validated in upper limb prosthesis users [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. While existing functional assessments may inadvertently reflect aspects of sensory feedback, they do not account for improvements that may arising from emerging surgical techniques such as TMR and osseointegration. In this study we utilised validated screening assessments designed for the intact limb, however there are notable limitations when applied to a prosthesis user, as discussed below. There is a clear need develop standardised and validated outcome measures in this patient group. Given that such are largely conducted by allied health specialists, interdisciplinary collaboration is essential to ensure clinical utility and validity. Several potential assessment approaches could be explored including tactile location accuracy to evaluate spatial perception, prosthesis-mediated joint position tasks and object recognition without visual or auditory feedback [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Patient-reported outcomes can complement objective measures. Validated tools such as the Patient Specific Functional Scale (PSFS) - in which patients identify and reassess five tasks pre and post intervention - and the modified OPUS Upper Extremity Functional Status (UEFS) survey \\u0026ndash; which assesses perceived ability to conduct a defined set of activities of daily living - may be incorporated alongside clinical metrics to provide a more comprehensive evaluation of sensory function [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn this pilot pre-post study, participants served as their own controls. For future research we intend to pursue a large-scale study and could adopt a case-controlled design incorporating three comparison groups: a socket based non TMR/osseointegration cohort, a TMR only cohort and a combined TMR and osseointegration group with matched demographics. Several of the proposed tools could be utilised to enable rigorous assessment of sensory and proprioceptive outcomes.\\u003c/p\\u003e\"},{\"header\":\"LIMITATIONS\",\"content\":\"\\u003cp\\u003eInterruptions to data collection were experienced due to varying restrictions with face-to-face contact during the COVID-19 pandemic. There are also inconsistencies in when patients were fit with their devices based on differing approval processes and timing across funding models.\\u003c/p\\u003e \\u003cp\\u003eLimited digit extension of the terminal devices impedes their ability to lay flat on a table in a supinated position like anatomical hands. This may further impact the detection of pressure. Resistance at end range, or slight movement of the terminal device in response to pressure may be noticeable to patients, particularly more experienced prosthetic users, rather than true pressure detection and should be considered when interpreting results.\\u003c/p\\u003e \\u003cp\\u003eThere are several limitations of monofilament utilisation for sensory testing. Inter-rate reliability is already a limitation even in validated populations and this has not been tested for use in the amputee cohort. This is further exacerbated when considering that the testing force of the thickest monofilament is evaluated by visually observing the skin at the testing site \\u0026ndash; which is not possible on a prosthetic arm. This lack of visual confirmation of force may affect the reliability of this test in prosthesis users.\\u003c/p\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eIn summary, the study provides insights into the sensory outcomes of TMR and osseointegration procedures in patients with upper limb amputations, indicating both variability in individual responses and potential positive effects on spatial perception. Further research with larger sample sizes and longer-term follow-up utilising validated assessment tools will help confirm these findings and better understand the underlying mechanisms driving sensory improvements post osseointegration.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eEthics statement\\u003c/h2\\u003e \\u003cp\\u003eEthical approval to report these cases was obtained from Ethics Committee of Alfred Health \\u0026ndash; HREA Project ID is 658/19.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eConsent to participate:\\u003c/strong\\u003e \\u003cp\\u003e Written informed consent was obtained from the patient for their anonymized information to be published in this article.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eClinical Trial Number\\u003c/strong\\u003e \\u003cp\\u003eNot applicable\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by F.B.R., N.S. and A.H. The first draft of the manuscript was written by N.S. and all authors read commented on previous versions of the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eDavidson J (2002) A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther 15(1):62\\u0026ndash;70. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1053/hanthe.2002.v15.01562\\u003c/span\\u003e\\u003cspan address=\\\"10.1053/hanthe.2002.v15.01562\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHebert JS, Rehani M, Stiegelmar R (2017) Osseointegration for Lower-Limb Amputation: A Systematic Review of Clinical Outcomes. JBJS Rev 5(10):e10. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.2106/JBJS.RVW.17.00037\\u003c/span\\u003e\\u003cspan address=\\\"10.2106/JBJS.RVW.17.00037\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eStephens-Fripp B, Jean Walker M, Goddard E, Alici G (2020) A survey on what Australians with upper limb difference want in a prosthesis: justification for using soft robotics and additive manufacturing for customized prosthetic hands. Disabil Rehabil Assist Technol 15(3):342\\u0026ndash;349. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1080/17483107.2019.1580777\\u003c/span\\u003e\\u003cspan address=\\\"10.1080/17483107.2019.1580777\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCordella F, Ciancio AL, Sacchetti R et al (2016) Literature Review on Needs of Upper Limb Prosthesis Users. Front Neurosci 12:10:209. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3389/fnins.2016.00209\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fnins.2016.00209\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBlank A, Okamura AM, Kuchenbecker KJ (2010) Identifying the role of proprioception in upper-limb prosthesis control: Studies on targeted motion. ACM Trans Appl Percept 7(3):1\\u0026ndash;23. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1145/1773965.1773966\\u003c/span\\u003e\\u003cspan address=\\\"10.1145/1773965.1773966\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZaid MB, OʼDonnell RJ, Potter BK, Forsberg JA (2019) Orthopaedic Osseointegration: State of the Art. J Am Acad Orthop Surg 27(22):e977\\u0026ndash;e985. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.5435/JAAOS-D-19-00016\\u003c/span\\u003e\\u003cspan address=\\\"10.5435/JAAOS-D-19-00016\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTropf J, Potter B (2023) Osseointegration for amputees: Current state of direct skeletal attachment of prostheses. Orthoplastic Surg 12:20\\u0026ndash;28. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.orthop.2023.05.004\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.orthop.2023.05.004\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBhatnagar VM, Karani JT, Khanna A, Badwaik P, Pai A (2015) Osseoperception: An Implant Mediated Sensory Motor Control- A Review. J Clin Diagn Res 9(9):ZE18\\u0026ndash;20. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.7860/JCDR/2015/14349.6532\\u003c/span\\u003e\\u003cspan address=\\\"10.7860/JCDR/2015/14349.6532\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBowen JB, Wee CE, Kalik J, Valerio IL (2017) Targeted Muscle Reinnervation to Improve Pain, Prosthetic Tolerance, and Bioprosthetic Outcomes in the Amputee. Adv Wound Care (New Rochelle) 1;6(8):261\\u0026ndash;267. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1089/wound.2016.0717\\u003c/span\\u003e\\u003cspan address=\\\"10.1089/wound.2016.0717\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCheesborough JE, Smith LH, Kuiken TA, Dumanian GA (2015) Targeted muscle reinnervation and advanced prosthetic arms. Semin Plast Surg 29(1):62\\u0026ndash;72. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1055/s-0035-1544166\\u003c/span\\u003e\\u003cspan address=\\\"10.1055/s-0035-1544166\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSparling T, Iyer L, Pasquina P, Petrus E (2024) Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery. J Neurosci. 3;44(1):e1051232024. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1523/JNEUROSCI.1051-23.2023\\u003c/span\\u003e\\u003cspan address=\\\"10.1523/JNEUROSCI.1051-23.2023\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWebster J, Heckman J, Borgia M, Delikat J, Resnik L (2025) Outcomes in transhumeral upper limb amputation with osseointegration and targeted muscle reinnervation: A preliminary observational cohort study. PM\\u0026amp;R. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1002/pmrj.13407\\u003c/span\\u003e\\u003cspan address=\\\"10.1002/pmrj.13407\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJabban L, Dupan S, Zhang D, Ainsworth B, Nazarpour K, Metcalfe BW (2022) Sensory Feedback for Upper-Limb Prostheses: Opportunities and Barriers. IEEE Trans Neural Syst Rehabil Eng 30:738\\u0026ndash;747. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1109/TNSRE.2022.3159186\\u003c/span\\u003e\\u003cspan address=\\\"10.1109/TNSRE.2022.3159186\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWang S, Hsu CJ, Trent L, Ryan T, Kearns NT, Civillico EF, Kontson KL (2018) Evaluation of Performance-Based Outcome Measures for the Upper Limb: A Comprehensive Narrative. Rev PM\\u0026amp;R 10(9):951\\u0026ndash;962e3. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.pmrj.2018.02.008\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.pmrj.2018.02.008\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCuberovic I, Gill A, Resnik LJ, Tyler DJ, Graczyk EL (2019) Learning of Artificial Sensation Through Long-Term Home Use of a Sensory-Enabled Prosthesis. Front Neurosci 21:13:853. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3389/fnins.2019.00853\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fnins.2019.00853\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, Ertl WJ, Tintle SM, Nanos GP, Valerio IL, Kuiken TA, Apkarian AV, Porter K, Jordan SW (2019) Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Ann Surg 270(2):238\\u0026ndash;246\\u003c/span\\u003e \\u003cspan\\u003ehttps //\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/SLA.0000000000003088\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/SLA.0000000000003088\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Osseointegration, Myoelectric prosthesis, Amputation, Targeted muscle reinnervation\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8580524/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8580524/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eUpper limb amputation significantly impairs physical and psychosocial functioning. Many upper limb amputees discontinue prosthesis use due to a multitude of complications. We embarked on a study that merged the surgical techniques of osseointegration and targeted muscle reinnervation (TMR) to explore the potential enhancement of sensory perception in a prosthetic limb. Osseointegration involves skeletal anchorage of an implant and abutment to establish a direct attachment point for a prosthesis. TMR involved transfer of residual peripheral nerves to nearby redundant motor nerves creating biologic amplifiers that convert native neural signals into distant muscle contractions. Both TMR and osseointegration are known to improve sensibility and proprioception, combining these procedures will improve intuitive control.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eRoutine testing on the prosthetic limb for patients enrolled in the Advanced Surgical Amputee Program (ASAP) included two-point discrimination, monofilament assessment and vibration detection. These tests were conducted at numerous time points pre and post osseointegration and were assessed for any improvement. All patients had already undergone TMR.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eFour patients were included in this study. The results showed variable improvement in deep pressure sensation detection, consistent improvement in vibration detection and no improvement in two-point discrimination. We also found an improved ability to correctly identify the location of a stimulus.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThis study provides early evidence supporting a positive correlation between improved sensibility and spatial awareness when combining osseointegration and TMR. We recommend future research with larger cohorts and longer follow-up periods to validate and strengthen these findings.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Enhancing sensory perception in upper limb prosthetics through combined Targeted Muscle Re-innervation and osseointegration\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-11 16:04:12\",\"doi\":\"10.21203/rs.3.rs-8580524/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"dfc10bfa-c964-41dc-9933-4197a9c92864\",\"owner\":[],\"postedDate\":\"February 11th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-11T14:25:49+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-11 16:04:12\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8580524\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8580524\",\"identity\":\"rs-8580524\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}