“Can you give me a thumbs up?” the surgeon asks Jerry Majetich, an Iraq War veteran, during a checkup this spring at a Boston hospital. “Can you make me a fist? And extend your fingers?”
It is an odd, even jarring, series of requests to make of a patient whose right arm has been amputated above the wrist and who, during the checkup, is not even wearing a prosthetic. And yet, to Majetich, they make sense. After each command from the doctor, he does what he is asked. You can see the muscles flex under the skin of what is left of his forearm.
“I can still feel it,” Majetich tells the doctor, explaining that in his mind’s eye, his missing hand is still there, attached to his stump. “All the fingers feel like they’re in the right place.”
Majetich’s feeling that a “phantom” hand is real is the result of a groundbreaking type of arm amputation performed in the summer of 2020 at Walter Reed National Military Medical Center in Bethesda, Md. First developed for patients requiring leg amputations, the experimental procedure recreates the connections between muscles that are lost in standard amputation surgery. Majetich was the first person to undergo the procedure on an arm.
The surgeons and engineers who pioneered the technique designed it to restore what’s known as proprioception. That’s the brain’s ability to sense where our limbs are in space and how fast and forcefully they’re moving. It doesn’t work when muscles are no longer paired up as they normally are, with one contracting and the other stretching.
The idea behind the new procedure is to help patients’ brains superimpose a phantom limb over a prosthetic one — and allow them to perceive the prosthetic as their own arm or leg. “The relevance of that is we believe it gives people a fuller sense of restoration of their body,” said Matthew Carty, the plastic surgeon who examined Majetich that afternoon last May.
Three additional patients have now had the new arm surgery as part of a 10-patient clinical trial, one at Walter Reed and two performed by Carty at Brigham and Women’s Faulkner Hospital. So far, these patients have described the sensation of their phantom limb in various ways, said Carty. Some say when they imagine moving their hand, it feels like where it used to be, while others say they feel like it extends and “rolls out of the residual limb.”
Amputation has long been viewed as a last resort, performed only when all efforts to reconstruct and save the injured limb have failed. But this trial, and the ongoing research testing a similar strategy in lower-limb patients, are a sign that amputation is increasingly seen as a viable alternative for restoring patients’ function.
“That takes both the patient and surgeon being open to the idea that amputation is not failure,” said U.S. Navy Commander Jason Souza, a plastic surgeon who operated on Majetich at Walter Reed and has since moved to The Ohio State University to direct its advanced amputation program. “It’s worth thinking about amputation as a reconstructive surgery because sometimes it’s the most effective way to address functional limitations and pain issues.”
It took Majetich a long time to be open to the idea — 15 years, in fact. By his count, the amputation was his 81st surgery.https://www.youtube.com/embed/CwI_CXMZmI0?feature=oembed
Unrelenting pain is what finally led Majetich to choose amputation. He was grievously injured in a bomb blast in Iraq in October 2005. A staff sergeant and tactical team leader in an Army psychological operations unit, his job entailed providing needed services to Iraqi communities to gain the cooperation of civic leaders and gather intelligence. He was given maps showing the locations of improvised explosive devices, bomb building facilities, and weapons caches. As retribution, he said, insurgents placed a bounty on his head. Not long after, an IED exploded under his Humvee nine miles south of Baghdad and “basically evaporated the rear half of the vehicle.”
he two soldiers seated behind him died instantly. Majetich suffered a traumatic brain injury, three spinal fractures, and urns over 37% of his body and his entire face and scalp. He lost both ears and his nose, and the thumb and pinky and he tips of the remaining three fingers of his right hand. Then, before he could be evacuated, he was shot once in the right shoulder and three times in the right leg during an hour-long firefight.
At a military hospital in Germany, he flatlined for a minute and a half. The medical team fought to stabilize him for two days, and somehow he pulled through. All the while, his gunner, who had been thrown from the Humvee, refused to leave Majetich’s side, though his own legs were shattered. On the flight home, Majetich said, “he sat next to my bed all the way back … to make sure I was safe.”
The recovery was long, and Majetich still carries many scars. He puts up with stares from strangers, PTSD, and impaired short-term memory. “I used to read about five or six books a week, but since I was injured, I’m no longer able to retain the information I read,” he said. “I’ll physically get ill if I read too much.”
Now 51, he lives in Jacksonville, Fla., and works in business development for a Wall Street firm that makes a point of hiring injured or disabled vets. Without the job and the support of his wife, Mary-Ella, Majetich says he would not have recovered as well as he has.
“I know essentially he’s disabled, or that’s how he would be labeled, but we don’t really act as if he’s disabled,” said Mary-Ella, a former pediatric nurse who works as a quality manager for the VA’s prosthetics department. “We do what we want.”
Over the years, Majetich had a dozen or so operations to relieve persistent pain in his right hand. Each time, bands of scar tissue would return within six months to a year, and the pain would too. Fearing addiction, he avoided opioid pain medications as best he could. He might be prescribed a dozen OxyContin after a surgery, and the bottle would usually last a year, he said. He did his best to mask his discomfort, but his wife saw it.
“I would be up all night with him and he was suffering, to the point that it was terrible,” said Mary-Ella. “I remember emailing one of his orthopedic surgeons saying, ‘I can’t keep doing this. We have to come up with something for him.’”
Doctors had broached amputation more than a decade ago, but Majetich wasn’t ready. “They suggested to take it off, but I didn’t want to because when she held my hand, I could feel it,” he said, looking at his wife. “I thought that was a major thing.”
But with the pain, he added with a laugh, “I was feeling too much now.”
In the end, amputation was his only option to get rid of the pain. When doctors told Majetich about the new surgery, and showed him videos of some of the patients who’d undergone leg amputations with the new approach, he was eager to be the first upper-limb patient, partly to help other injured vets who come after him.
Souza said it took courage for Majetich to undergo a surgery that had been practiced on cadaver arms but was still, to some extent, “going to be planned on the table.” Reconstructive surgeons seek strategies that restore normal anatomical relationships “but we have no clear idea how it all works,” he added. “Presented with all that uncertainty, all of that unknown, he said ‘Let’s do it.’”
Souza and a Walter Reed orthopedic surgeon, Navy Commander Scott Tintle, performed the amputation in August 2020. Two months later, Majetich got to try out an advanced brain-controlled prosthetic hand. On his right arm, he wore a sleeve embedded with sensors, which detected the electrical activity of the muscles and triggered corresponding movements in the fingers of a robotic hand on a nearby table.
“I could open it and close it. And I could do pinches and move my thumb and – it’s incredible,” he exclaimed in a Zoom interview afterward. “I could even wave.”
It took him awhile to get the knack of controlling the hand, but once he did, he explained, “when I was moving my fingers in my head and I can feel them moving, it was moving the same with the prosthetic. … Once I get used to it, I think it’s going to be pretty much like not thinking about it.”
By this summer, when he was visiting Carty in Boston, Majetich was even more enthusiastic about another aspect of his recovery. “If I never get a prosthetic, I’m happy because the pain is gone,” he told the surgeon. “Living without pain is everything.”
Since the first of the new amputation procedures was performed in 2016, 30 patients have had the surgery performed on one or both legs — including U.S. Paralympian Morgan Stickney, a double amputee who just won two swimming gold medals in Tokyo. Their results show that Majetich’s experience is not uncommon.
“What we’ve found are a number of distinct advantages of the AMI amputation,” said Hugh Herr, an MIT Media Lab professor, using the shorthand for the procedure he jointly developed with Carty. (AMI stands for agonist-antagonist myoneural interface, which refers to the joining of opposing, agonist and antagonist, muscles.) Herr said the AMI patients have felt less pain in their residual limbs, and their limbs don’t atrophy, as is typical after a standard amputation, resulting in a poor fit and pain when using a prosthesis.
In a study published last December, MIT postdoctoral fellow Shriya Srinivasan and colleagues in Herr’s group reported that when AMI patients moved their phantom ankle, a part of the brain associated with proprioception lit up on functional MRI scans just as much as it did in patients with intact limbs. This suggests the surgery fully restored patients’ ability to sense their limbs’ position and motion, a result Herr called “truly remarkable.” In people who had standard amputations, activation of this region was significantly reduced.
Outside of a brain scanner, the restoration of proprioception can in some ways give patients the feeling of having a real foot. One AMI amputee was hiking recently while wearing a standard prosthesis and stepped into a creek. He later described having the sensation of water flowing over his prosthetic foot even though it had no way to perceive that. “He trusted or embodied his prosthesis more than someone who doesn’t have this phantom sensation,” said Carty.
There’s still more work to be done to perfect the procedure, especially to enable amputees to seamlessly control bionic limbs like the arms and legs nature gave them. Among the innovations being developed by Herr’s team are magnetic beads, which would be implanted in the muscles of AMI amputees to facilitate precise tracking of every stretch and twitch — readings a computerized prosthetic could use to mimic the “motor intent of the human,” as Herr put it.
That technology is probably at least five years away from being commercially available, estimated Herr, himself a double leg amputee. For now, the reconstructive surgical techniques developed for Majetich and the other patients are ahead of the technology for meshing human physiology with robotic electronics, a point that dawned on Mary-Ella Majetich one day in June, when her husband reached for her hand with his amputated right arm.
At first she was so excited that he perceived his hand was there that she texted Souza to tell him what happened. But almost immediately, she felt sad “knowing that he can’t really feel like he could before,” she recalled in an email. “The first time he reached for me it was a sweet moment between us. It’s happened several times and we laugh it off; maybe someday he’ll have a prosthetic that he will be able to follow through with and hold my hand.”