Combining free muscle flap lower limb reconstruction with targeted muscle reinnervation: A novel strategy to prevent neuropathic pain and promote sensory restoration

Background: Severe lower extremity trauma with extensive tissue loss is often reconstructed using free muscle flaps. However, it involves vascular anastomosis but no nerve coaptation at the recipient site. Consequently, transected nerves have no opportunity to restore continuity, which can lead to neuroma formation and chronic neuropathic pain. Preventative targeted muscle reinnervation has been shown to facilitate reinnervation and reduce neuroma-related pain. This case series introduces a novel approach integrating targeted muscle reinnervation with free muscle flap reconstruction. Methods: A prospective case series was conducted at the Erasmus University Medical Center between April 2024 and June 2025. Surgical details and patient characteristics where documented, with patient- and clinician-reported outcomes assessed at 6 and 12 months. Results: Three patients with large soft tissue defects after traumatic injury of their lower extremities underwent reconstruction with a vascularized free muscle flap combined with targeted muscle reinnervation. At one year, no neuropathic pain was observed and two patients experienced partial return of deep pressure sensation. Throughout follow-up, patients reported only mild to moderate reductions in lower extremity function, stable or improved perceived quality of life and were highly satisfied with the procedure. Conclusion: Targeted muscle reinnervation combined with a free muscle flap is a technically feasible and functionally promising strategy for nerve management in soft tissue reconstruction, potentially enabling effective partial sensory restoration and potentially preventing neuroma-related pain. These findings support further investigation for broader clinical use in traumatic and elective reconstruction.