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Kang N, Al-Ajam Y, Keen P, Woollard A, Steinitz H, Farrant J, Chow G. Radiological evaluation before and after treatment with an osseointegrated bone-anchor following major limb amputation-a guide for radiologists. Skeletal Radiol 2024; 53:1033-1043. [PMID: 38044373 PMCID: PMC11001742 DOI: 10.1007/s00256-023-04524-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
Osseointegrated implants have been developed to allow direct skeletal fixation of a prosthesis as an alternative to traditional socket-fitted prostheses for patients who have suffered from a major limb amputation. The implants contribute to improvements in functional outcome and quality of life and radiological evaluation plays a crucial role in pre- and post-operative assessment. This article acts as a guide for radiologists who may be tasked with providing the radiological information required by surgeons and prosthetists. We also look at the radiological appearances of complications that may arise in patients treated with an osseointegrated implant. Plain X-rays are used to screen patients who wish to undergo treatment. Limb-length X-rays are then used to measure the length of any residual bone, and comparisons can be made with the normal side (if present). From this, decisions about the likely size of the implant and the need for further amputation can be made. CT scans enable accurate assessment of the medullary cavity and cortical thickness. Post-operatively, plain X-rays form the mainstay of the routine monitoring of the bone-implant interface. Potential complications include infection, aseptic loosening, mechanical fracture of the implant and periprosthetic fracture. Infection and aseptic loosening can be seen as a lucency at the bone-implant interface which (if left untreated) can lead to loss of the implant. Implant and periprosthetic fractures are radiographically obvious. Radiologists involved in the care of patients undergoing treatment with an osseointegrated implant should become familiar with the imaging requirements so they can contribute to optimal patient outcomes.
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Affiliation(s)
- Norbert Kang
- Department of Plastic Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Yazan Al-Ajam
- Department of Plastic Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Phyllis Keen
- Faculty of Medicine, Imperial College London, Sir Alexander Fleming Building, Imperial College Rd, London, UK.
| | - Alexander Woollard
- Department of Plastic Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Hannah Steinitz
- Department of Radiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Joanna Farrant
- Department of Radiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Geoffrey Chow
- Department of Radiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
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Sturma A, Boesendorfer A, Gstoettner C, Baumgartner B, Salminger S, Farina D, Brånemark R, Vujaklija I, Hobusch G, Aszmann O. Long-term functional and clinical outcome of combined targeted muscle reinnervation and osseointegration for functional bionic reconstruction in transhumeral amputees: a case series. J Rehabil Med 2024; 56:jrm34141. [PMID: 38770700 DOI: 10.2340/jrm.v56.34141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE To describe and evaluate the combination of osseointegration and nerve transfers in 3 transhumeral amputees. DESIGN Case series. PATIENTS Three male patients with a unilateral traumatic transhumeral amputation. METHODS Patients received a combination of osseointegration and targeted muscle reinnervation surgery. Rehabilitation included graded weight training, range of motion exercises, biofeedback, table-top prosthesis training, and controlling the actual device. The impairment in daily life, health-related quality of life, and pain before and after the intervention was evaluated in these patients. Their shoulder range of motion, prosthesis embodiment, and function were documented at a 2- to 5-year follow-up. RESULTS All 3 patients attended rehabilitation and used their myoelectric prosthesis on a daily basis. Two patients had full shoulder range of motion with the prosthesis, while the other patient had 55° of abduction and 45° of anteversion. They became more independent in their daily life activities after the intervention and incorporated their prosthesis into their body scheme to a high extent. CONCLUSION These results indicate that patients can benefit from the combined procedure. However, the patients' perspective, risks of the surgical procedures, and the relatively long rehabilitation procedure need to be incorporated in the decision-making.
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Affiliation(s)
- Agnes Sturma
- Degree Program Physiotherapy, Department of Health Sciences, University of Applied Sciences FH Campus Vienna, Vienna, Austria; Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Benedikt Baumgartner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Stefan Salminger
- AUVA Trauma Hospital Lorenz Böhler-European Hand Trauma Center, Vienna, Austria.
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, UK.
| | - Rickard Brånemark
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; K. Lisa Yang Center for Bionics, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, USA.
| | - Ivan Vujaklija
- Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland.
| | - Gerhard Hobusch
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria.
| | - Oskar Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.
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Shrivas S, Samaur H, Yadav V, Boda SK. Soft and Hard Tissue Integration around Percutaneous Bone-Anchored Titanium Prostheses: Toward Achieving Holistic Biointegration. ACS Biomater Sci Eng 2024; 10:1966-1987. [PMID: 38530973 DOI: 10.1021/acsbiomaterials.3c01555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
A holistic biointegration of percutaneous bone-anchored metallic prostheses with both hard and soft tissues dictates their longevity in the human body. While titanium (Ti) has nearly solved osseointegration, soft tissue integration of percutaneous metallic prostheses is a perennial problem. Unlike the firm soft tissue sealing in biological percutaneous structures (fingernails and teeth), foreign body response of the skin to titanium (Ti) leads to inflammation, epidermal downgrowth and inferior peri-implant soft tissue sealing. This review discusses various implant surface treatments/texturing and coatings for osseointegration, soft tissue integration, and against bacterial attachment. While surface microroughness by SLA (sandblasting with large grit and acid etched) and porous calcium phosphate (CaP) coatings improve Ti osseointegration, smooth and textured titania nanopores, nanotubes, microgrooves, and biomolecular coatings encourage soft tissue attachment. However, the inferior peri-implant soft tissue sealing compared to natural teeth can lead to peri-implantitis. Toward this end, the application of smart multifunctional bioadhesives with strong adhesion to soft tissues, mechanical resilience, durability, antibacterial, and immunomodulatory properties for soft tissue attachment to metallic prostheses is proposed.
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Affiliation(s)
- Sangeeta Shrivas
- Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Khandwa Road, Simrol, Indore 453552, India
| | - Harshita Samaur
- Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Khandwa Road, Simrol, Indore 453552, India
| | - Vinod Yadav
- Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Khandwa Road, Simrol, Indore 453552, India
| | - Sunil Kumar Boda
- Department of Biosciences and Biomedical Engineering, Indian Institute of Technology Indore, Khandwa Road, Simrol, Indore 453552, India
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Black GG, Vaeth AM, Kochheiser M, Chen Y, Truong AY, Reif T, Rozbruch SR, Henry MW, Otterburn DM. Infection After Lower-Limb Osseointegration: A Single-Center Retrospective Evaluation of Pathogens, Management, and Outcomes. Ann Plast Surg 2024; 92:S96-S100. [PMID: 38556655 DOI: 10.1097/sap.0000000000003856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
PURPOSE Osseointegration (OI) is a novel alternative to traditional socket-suspended prostheses for lower-limb amputees, eliminating the socket-skin interface and allowing for weight bearing directly on the skeletal system. However, the stoma through which the implant attaches to the external prosthesis creates an ingress route for bacteria, and infection rates as high as 66% have been reported. The aims of this study are to classify infection management and long-term outcomes in this patient population to maximize implant salvage. METHODS An institutional review board-approved retrospective analysis was performed on all patients who underwent lower-limb OI at our institution between 2017 and 2022. Demographic, operative, and outcome data were collected for all patients. Patients were stratified by the presence and severity of infection. Chi-square and t tests were performed on categorical and continuous data, respectively, using an alpha of 0.05. RESULTS One hundred two patients met our study criteria; 62 had transfemoral OI and 40 had transtibial OI. Patients were followed for 23.8 months on average (range, 3.5-63.7). Osteomyelitis was more likely than soft tissue infection to be polymicrobial in nature (71% vs 23%, P < 0.05). Infections at the stoma were mostly (96%) managed with oral antibiotics alone, whereas deeper soft tissue infections also required intravenous antibiotics (75%) or operative washout (19%). Osteomyelitis was managed with intravenous antibiotics and required operative attention; 5 (71%) underwent washout and 2 (29%) underwent explantation. Both implants were replaced an average of 3.5 months after explantation. There was no correlation between history of soft tissue infection and development of osteomyelitis (P > 0.05). The overall implant salvage rate after infection was 96%. CONCLUSIONS This study describes our institution's experience managing infection after OI and soft tissue reconstruction. Although infections do occur, they are easily treatable and rarely require operative intervention. Explantation due to infection is rare and can be followed up with reimplantation, reaffirming that OI is a safe and effective treatment modality.
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Affiliation(s)
- Grant G Black
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Anna M Vaeth
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Makayla Kochheiser
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Yunchan Chen
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Albert Y Truong
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Taylor Reif
- Limb Lengthening and Complex Reconstruction Service
| | | | - Michael W Henry
- Division of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - David M Otterburn
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
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5
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Bregoli C, Lando M, Adani R, Sette PD, Rampoldi M, Morellato K, Gruppioni E, Tuissi A. Patient-matched osseointegrated prostheses for thumb amputees: a cadaver and feasibility study. J Hand Surg Eur Vol 2024; 49:512-519. [PMID: 37606585 DOI: 10.1177/17531934231193880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Thumb amputations affect 50% of hand functionality. Common solutions consist of microsurgical treatments or silicone vacuum prosthesis. Not all patients are eligible for microsurgical treatment and the use of vacuum prosthesis is often discouraged because of their instability. On the contrary, osseointegrated prosthesis provide stable retention and osseoperception. This cadaveric study evaluated the process of a patient-matched osseointegrated prosthesis for the treatment of thumb amputees. Computed tomography (CT) medical images reconstruction provided information on metacarpal stump, used as input for the parametric screw design. Preoperative planning guided the surgeons in the surgery: postoperative placement confirmed the accuracy of the preoperative planning. Surgeons were directly involved in the implant design to meet their requirements and patient needs. Implants were inserted into cadaveric specimens in one-stage surgery. A similar process can be adopted and exploited for the treatment of different levels of thumb amputations and long finger amputations.
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Affiliation(s)
- Chiara Bregoli
- CNR ICMATE, National Research Council, Unit of Lecco, Lecco, Italy
| | - Mario Lando
- Department of Hand surgery and Microsurgery, University Hospital of Modena, Modena, Italy
| | - Roberto Adani
- Department of Hand surgery and Microsurgery, University Hospital of Modena, Modena, Italy
| | - Priscilla Di Sette
- Hand and Reconstructive Surgery Unit, Centro Traumatologico Ortopedico A. Alesini, Rome, Italy
| | - Michele Rampoldi
- Hand and Reconstructive Surgery Unit, Centro Traumatologico Ortopedico A. Alesini, Rome, Italy
| | | | | | - Ausonio Tuissi
- CNR ICMATE, National Research Council, Unit of Lecco, Lecco, Italy
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Evans AR, Tetsworth K, Quinnan S, Wixted JJ. Transcutaneous osseointegration for amputees. OTA Int 2024; 7:e326. [PMID: 38487401 PMCID: PMC10936159 DOI: 10.1097/oi9.0000000000000326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 03/17/2024]
Abstract
Transcutaneous osseointegration for amputees (TOFA) is an evolving technology that has the potential to revolutionize the interface between the amputee and their prosthesis, showing potential at many levels of amputation. While no amputation is without its challenges, TOFA requires a highly specialized prosthesis and a multidisciplinary team that includes specialized surgeons, physical therapists, wound care teams, and social workers who guide the amputee through surgery, postoperative rehabilitation, and the chronic wound care that goes into maintaining the prosthesis. The infrastructure required to facilitate care pathways that lead to reliable, successful outcomes are unique in each health care setting, including those in advanced health care systems such as the United States and Australia. This article details the emerging evidence supporting the use of this prosthetic interface design and many of the challenges that providers face when establishing programs to offer this type of care in the United States.
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Affiliation(s)
- Andrew R. Evans
- Orthopedic Trauma Service, Department of Orthopedics, The Warren Alpert School of Medicine, Brown University/Rhode Island Hospital, Providence, RI
| | - Kevin Tetsworth
- Trauma & Limb Reconstruction Unit, Department of Orthopaedics, Royal Brisbane Hospital, Herston, Australia
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Hauschild G, Hardes J, Dudda M, Streitbürger A, Wahrenburg M. Impact of topography and added TiN-coating on adult human dermal fibroblasts after seeding on titanium surface in-vitro. J Biomater Appl 2024; 38:905-914. [PMID: 38358702 PMCID: PMC10893772 DOI: 10.1177/08853282241233194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Complications of transcutaneous osseointegrated prosthetic systems (TOPS) focus on the metal-cutaneous interface at the stoma. Besides pain due to scare tissue as well as undefined neuropathic disorders, there is high evidence that the stoma presents the main risk causing hypergranulation and ascending infection. To restore the cutaneous barrier function in this functional area, soft-tissue on- or in-growth providing a vital and mechanically stable bio-artificial conjunction is considered a promising approach. In this study we assessed viability and proliferation of adult human dermal fibroblasts (HDFa) on modifications of a standard prosthetic titanium surface. Un-coated (TiAl6V4) as well as a titanium-nitrite (TiN) coated additive manufactured porous three-dimensional surface structures (EPORE®) were seeded with HDFa and compared to plain TiAl6V4 and polystyrene surfaces as control. Cell viability and proliferation were assessed at 24 h and 7 days after seeding with a fluorescence-based live-dead assay. Adhesion and cell morphology were analyzed by scanning electron microscopy at the respective measurements. Both EPORE® surface specifications revealed a homogenous cell distribution with flat and spread cell morphology forming filopodia at both measurements. Proliferation and trend to confluence was seen on un-coated EPORE® surfaces with ongoing incubation but appeared substantially lower on the TiN-coated EPORE® specification. While cell viability on both EPORE® specifications was comparable to plain TiAL6V4 and polystyrene controls, cell proliferation and confluence were less pronounced when compared to controls. The EPORE® topography allows for fibroblast adhesion and viability in both standard TiAl6V4 and - to a minor degree - TiN-coated specifications as a proof of principle.
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Affiliation(s)
- G. Hauschild
- Department of Orthopedic Oncology, University Hospital Essen, Essen, Germany
| | - J. Hardes
- Department of Orthopedic Oncology, University Hospital Essen, Essen, Germany
| | - M. Dudda
- Clinic of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - A. Streitbürger
- Department of Orthopedic Oncology, University Hospital Essen, Essen, Germany
| | - M. Wahrenburg
- Department of Orthopedic Oncology, University Hospital Essen, Essen, Germany
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Mirulla AI, Brogi C, Barone G, Secciani N, Sansom W, Bartalucci L, Ridolfi A, Allotta B, Bragonzoni L. External devices increasing bone quality in animals: A systematic review. Heliyon 2023; 9:e22379. [PMID: 38027551 PMCID: PMC10679491 DOI: 10.1016/j.heliyon.2023.e22379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/28/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background: Osteoporosis can reduce bone quality and increase the risk of fractures. In addition to pharmacological approaches, physical activity, and implanted devices, external devices can also be detected in the literature as a technique to strengthen bones. This type of intervention arises to be particularly promising because it minimizes the invasiveness of therapy. Methods: A systematic review of the technologies involved in such devices was carried out to identify the most fruitful ones in improving bone quality. This review, according to the PRISMA Statement, focuses on studies involving animals, and excludes pharmaceutical approaches. Findings: The animal models and devices used, their settings, interventions, outcomes measured, and consequent effect on bone quality are reported for each detected technology. Ultrasound and laser arose to be the most studied technologies in the literature, even if they have yet to be proved to have a significant effect on bone quality. Interpretation: External devices for bone quality improvement offer a non-invasive approach that causes minimum discomfort to the patient. This review aimed to detect which technologies reported in the literature significantly affect bone quality. The results showed that several technologies are currently used to improve bone quality. However, each study measures different outcomes and uses different measurement methods, device settings, and interventions. This lack of standardization and the reduced number of articles found do not allow for proper quantitative comparisons.
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Affiliation(s)
- Agostino Igor Mirulla
- Department for Life Quality Studies, University of Bologna, Corso d'Augusto 237, 47921, Rimini, Italy
| | - Chiara Brogi
- Department of Industrial Engineering, University of Florence, Via di Santa Marta 3, 50139, Firenze, Italy
| | - Giuseppe Barone
- Department for Life Quality Studies, University of Bologna, Corso d'Augusto 237, 47921, Rimini, Italy
| | - Nicola Secciani
- Department of Industrial Engineering, University of Florence, Via di Santa Marta 3, 50139, Firenze, Italy
| | - William Sansom
- Department for Life Quality Studies, University of Bologna, Corso d'Augusto 237, 47921, Rimini, Italy
| | - Lorenzo Bartalucci
- Department of Industrial Engineering, University of Florence, Via di Santa Marta 3, 50139, Firenze, Italy
| | - Alessandro Ridolfi
- Department of Industrial Engineering, University of Florence, Via di Santa Marta 3, 50139, Firenze, Italy
| | - Benedetto Allotta
- Department of Industrial Engineering, University of Florence, Via di Santa Marta 3, 50139, Firenze, Italy
| | - Laura Bragonzoni
- Department for Life Quality Studies, University of Bologna, Corso d'Augusto 237, 47921, Rimini, Italy
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Rask DMG, Adams MH, Liverneaux P, Plucknette BF, Wilson DJ, Alderete JF, Sabbag CM. Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review. Hand Surg Rehabil 2023; 42:392-399. [PMID: 37499798 DOI: 10.1016/j.hansur.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.
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Affiliation(s)
- Dawn M G Rask
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mason H Adams
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA.
| | - Philippe Liverneaux
- ICube, University of Strasbourg, CNRS, 2-4 rue Boussingault, 67000 Strasbourg, France; Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 avenue Molière, 67200 Strasbourg, France
| | | | - David J Wilson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Joseph F Alderete
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Casey M Sabbag
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
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10
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Di Paolo S, Barone G, Alesi D, Mirulla AI, Gruppioni E, Zaffagnini S, Bragonzoni L. Longitudinal Gait Analysis of a Transfemoral Amputee Patient: Single-Case Report from Socket-Type to Osseointegrated Prosthesis. Sensors (Basel) 2023; 23:4037. [PMID: 37112378 PMCID: PMC10143735 DOI: 10.3390/s23084037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/07/2023] [Indexed: 06/19/2023]
Abstract
The aim of the present case report was to provide a longitudinal functional assessment of a patient with transfemoral amputation from the preoperative status with socket-type prosthesis to one year after the osseointegration surgery. A 44 years-old male patient was scheduled for osseointegration surgery 17 years after transfemoral amputation. Gait analysis was performed through 15 wearable inertial sensors (MTw Awinda, Xsens) before surgery (patient wearing his standard socket-type prosthesis) and at 3-, 6-, and 12-month follow-ups after osseointegration. ANOVA in Statistical Parametric Mapping was used to assess the changes in amputee and sound limb hip and pelvis kinematics. The gait symmetry index progressively improved from the pre-op with socket-type (1.14) to the last follow-up (1.04). Step width after osseointegration surgery was half of the pre-op. Hip flexion-extension range significantly improved at follow-ups while frontal and transverse plane rotations decreased (p < 0.001). Pelvis anteversion, obliquity, and rotation also decreased over time (p < 0.001). Spatiotemporal and gait kinematics improved after osseointegration surgery. One year after surgery, symmetry indices were close to non-pathological gait and gait compensation was sensibly decreased. From a functional point of view, osseointegration surgery could be a valid solution in patients with transfemoral amputation facing issues with traditional socket-type prosthesis.
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Affiliation(s)
- Stefano Di Paolo
- Department for Life Quality Studies, University of Bologna, 47921 Rimini, Italy
| | - Giuseppe Barone
- Department for Life Quality Studies, University of Bologna, 47921 Rimini, Italy
| | - Domenico Alesi
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Agostino Igor Mirulla
- Department for Life Quality Studies, University of Bologna, 47921 Rimini, Italy
- Department of Engineering, University of Palermo, 40126 Palermo, Italy
| | - Emanuele Gruppioni
- Istituto Nazionale Assicurazione Infortuni sul Lavoro (INAIL), Centro Protesi Inail, 40054 Vigorso di Budrio, Italy
| | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Laura Bragonzoni
- Department for Life Quality Studies, University of Bologna, 47921 Rimini, Italy
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11
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Davis-Wilson HC, Christiansen CL, Gaffney BMM, Lev G, Enabulele E, Hoyt C, Stoneback JW. Changes in lower extremity joint moments one-year following osseointegration in individuals with Transfemoral lower-limb amputation: A case series. Clin Biomech (Bristol, Avon) 2023; 104:105948. [PMID: 37043833 PMCID: PMC10988390 DOI: 10.1016/j.clinbiomech.2023.105948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Dissatisfaction with socket prostheses has led to the development of bone-anchored prostheses through osseointegration for people with transfemoral amputation, eliminating the need for a prosthetic socket. Gait deviations of transfemoral prosthesis users may be linked to increased risk of osteoarthritis, and it remains unknown if gait biomechanics change following osseointegration. The purpose of this case series was to evaluate the longitudinal changes in joint kinetics one year post-osseointegration in patients with transfemoral amputation during walking. METHODS Knee, hip, and trunk internal moments were evaluated in the prosthetic and intact limbs during walking at a self-selected speed in four participants pre- and one-year post-osseointegration. Longitudinal changes were quantified using the percent change (%∆) in peak joint moments between the two time points and Cohen's d (d) effect size was used to determine the magnitude of effect on joint moments during walking one year following osseointegration. FINDINGS Participants demonstrated increased peak knee extension moment (224 ± 308%∆, d = -1.31) in the prosthetic limb, while demonstrating reduced peak knee extension moment (-43 ± 34%∆, d = 1.82) in the intact limb post-osseointegration. Participants demonstrated bilateral reduction of peak hip extension moment (prosthetic: -22 ± 37%∆, d = 0.86; intact: -29 ± 10%∆, d = 1.27) and bilateral increase of peak hip abduction moment (prosthetic: 45 ± 40%∆, d = 1.20; intact: 23 ± 44%∆, d = 0.74) post-osseointegration. Participants demonstrated reduced peak trunk moments on both the prosthetic (extension: -31 ± 16%∆, d = 1.51; lateral flexion: -21 ± 20%∆, d = 0.63) and intact side (extension: -7 ± 22%∆, d = 0.38; lateral flexion: -22 ± 18%∆, d = 1.12) post-osseointegration. INTERPRETATION This case series suggests improved gait symmetry in individuals with transfemoral amputation one year following osseointegration, justifying future investigation.
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Affiliation(s)
- Hope C Davis-Wilson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurura, CO, USA.
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurura, CO, USA
| | - Brecca M M Gaffney
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, USA; Center for Bioengineering, Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Guy Lev
- University of Colorado, Hospital, Aurora, CO, USA
| | - Eseosa Enabulele
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher Hoyt
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jason W Stoneback
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Hoellwarth JS, Tetsworth K, Akhtar MA, Al Muderis M. Transcutaneous Osseointegration for Amputees: What Is It, How Did It Evolve, and What May Develop? Curr Phys Med Rehabil Rep 2023. [DOI: 10.1007/s40141-023-00376-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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13
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Krauskopf T, Lauck T, Meyer B, Klein L, Mueller M, Kubosch J, Herget G, von Tscharner V, Ernst J, Stieglitz T, Pasluosta C. Neuromuscular adaptations after osseointegration of a bone-anchored prosthesis in a unilateral transfemoral amputee - a case study. Ann Med 2023; 55:2255206. [PMID: 37677026 PMCID: PMC10486294 DOI: 10.1080/07853890.2023.2255206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023] Open
Abstract
PURPOSE Many individuals with a lower limb amputation experience problems with the fitting of the socket of their prosthesis, leading to dissatisfaction or device rejection. Osseointegration (OI)- the implantation of a shaft directly interfacing with the remaining bone- is an alternative for these patients. In this observational study, we investigated how bone anchoring influences neuromuscular parameters during balance control in a patient with a unilateral transfemoral amputation. MATERIAL AND METHODS Center of pressure (CoP) and electromyography (EMG) signals from muscles controlling the hip and the ankle of the intact leg were recorded during quiet standing six months before and one and a half years after this patient underwent an OI surgery. Results were compared to a control group of nine able-bodied individuals. RESULTS Muscle co-activation and EMG intensity decreased after bone anchoring, approaching the levels of able-bodied individuals. Muscle co-activation controlling the ankle decreased in the high-frequency range, and the EMG intensity spectrum decreased in the lower-frequency range for all muscles when vision was allowed. With eyes closed, the ankle extensor muscle showed an increased EMG intensity in the high-frequency range post-surgery. CoP length increased in the mediolateral direction of the amputated leg. CONCLUSIONS These findings point to shifts in the patient's neuromuscular profile towards the one of able-bodied individuals.
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Affiliation(s)
- Thomas Krauskopf
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- BrainLinks-BrainTools Center, University of Freiburg, Freiburg, Freiburg, Germany
| | - Torben Lauck
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - Britta Meyer
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - Lukas Klein
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Johanna Kubosch
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Georg Herget
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Jennifer Ernst
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
- Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Goettingen, Göttingen, Germany
| | - Thomas Stieglitz
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- BrainLinks-BrainTools Center, University of Freiburg, Freiburg, Freiburg, Germany
- Bernstein Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Cristian Pasluosta
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
- BrainLinks-BrainTools Center, University of Freiburg, Freiburg, Freiburg, Germany
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14
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Wankier Z, Taylor C, Drew A, Kubiak E, Agarwal J, Sinclair S. Use of computer tomography imaging for analyzing bone remodeling around a percutaneous osseointegrated implant. J Orthop Res 2022; 40:2065-2075. [PMID: 34910325 DOI: 10.1002/jor.25247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/01/2021] [Accepted: 12/11/2021] [Indexed: 02/04/2023]
Abstract
Osseointegration (OI) is being used for the direct skeletal attachment of prosthetic limbs using an intramedullary stem that extends percutaneously from the subject's residual limb. For this technology to be successful, bone ingrowth and remodeling around the implant must occur. Physicians need an effective way to assess bone remodeling to make informed treatment and rehabilitation decisions. Previous studies utilizing two-dimensional imaging X-ray as a tool to monitor bone-remodeling around OI devices have limitations. This study describes methodology that was developed utilizing computed tomography (CT) imaging as a tool for analyzing bone remodeling around a percutaneous OI implant. Six transfemoral amputees implanted with a percutaneous osseointegrated prosthesis (POP) had CT scans taken of their residual femur at 6 and 52 weeks postoperatively. Three-dimensional femoral models were processed using custom MATLAB script to collect cortical and medullary morphology measurements. Morphology data from 6- and 52-week scans were compared to quantify bone remodeling around the POP implant. Fifty-two weeks after implantation of the POP device, increases in cortical bone area and thickness were observed around the porous-coated stem. Minimal changes were observed in the medullary canal parameters within the periprosthetic regions. This study successfully utilized CT imaging and three-dimensional modeling techniques to analyze longitudinal data of bone remodeling around a transfemoral percutaneous implant. These methods have the potential to be used as a clinical tool for evaluating orthopedic implants in vivo. Data collected suggests that the POP device achieved the desired bone remodeling around the porous-coated region of the implanted stem.
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Affiliation(s)
- Zakary Wankier
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Carolyn Taylor
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Alex Drew
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Erik Kubiak
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA.,Department of Orthopedic Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Jayant Agarwal
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA.,Division of Plastic Surgery, Salt Lake City, Utah, USA
| | - Sarina Sinclair
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
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15
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Gaffney BMM, Vandenberg NW, Davis-Wilson HC, Christiansen CL, Roda GF, Schneider G, Johnson T, Stoneback JW. Biomechanical compensations during a stand-to-sit maneuver using transfemoral osseointegrated prostheses: A case series. Clin Biomech (Bristol, Avon) 2022; 98:105715. [PMID: 35839740 DOI: 10.1016/j.clinbiomech.2022.105715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/24/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with transfemoral amputation and socket prostheses are at a heightened risk of developing musculoskeletal overuse injuries, commonly due to altered joint biomechanics. Osseointegrated prostheses, which involve direct anchorage of the prosthesis to the residual limb through a bone anchored prosthesis, are a novel alternative to sockets yet their biomechanical effect is largely unknown. METHODS Four patients scheduled to undergo unilateral transfemoral prosthesis osseointegration completed two data collections (baseline with socket prosthesis and 12-months after prosthesis osseointegration) in which whole-body kinematics and ground reaction forces were collected during stand-to-sit tasks. Trunk, pelvis, and hip kinematics, and the surrounding muscle forces, were calculated using subject-specific musculoskeletal models developed in OpenSim. Peak joint angles and muscle forces were compared between timepoints using Cohen's d effect sizes. FINDINGS Compared to baseline with socket prostheses, patients with osseointegrated prostheses demonstrated reduced lateral trunk bending (d = 1.46), pelvic obliquity (d = 1.09), and rotation (d = 1.77) toward the amputated limb during the stand to sit task. This was accompanied by increased amputated limb hip flexor, abductor, and rotator muscle forces (d> > 0.8). INTERPRETATION Improved lumbopelvic movement patterns and stabilizing muscle forces when using an osseointegrated prosthesis indicate that this novel prosthesis type likely reduces the risk of the development and/or progression of overuse injuries, such as low back pain and osteoarthritis. We attribute the increased muscle hip muscle forces to the increased load transmission between the osseointegrated prosthesis and residual limb, which allows a greater eccentric ability of the amputated limb to control lowering during the stand-to-sit task.
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Affiliation(s)
- Brecca M M Gaffney
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America; Center for Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America.
| | - Nicholas W Vandenberg
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America
| | - Hope C Davis-Wilson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America; VA Eastern Colorado Healthcare System, Aurora, CO, United States of America
| | - Cory L Christiansen
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America; VA Eastern Colorado Healthcare System, Aurora, CO, United States of America
| | - Galen F Roda
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America
| | - Gary Schneider
- University of Colorado Hospital, Aurora, CO, United States of America
| | - Tony Johnson
- University of Colorado Hospital, Aurora, CO, United States of America
| | - Jason W Stoneback
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
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Sinclair S, Beck JP, Webster J, Agarwal J, Gillespie B, Stevens P, Gililland J, Kubiak E. The First FDA Approved Early Feasibility Study of a Novel Percutaneous Bone Anchored Prosthesis for Transfemoral Amputees: A Prospective One-year Follow-up Cohort Study. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/20/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
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Stogov MV, Emanov AA, Goodovykh NV, Ovchinnikov EN, Tushina NV, Kuznetsov VP. Microbiological Profile of the Implantation Zone under Different Mechanical Compression of Percutaneous Implants: Experimental Study. Traumatology and Orthopedics of Russia 2022; 28:38-47. [DOI: 10.17816/2311-2905-1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Background. Infection of percutaneous implants in patients with limb amputation is the most common complication.
Aim of the study evaluation of the microflora in the implantation zone depending on the mechanical compression of the implant in conditions of its additional external fixation.
Methods. The study was performed on 36 male rabbits. The tibia of all the rabbits was sawn at the border of the upper and middle parts. The medullary canal was reamed and a percutaneous implant was placed in the tibial stump. The segment and the implant were fixed with an Ilizarov apparatus. An additional compression device was installed in 30 animals. We used 5 compression modes, accordingly, 6 experimental groups were formed, 6 animals in each: group 1 without compression, group 2 compression on the implant with force of 0.053 N/mm2, group 3 compression on the implant with force of 0.105 N/mm2, group 4 compression on the implant with force of 0.158 N/mm2, group 5 compression on the implant with force of 0.211 N/mm2, group 6 compression on the implant with force of 0.263 N/mm2. The restraint was removed 6 weeks after implantation for a total follow-up of 26 weeks. The microflora of the place where the implant enters the skin (the implant / skin interface) was investigated, the level of blood leukocytes and the level of C-reactive protein in blood serum were determined.
Results. On days 9-10 after implantation, significant differences in the microbial landscape were found at the site of the exit of the metal implant in animals of different groups. The largest number of strains was found in animals of groups 1, 5 and 6, the smallest in groups 2 and 3. The most frequently detected strains: S. saprophyticus and Enterococcus spp. It was found that the greatest statistically significant increase in the level of CRP in the blood serum was observed in animals of group 6. The level of leukocytes in animals of all groups did not change statistically significantly relative to preoperative values. Animals with better osseointegration (groups 2 and 3 no cases of implant loss) showed a minimal number of growing strains.
Conclusions. The microbiological profile of the implantation zone of percutaneous implants changes depending on the amount of mechanical compression. The optimal mode is 0.053-0.105 N/mm2.
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Bregoli C, Biffi CA, Morellato K, Gruppioni E, Primavera M, Rampoldi M, Lando M, Adani R, Tuissi A. Osseointegrated Metallic Implants for Finger Amputees: A Review of the Literature. Orthop Surg 2022; 14:1019-1033. [PMID: 35524645 PMCID: PMC9163974 DOI: 10.1111/os.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 12/01/2022] Open
Abstract
Digital trauma amputations and digital agenesis strongly affect the functionality and aesthetic appearance of the hand. Autologous reconstruction is the gold standard of treatment. Unfortunately, microsurgical options and transplantation procedures are not possible for patients who present contraindications or refuse to undergo transplantation from the toe (e.g. toe‐to‐thumb transplantation). To address these issues, osseointegrated finger prostheses are a promising alternative. The functional assessments registered during follow‐up confirmed the promising outcomes of osseointegrated prostheses in the treatment of hand finger amputees. This review outlines (a) a detailed analysis of osseointegrated finger metallic components of the implants, (b) the surgical procedures suggested in the literature, and (c) the functional assessments and promising outcomes that demonstrate the potential of these medical osseointegrated devices in the treatment of finger amputees.
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Affiliation(s)
- Chiara Bregoli
- Unit of Lecco, CNR ICMATE, National Research Council, Lecco, Italy
| | | | | | | | - Matteo Primavera
- Hand and Reconstructive Surgery Unit, Centro Traumatologico Ortopedico A. Alesini, Rome, Italy
| | - Michele Rampoldi
- Hand and Reconstructive Surgery Unit, Centro Traumatologico Ortopedico A. Alesini, Rome, Italy
| | - Mario Lando
- Department of Hand surgery and Microsurgery, University Hospital of Modena, Modena, Italy
| | - Roberto Adani
- Department of Hand surgery and Microsurgery, University Hospital of Modena, Modena, Italy
| | - Ausonio Tuissi
- Unit of Lecco, CNR ICMATE, National Research Council, Lecco, Italy
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Mohamed J, Reetz D, van de Meent H, Schreuder H, Frölke JP, Leijendekkers R. What Are the Risk Factors for Mechanical Failure and Loosening of a Transfemoral Osseointegrated Implant System in Patients with a Lower-limb Amputation? Clin Orthop Relat Res 2022; 480:722-731. [PMID: 34889879 PMCID: PMC8923606 DOI: 10.1097/corr.0000000000002074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/16/2021] [Accepted: 11/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Septic loosening and stem breakage due to metal fatigue is a rare but well-known cause of orthopaedic implant failure. This may also affect the components of the osseointegrated implant system for individuals with transfemoral amputation who subsequently undergo revision. Identifying risk factors is important to minimize the frequency of revision surgery after implant breakage. QUESTIONS/PURPOSES (1) What proportion of patients who received an osseointegrated implant after transfemoral amputation underwent revision surgery, and what were the causes of those revisions? (2) What factors were associated with revision surgery when stratified by the location of the mechanical failure and (septic) loosening (intramedullary stem versus dual cone adapter)? METHODS Between May 2009 and July 2015, we treated 72 patients with an osseointegrated implant. Inclusion criteria were a minimum follow-up of 5-years and a standard press-fit cobalt-chromium-molybdenum (CoCrMb) transfemoral osseointegrated implant. Based on that, 83% (60 of 72) of patients were eligible; a further 3% (2 of 60) were excluded because of no received informed consent (n = 1) and loss to follow-up (n = 1). Eventually, we included 81% (58 of 72) of patients for analysis in this retrospective, comparative study. We compared patient characteristics (gender, age, and BMI), implant details (diameter of the intramedullary stem, length of the dual cone, and implant survival time), and event characteristics (infectious complications and distal bone resorption). The data were retrieved from our electronic patient file and from our cloud-based database and analyzed by individuals not involved in patient care. Failures were categorized as: (1) mechanical failures, defined as breakage of the intramedullary stem or dual-cone adapter, or (2) (septic) loosening of the osseointegrated implant. RESULTS Thirty-four percent (20 of 58) of patients had revision surgery. In 12% (7 of 58) of patients, the reason for revision was due to intramedullary stem failures (six breakages, one septic loosening), and in 22% (13 of 58) of patients it was due to dual-cone adaptor failure (10 weak-point breakages and four distal taper breakages; one patient broke both the weak-point and the dual-cone adapter). Smaller median stem diameter (failure: 15 mm [interquartile range 1.3], nonfailure: 17 mm [IQR 2.0], difference of medians 2 mm; p < 0.01) and higher median number of infectious events (failure: 6 [IQR 11], nonfailure: 1 [IQR 3.0], difference of medians -5; p < 0.01) were associated with revision intramedullary stem surgery. No risk factors could be identified for broken dual-cone adapters. CONCLUSION Possible risk factors for system failure of this osteointegration implant include small stem diameter and high number of infectious events. We did not find factors associated with dual-cone adapter weak-point failure and distal taper failure, most likely because of the small sample size. When treating a person with a lower-limb amputation with a CoCrMb osseointegrated implant, we recommend avoiding a small stem diameter. Further research with longer follow-up is needed to study the success of revised patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jamal Mohamed
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - David Reetz
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henk van de Meent
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hendrik Schreuder
- Department of Orthopedics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan Paul Frölke
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ruud Leijendekkers
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
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Hoellwarth JS, Tetsworth K, Akhtar MA, Al Muderis M. The Clinical History and Basic Science Origins of Transcutaneous Osseointegration for Amputees. Adv Orthop 2022; 2022:7960559. [PMID: 35340813 DOI: 10.1155/2022/7960559] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/23/2022] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Transcutaneous osseointegration for amputees (TOFA) refers to an intramedullary metal endoprosthesis which passes transcutaneously to connect with a limb exoprosthesis. The first recognizably modern experiments and attempts occurred in the 1940s. Multiple researchers using a plethora of materials and techniques over the following 50 years identified principles and obstacles which informed the first long-term successful surgery in 1990. Unfortunately, the current mainstream TOFA literature presents almost exclusively subsequent developments, generally omitting prior research, leading to some historical mistakes being repeated. Given the increasing interest and surgical volume of TOFA, this literature review was performed to delineate TOFA's basic science and surgical origins and to integrate these early efforts within the contemporary understanding. Studying this research could protect and benefit future patients, surgeons, and implant developers as TOFA is entering a phase of increased attention and innovation. The aim of this article is to provide a focused reference of foundational research, much of which is difficult to identify and retrieve, for clinicians and researchers.
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21
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Kia C, Antonacci CL, Wellington I, Makanji HS, Esmende SM. Spinal Implant Osseointegration and the Role of 3D Printing: An Analysis and Review of the Literature. Bioengineering (Basel) 2022; 9:108. [PMID: 35324797 PMCID: PMC8944949 DOI: 10.3390/bioengineering9030108] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/12/2022] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
The use of interbody implants for spinal fusion has been steadily increasing to avoid the risks of complications and donor site morbidity when using autologous bone. Understanding the pros and cons of various implant designs can assist the surgeon in choosing the ideal interbody for each individual patient. The goal of these interbody cages is to promote a surface area for bony ingrowth while having the biomechanical properties to support the axial skeleton. Currently, the majority of interbody implants consists of metal or polyether ether ketone (PEEK) cages with bone graft incorporated inside. Titanium alloy implants have been commonly used, however, the large difference in modulus of elasticity from bone has inherent issues. PEEK implants have a desirable surface area with the benefit of a modulus of elasticity closer to that of bone. Unfortunately, clinically, these devices have had increased risk of subsidence. More recently, 3D printed implants have come into the market, providing mechanical stability with increased surface design for bony ingrowth. While clinical outcomes studies are limited, early results have demonstrated more reliable and quicker fusion rates using 3D custom interbody devices. In this review, we discuss the biology of osseointegration, the use of surface coated implants, as well as the potential benefits of using 3D printed interbodies.
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22
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Sun Y, Xu J, Lv S, Xu Z, Li L, Li Y, Li Y. Extramedullary Osseointegration-A Novel Design of Percutaneous Osseointegration Prosthesis for Amputees. Front Bioeng Biotechnol 2022; 10:811128. [PMID: 35223785 PMCID: PMC8867013 DOI: 10.3389/fbioe.2022.811128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
The percutaneous osseointegrated (OI) prostheses have greatly improved the overall quality of life for amputees. However, the long-term maintenance of the OI prostheses is still challenging. A major problem is bone resorption around the bone-implant-skin interface, which might cause implant loosening or osteomyelitis. Another problem is the breakage of connecting components between the intramedullary implant and external prosthesis due to excessive stress. We designed a novel osseointegration implant by changing the bone-implant contact from the inner cortex to the outer surface of cortical bone. In the current study, we compared the extramedullary cap-shaped implants with the intramedullary screw-type implants in rabbits. Osteointegration was confirmed at the interface of bone to implant contact (BIC) in both implant types. The external implant induced intramedullary bone regeneration in the medullary canal and increased the cortical bone density at the end of the stump. This study provides a new perspective on the design of osseointegration implants which might prevent the currently reported complications of the intramedullary OI systems.
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Affiliation(s)
- Yingying Sun
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China.,Department of Stomatology, the First Hospital of Jilin University, Changchun, China
| | - Jinying Xu
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China
| | - Shuang Lv
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China
| | - Ziran Xu
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China
| | - Lisha Li
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China
| | - Yan Li
- Division of Orthopedics and Biotechnology, Department for Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Yulin Li
- The Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun, China
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Richter K, Krause K, Rotter R, Fischer DC, Aschoff HH, Mittlmeier T. [Functional rehabilitation after transfemoral amputation : Shaft prosthesis or endo-exo prosthesis?]. Unfallchirurg 2022; 125:266-274. [PMID: 35212810 DOI: 10.1007/s00113-022-01148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND After transfemoral amputation a prosthesis is required to restore autonomous standing and bipedal locomotion. Attachment of the prosthesis can be achieved either classically via socket suspension with a shaft in the stump or directly via implantation of an intramedullary transcutaneous femoral prosthesis (osseointegrated prosthesis). AIM A fully instrumented gait analysis should enable objectification of the anticipated advantages of the EEP with respect to the gait pattern and individual mobility. MATERIAL AND METHODS In two patients with a unilateral transfemoral amputation a comprehensive gait analysis was carried out prior to and 6 months (patient 1) or 11 and 20 months (patient 2) after switching from a socket prosthesis to an EEP. This was carried out in the Gait Realtime Analysis Interactive Lab (GRAIL), a fully instrumented gait laboratory with virtual reality and enables assessment close to the conditions of daily life. RESULTS In both cases the gait analysis confirmed the advantages associated with an EEP for the transmission of force to the prosthesis and the accompanying improvement in gait symmetry.
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Affiliation(s)
- Katherina Richter
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland.,Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Katharina Krause
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland.,Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Robert Rotter
- Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Dagmar-C Fischer
- Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Horst-H Aschoff
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Mittlmeier
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland. .,Klinik und Poliklinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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24
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Affiliation(s)
- Jason Shih Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia.,Limb Lengthening and Complex Reconstruction, Hospital for Special Surgery, New York, New York, USA
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, Australia
| | | | - Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
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25
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Berg D, Frossard L. Health Service Delivery and Economic Evaluation of Limb Lower Bone-Anchored Prostheses: A Summary of the Queensland Artificial Limb Service's Experience. Can Prosthet Orthot J 2021; 4:36210. [PMID: 37614998 PMCID: PMC10443483 DOI: 10.33137/cpoj.v4i2.36210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The emergence of skeletal prosthetic attachments leaves governmental organizations facing the challenge of implementing equitable policies that support the provision of bone-anchored prostheses (BAPs). In 2013, the Queensland Artificial Limb Service (QALS) started a five-year research project focusing on health service delivery and economic evaluation of BAPs. This paper reflects on the QALS experience, particularly the lessons learned. QALS' jurisdiction and drivers are presented first, followed by the impact of outcomes, barriers, and facilitators, as well as future developments of this work. The 21 publications produced during this project (e.g., reimbursement policy, role of prosthetists, continuous improvement procedure, quality of life, preliminary cost-utilities) were summarized. Literature on past, current, and upcoming developments of BAP was reviewed to discuss the practical implications of this work. A primary outcome of this project was a policy developed by QALS supporting up to 22 h of labor for the provision of BAP care. The indicative incremental cost-utility ratio for transfemoral and transtibial BAPs was approximately AUD$17,000 and AUD$12,000, respectively, per quality-adjusted life-year compared to socket prostheses. This project was challenged by 17 barriers (e.g., limited resources, inconsistency of care pathways, design of preliminary cost-utility analyses) but eased by 18 facilitators (e.g., action research plan, customized database, use of free repositories). In conclusion, we concluded that lower limb BAP might be an acceptable alternative to socket prostheses from an Australian government prosthetic care perspective. Hopefully, this work will inform promoters of prosthetic innovations committed to making bionic solutions widely accessible to a growing population of individuals suffering from limb loss worldwide.
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Affiliation(s)
- D Berg
- Queensland Artificial Limb Service, Brisbane, Australia
| | - L Frossard
- Your Research Project Pty Ltd, Brisbane, Australia
- Griffith University, Gold Coast, Australia
- University of the Sunshine Coast, Maroochydore, Australia
- Queensland University of Technology, Brisbane, Australia
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26
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Khan I, Gerrand C, Saifuddin A. Imaging following surgery for primary appendicular bone tumours. Skeletal Radiol 2021; 50:1527-55. [PMID: 33481074 DOI: 10.1007/s00256-021-03712-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/22/2020] [Accepted: 01/10/2021] [Indexed: 02/02/2023]
Abstract
Primary bone tumours are uncommon, with sarcomas accounting for < 0.2% of all malignancies. The survival rate of primary bone sarcomas has significantly improved due to (neo)adjuvant therapy, while improved surgical techniques and development of new prostheses have shifted the surgical focus from amputation to limb preservation in the vast majority of patients. A wide variety of surgical options are available for the treatment of primary bone tumours which depend upon histological diagnosis, their appearance at the time of presentation and response to any (neo)adjuvant therapy as required. This review is intended to help radiologists familiarise themselves with the management of primary appendicular bone tumours and expected normal postoperative appearances for the various surgical techniques, and to recognise potential complications.
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27
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Li Y, Felländer-Tsai L. The bone anchored prostheses for amputees - Historical development, current status, and future aspects. Biomaterials 2021; 273:120836. [PMID: 33894405 DOI: 10.1016/j.biomaterials.2021.120836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/28/2021] [Accepted: 04/14/2021] [Indexed: 12/27/2022]
Abstract
In the past 50 years, bone anchored prostheses have evolved from a concept for experimental treatment to a rapidly developing area in orthopedics and traumatology. Up to date, there are dozens of centers in the world providing osseointegration amputation reconstructions and more than a thousand patients using the bone anchored prostheses. Compared with conventional socket prostheses, the bone anchored prosthesis by osseointegration avoids the debilitating problems related with soft tissues. It also provides physiological weight bearing, improved range of motion, and sensory feedback, all of which contribute to the improvement on quality of life for amputees. The present article briefly reviews the historical development of osseointegration surgery for amputation reconstruction and the current challenges. The implant design characters and surgical techniques of the two types of implants; the screw-type implant (presented by the OPRA system), and the press-fit implants (presented by EEP and OPL systems) are described. The major complications, infections and mechanical failures, are discussed in detail based on the latest evidence. Future aspects and experimental trials aiming to overcome the current challenges are presented.
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Affiliation(s)
- Yan Li
- Division of Orthopaedics and Biotechnology, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Theme Trauma and Reparative Medicine, Department of Orthopedics and Traumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Theme Trauma and Reparative Medicine, Department of Orthopedics and Traumatology, Karolinska University Hospital, Stockholm, Sweden.
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28
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Hoellwarth JS, Tetsworth K, Rozbruch SR, Handal MB, Coughlan A, Al Muderis M. Osseointegration for Amputees: Current Implants, Techniques, and Future Directions. JBJS Rev 2021; 8:e0043. [PMID: 32224634 PMCID: PMC7161721 DOI: 10.2106/jbjs.rvw.19.00043] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Osseointegrated prostheses provide a rehabilitation option for amputees offering greater mobility, better satisfaction, and higher use than traditional socket prostheses. There are several different osseointegrated implant designs, surgical techniques, and rehabilitation protocols with their own strengths and limitations. The 2 most prominent risks, infection and periprosthetic fracture, do not seem unacceptably frequent or insurmountable. Proximal amputations or situations leading to reduced mobility are exceptionally infrequent. Osseointegrated implants can be attached to advanced sensory and motor prostheses.
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Affiliation(s)
- Jason Shih Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kevin Tetsworth
- Department of Orthopaedics, The Royal Brisbane Hospital, Brisbane, Victoria, Australia
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY
| | - M Brianne Handal
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Adam Coughlan
- Department of Orthopaedics, The Royal Brisbane Hospital, Brisbane, Victoria, Australia
| | - Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
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29
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Felder JM, Skladman R. Translating Technique into Outcomes in Amputation Surgeries. Mo Med 2021; 118:141-146. [PMID: 33840857 PMCID: PMC8029626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The department of surgery at Washington University is putting increased emphasis on outcomes for amputees. This multidisciplinary effort begins with choosing the correct surgery and incorporating the latest technical advances in amputation surgery.
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Affiliation(s)
- John M Felder
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
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30
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Herr HM, Clites TR, Srinivasan S, Talbot SG, Dumanian GA, Cederna PS, Carty MJ. Reinventing Extremity Amputation in the Era of Functional Limb Restoration. Ann Surg 2021; 273:269-79. [PMID: 32324689 DOI: 10.1097/SLA.0000000000003895] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent progress in biomechatronics and vascularized composite allotransplantation have occurred in the absence of congruent advancements in the surgical approaches generally utilized for limb amputation. Consideration of these advances, as well as of both novel and time-honored reconstructive surgical techniques, argues for a fundamental reframing of the way in which amputation procedures should be performed. METHODS We review sentinel developments in external prosthetic limb technology and limb transplantation, in addition to standard and emerging reconstructive surgical techniques relevant to limb modification, and then propose a new paradigm for limb amputation. RESULTS An approach to limb amputation based on the availability of native tissues is proposed, with the intent of maximizing limb function, limiting neuropathic pain, restoring limb perception/proprioception and mitigating limb atrophy. CONCLUSIONS We propose a reinvention of the manner in which limb amputations are performed, framed in the context of time-tested reconstructive techniques, as well as novel, state-of-the-art surgical procedures. Implementation of the proposed techniques in the acute setting has the potential to elevate advanced limb replacement strategies to a clinical solution that perhaps exceeds what is possible through traditional surgical approaches to limb salvage. We therefore argue that amputation, performed with the intent of optimizing the residuum for interaction with either a bionic or a transplanted limb, should be viewed not as a surgical failure, but as an alternative form of limb reconstruction.
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Abstract
Interest in amputation surgery has increased in conjunction with rising public awareness about amputee care. To date, plastic surgeons have impacted the quality of life and functional potential of amputees through novel strategies for sensory feedback and prosthesis control and various techniques for neuroma treatment and prevention. Osseointegration, which involves the direct skeletal attachment of a prosthesis to bone, has the ability to further maximize amputee function. There exists a critical role for plastic surgeons to help optimize techniques for extremity osseointegration through improved wound care and soft-tissue management. An overview of current osseointegrated prostheses and their associated limitations, and potential avenues through which plastic surgeons can help mitigate these challenges, are discussed in this article.
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Affiliation(s)
- Jason M Souza
- From the Division of Plastic Surgery and the Department of Orthopedics, Uniformed Services University-Walter Reed National Military Medical Center; and the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine
| | - Lauren M Mioton
- From the Division of Plastic Surgery and the Department of Orthopedics, Uniformed Services University-Walter Reed National Military Medical Center; and the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine
| | - Colin J Harrington
- From the Division of Plastic Surgery and the Department of Orthopedics, Uniformed Services University-Walter Reed National Military Medical Center; and the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine
| | - Benjamin K Potter
- From the Division of Plastic Surgery and the Department of Orthopedics, Uniformed Services University-Walter Reed National Military Medical Center; and the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine
| | - Jonathan A Forsberg
- From the Division of Plastic Surgery and the Department of Orthopedics, Uniformed Services University-Walter Reed National Military Medical Center; and the Division of Plastic Surgery, Northwestern University Feinberg School of Medicine
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32
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Haque R, Al-Jawazneh S, Hoellwarth J, Akhtar MA, Doshi K, Tan YC, Lu WYR, Roberts C, Al Muderis M. Osseointegrated reconstruction and rehabilitation of transtibial amputees: the Osseointegration Group of Australia surgical technique and protocol for a prospective cohort study. BMJ Open 2020; 10:e038346. [PMID: 33082192 PMCID: PMC7577069 DOI: 10.1136/bmjopen-2020-038346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Lower extremity amputation uniformly impairs a person's vocational, social and recreational capacity. Rehabilitation in traditional socket prostheses (TSP) is associated with a spectrum of complications involving the socket-residuum interface which lead to reduced prosthetic use and quality of life. Osseointegration has recently emerged as a novel concept to overcome these complications by eliminating this interface and anchoring the prosthesis directly to bone. Though the complications of TSPs affect both transfemoral and transtibial amputees, Osseointegration has been predominantly performed in transfemoral ones assuming a greater benefit/risk ratio. However, as the safety of the procedure has been established, we intend to extend the concept to transtibial amputees and document the outcomes. METHODS AND ANALYSIS This is protocol for a prospective cohort study, with patient enrolment started in 2014 and expected to be completed by 2022. The inclusion criteria are age over 18 years, unilateral, bilateral and mixed transtibial amputation and experiencing socket-related problems. All patients receive osseointegrated implants, the type of which depend on the length of the residuum and quality of bone, which are press-fitted into the residual bone. Objective functional outcomes comprising 6-Minute Walk Test, Timed Up-and-Go test and K-level, subjective patient-reported-quality-of-life outcomes (Short Form Health Survey 36, daily prosthetic wear hours, prosthetic wear satisfaction) and adverse events are recorded preoperatively and at postoperative follow-up intervals of 3, 6, 12 months and yearly, and compared with the preoperative values using appropriate statistical tests. Multivariable multilevel logistic regression will be performed with a focus to identify factors associated with outcomes and adverse events, specifically infection, periprosthetic fracture, implant fracture and aseptic loosening. ETHICS AND DISSEMINATION The Ethics approval for the study has been received from the University of Notre Dame, Sydney, Australia (014153S). The outcomes of this study will be disseminated by publications in peer-reviewed academic journals and scientific presentations at relevant orthopaedic conferences.
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Affiliation(s)
- Russel Haque
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Shakib Al-Jawazneh
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | | | - Karan Doshi
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Yao Chang Tan
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - William Yenn-Ru Lu
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Claudia Roberts
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
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34
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Ranker A, Örgel M, Beck JP, Krettek C, Aschoff HH. Transkutane osseointegrierte Prothesensysteme (TOPS) zur Versorgung
Oberschenkelamputierter. REHABILITATION 2020; 59:357-365. [DOI: 10.1055/a-1223-3205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Zusammenfassung
Ziel Der Studie Durchgeführt wurde eine retrospektive Analyse der
klinischen Ergebnisse und Komplikationsraten aller oberschenkelamputierten
Patienten eines Zentrums, die mit dem neuesten Implantatdesign der sogenannten
Endo-Exo-Femur-Prothese (EEFP, dritte Generation) versorgt wurden. Ziel ist es,
spezifische Informationen zu Langzeitkomplikationen dieser
Amputationsversorgungsform zu gewinnen.
Methodik Im Januar 2019 wurden Daten aller Oberschenkelamputierten, die
von 2010 bis 2016 an einer Akutklinik aus Schleswig-Holstein mit TOPS versorgt
wurden, retrospektiv analysiert. Dies geschah unter besonderer
Berücksichtigung der postoperativen Komplikationen. Hierfür
wurden alle Untersuchungsbefunde der klinischen Routine-Nachsorge-Untersuchungen
herangezogen. Die Komplikationen wurden unterteilt in Stomaprobleme,
orthopädie-technische Probleme, Frakturen und Explantationen. Alle EEFPs
besaßen das gleiche Implantatdesign (dritte Generation). Dieses
Implantat findet derzeit als einziges TOPS in Deutschland klinische Anwendung.
Eine deskriptive Statistik des Patientenkollektivs, sowie
Verhältnisangaben über aufgetretene Komplikationen wurden
berechnet.
Ergebnisse Insgesamt wurden in diesem Zeitraum 68 Implantationen
durchgeführt. Durchschnittliche Beobachtungszeit war 6,32 Jahre
(±2,16 Jahre). Das mittlere Alter der Patienten betrug 51,84
Jahre±12,12 Jahre. Ursache der Amputation waren überwiegend
Traumata (82,35%). Stoma-assoziierte Probleme zeigten mit 7% die
höchste Inzidenz innerhalb aller beobachteten, patientenassoziierten
Komplikationen und stellten die größten Herausforderungen
während des Rehabilitationsprozesses dar. Betrachtet man nur die
chirurgischen Komplikationen, so hatten 81% überhaupt keine
Komplikationen. Insgesamt wiesen 15% orthopädie-technische
Probleme auf, 6% eine peri-prothetische Fraktur, 7% Probleme am
Stoma und 3% mussten aufgrund einer Infektion explantiert werden.
Schlussfolgerung Die erhobene Datenanalyse zeigt, dass TOPS (hier die
EEFP der dritten Generation) eine erfolgreiche alternative Behandlungsmethode
zur Schaftprothesenversorgung für Patienten mit
Oberschenkelknochenverlust darstellen können. Die Indikation sollte erst
nach dem Versagen einer Schaftversorgung erfolgen und Kontraindikationen
müssen umfassend ausgeschlossen werden. Die größten
Herausforderungen im Rehabilitationsprozess stellen die Vermeidung von
Stomakomplikationen, Infektionen und orthopädie-technischen Problemen
dar. Die Rehabilitation von Amputierten, die mit TOPS behandelt werden,
erfordert daher ein interdisziplinäres, spezialisiertes
Rehabilitations-Team und eine lebenslange rehabilitative Versorgung.
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Affiliation(s)
- Alexander Ranker
- Klinik für Rehabilitationsmedizin, Medizinische Hochschule
Hannover
- Klinik für Unfallchirurgie, Medizinische Hochschule
Hannover
| | - Marcus Örgel
- Klinik für Unfallchirurgie, Medizinische Hochschule
Hannover
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Affiliation(s)
- Christine Oh
- Division of Plastic Surgery, Department of Surgery (C.O. and B.T.C.), and Division of Hand Surgery, Department of Orthopedic Surgery (B.T.C.), Mayo Clinic, Rochester, Minnesota
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Vincitorio F, Staffa G, Aszmann OC, Fontana M, Brånemark R, Randi P, Macchiavelli T, Cutti AG. Targeted Muscle Reinnervation and Osseointegration for Pain Relief and Prosthetic Arm Control in a Woman with Bilateral Proximal Upper Limb Amputation. World Neurosurg 2020; 143:365-373. [PMID: 32791219 DOI: 10.1016/j.wneu.2020.08.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bilateral proximal upper limb loss is a dramatic life-changing event. Replacement of the lost function with prosthetic arms, including multiple mechatronic joints, has remained a challenge from the control, comfort, and pain management perspectives. Targeted muscle reinnervation (TMR) is a peripheral nerve surgical procedure proposed to improve the intuitive control of the prosthetic arm and for neuroma and phantom pain management. Moreover, osseointegrated percutaneous implants (OPIs) allow for direct skeletal attachment of the prosthetic arm, ensuring freedom of movement to the patient's residual articulations. CASE DESCRIPTION We have reported the first combined application of TMR and an OPI to treat a 24-year-old woman with a bilateral amputation at the shoulder level on the right side and at the very proximal transhumeral level on the left side. TMR was performed bilaterally in a single day, accounting for the peculiar patient's anatomy, as preparatory stage to placement of the OPI, and considering the future availability of implantable electromyographic sensors. The 2 OPI surgeries on the left side were completed after 8.5 months, and prosthetic treatment was completed 17 months after TMR. CONCLUSIONS The use of TMR resolved the phantom pain bilaterally and the right-side neuroma pain. It had also substantially reduced the left side neuroma pain. The actual prosthetic control result was intuitive, although partially different from expectations. At 2 years after TMR, the patient reported improvement in essential activities of daily living, with a remarkable preference for the OPI prosthesis. Only 1 suspected case of superficial infection was noted, which had resolved. Overall, this combined treatment required a highly competent multidisciplinary team and exceptional commitment by the patient and her family.
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Affiliation(s)
- Francesca Vincitorio
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Guido Staffa
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Oskar C Aszmann
- Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria; Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Maurizio Fontana
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Rickard Brånemark
- Center for Extreme Bionics, Biomechatronics Group, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Pericle Randi
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy
| | - Thomas Macchiavelli
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy
| | - Andrea G Cutti
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy.
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Overmann AL, Aparicio C, Richards JT, Mutreja I, Fischer NG, Wade SM, Potter BK, Davis TA, Bechtold JE, Forsberg JA, Dey D. Orthopaedic osseointegration: Implantology and future directions. J Orthop Res 2020; 38:1445-1454. [PMID: 31876306 DOI: 10.1002/jor.24576] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/04/2019] [Indexed: 02/04/2023]
Abstract
Osseointegration (OI) is the direct anchorage of a metal implant into bone, allowing for the connection of an external prosthesis to the skeleton. Osseointegration was first discovered in the 1960s based on the microscopic analysis of titanium implant placed into host bone. New bone was observed to attach directly to the metal surface. Following clinical investigations into dentistry applications, OI was adapted to treat extremity amputations. These bone anchored implants, which penetrate the skin and soft tissues, eliminate many of the challenges of conventional prosthetic sockets, such as poor fit and suspension, skin breakdown, and pain. Osseointegrated implants show promise to improve prosthesis use, pain, and function for amputees. The successful process of transcutaneous metal integration into host bone requires three synergistic systems: the host bone, the metal implant, and the skin-implant interface. All three systems must be optimized for successful incorporation and longevity of the implant. Osseointegration begins during surgical implantation of the metal components through a complex interplay of cellular mechanisms. While implants can vary in design-including the original screw, press fit implants, and compressive osseointegration-they face common challenges to successful integration and maintenance of fixation within the host bone. Overcoming these challenges requires the understanding of the complex interactions between each element of OI. This review outlines (a) the basic components of OI, (b) the science behind both the bone-implant and the skin-implant interfaces, (c) the current challenges of OI, and (d) future opportunities within the field.
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Affiliation(s)
- Archie L Overmann
- Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Conrado Aparicio
- MDRCBB-Minnesota Dental Research Center for Biomaterials and Biomechanics and Department of Restorative Sciences, University of Minnesota, Minneapolis, Minnesota
| | - John T Richards
- Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Isha Mutreja
- MDRCBB-Minnesota Dental Research Center for Biomaterials and Biomechanics and Department of Restorative Sciences, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas G Fischer
- MDRCBB-Minnesota Dental Research Center for Biomaterials and Biomechanics and Department of Restorative Sciences, University of Minnesota, Minneapolis, Minnesota
| | - Sean M Wade
- Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Benjamin K Potter
- Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Thomas A Davis
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joan E Bechtold
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota.,Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jonathan A Forsberg
- Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland.,USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Devaveena Dey
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
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Mayer RM, Garcia-Rosas R, Mohammadi A, Tan Y, Alici G, Choong P, Oetomo D. Tactile Feedback in Closed-Loop Control of Myoelectric Hand Grasping: Conveying Information of Multiple Sensors Simultaneously via a Single Feedback Channel. Front Neurosci 2020; 14:348. [PMID: 32395102 PMCID: PMC7197324 DOI: 10.3389/fnins.2020.00348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 03/23/2020] [Indexed: 12/03/2022] Open
Abstract
The appropriate sensory information feedback is important for the success of an object grasping and manipulation task. In many scenarios, the need arises for multiple feedback information to be conveyed to a prosthetic hand user simultaneously. The multiple sets of information may either (1) directly contribute to the performance of the grasping or object manipulation task, such as the feedback of the grasping force, or (2) simply form additional independent set(s) of information. In this paper, the efficacy of simultaneously conveying two independent sets of sensor information (the grasp force and a secondary set of information) through a single channel of feedback stimulation (vibrotactile via bone conduction) to the human user in a prosthetic application is investigated. The performance of the grasping task is not dependent to the second set of information in this study. Subject performance in two tasks: regulating the grasp force and identifying the secondary information, were evaluated when provided with either one corresponding information or both sets of feedback information. Visual feedback is involved in the training stage. The proposed approach is validated on human-subject experiments using a vibrotactile transducer worn on the elbow bony landmark (to realize a non-invasive bone conduction interface) carried out in a virtual reality environment to perform a closed-loop object grasping task. The experimental results show that the performance of the human subjects on either task, whilst perceiving two sets of sensory information, is not inferior to that when receiving only one set of corresponding sensory information, demonstrating the potential of conveying a second set of information through a bone conduction interface in an upper limb prosthetic task.
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Affiliation(s)
- Raphael M Mayer
- Human Robotics Laboratory, Department of Mechanical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Ricardo Garcia-Rosas
- Human Robotics Laboratory, Department of Mechanical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Alireza Mohammadi
- Human Robotics Laboratory, Department of Mechanical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Ying Tan
- Human Robotics Laboratory, Department of Mechanical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Gursel Alici
- School of Mechanical, Materials, Mechatronic and Biomedical Engineering, University of Wollongong, Wollongong, NSW, Australia.,ARC Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia
| | - Peter Choong
- ARC Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia.,Department of Surgery, St. Vincent's Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Denny Oetomo
- Human Robotics Laboratory, Department of Mechanical Engineering, The University of Melbourne, Parkville, VIC, Australia.,ARC Centre of Excellence for Electromaterials Science, Wollongong, NSW, Australia
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Marano AA, Modiri O, Rozbruch SR, Otterburn DM. Soft Tissue Contouring at the Time of Osseointegrated Implant Reconstruction for Lower Extremity Amputation. Ann Plast Surg 2020; 85:S33-6. [PMID: 32187066 DOI: 10.1097/SAP.0000000000002329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patients with lower extremity amputations using a classic socket prosthesis face many challenges related to the socket-limb interface. The adaptation of osseointegration has allowed for the attachment of a prosthesis directly to bone, eliminating this interface and providing mechanical benefits. Contrary to the socket prosthesis, the osseointegrated prosthesis requires reducing and minimizing the soft tissue envelope. Studies have shown that patients who have undergone placement of these implants have high rates of reoperation for soft tissue redundancy. The purpose of our study was to evaluate complication rates and need for revisional surgery using our technique of soft tissue closure around the prosthesis at the time of implant placement. METHODS An institutional review board-approved, retrospective chart review was performed on all patients who underwent implantation of an osseointegrated prosthesis for lower extremity amputation with concomitant plastic surgery closure at our institution during a 2-year period from June 2017 to June 2019. Patient demographics, health status descriptors, operative data, length of admission, and rates of postoperative complications were gathered from the electronic medical record and coded into a HIPAA-compliant database. Specific outcomes tracked included minor and major infection, osteomyelitis, implant failure, hematoma, seroma, delayed wound healing, and rates of reoperation and readmission. RESULTS There were a total of 14 patients who underwent osseointegrated implant placement with concomitant plastic surgical coverage of the prosthesis during the study period. The average patient age was 50 years (range, 26-70 years), and average body mass index was 32.2 kg/m (range, 19.7-44.8 kg/m). Average follow-up time was 28 weeks (range, 10-73 weeks). There were 2 cases of local infection resolved with a course of oral antibiotics. There were no instances of infection requiring procedural intervention or hospital admission, nor any cases of osteomyelitis. Two patients required outpatient surgery for exchange of implant abutment, one required revision of a prosthesis for hardware loosening, and one required targeted muscle reinnervation of a sciatic nerve neuroma. There were no patients who required revisional surgery for soft tissue redundancy and no cases of delayed wound healing. CONCLUSIONS Adequate planning of incisions and soft tissue contouring is important in the care of osseointegrated patients. Plastic surgery involvement can decrease soft tissue complications and lead to improved patient outcomes.
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Lindsay C, Ruppert D, Abumoussa S, Dahners L, Weinhold P. Benefits of additive manufacturing and micro and nano surface texture modifications on mechanical strength and infection resistance of skin-implant interfaces in rats. J Biomater Appl 2020; 34:1193-1200. [PMID: 32041456 DOI: 10.1177/0885328220903961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher Lindsay
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David Ruppert
- Joint Department of Biomedical Engineering, University of North Carolina / North Carolina State University, Chapel Hill / Raleigh, NC, USA
| | - Sam Abumoussa
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Laurence Dahners
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Paul Weinhold
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.,Joint Department of Biomedical Engineering, University of North Carolina / North Carolina State University, Chapel Hill / Raleigh, NC, USA
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Abstract
Aims Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169.
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Affiliation(s)
- Jason S Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - John Kendrew
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Oscar van Waes
- Trauma Research Unit Department of Surgery, Rotterdam, The Netherlands
| | - Qutaiba Al-Maawi
- Department of Orthopaedic Surgery, Ibn Sina Training Hospital, Baghdad, Iraq
| | - Claudia Roberts
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
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Overmann AL, Forsberg JA. The state of the art of osseointegration for limb prosthesis. Biomed Eng Lett 2020; 10:5-16. [PMID: 32175127 PMCID: PMC7046912 DOI: 10.1007/s13534-019-00133-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/28/2019] [Accepted: 10/10/2019] [Indexed: 12/27/2022] Open
Abstract
Osseointegration (OI) is the direct attachment of bone onto a titanium implant. Recently, the term is used to describe "transdermal" implants that allow an external prosthesis to be connected directly to the skeleton. This technology eliminates the challenges of conventional socket-based prostheses, such as skin breakdown and poor fit, which are common in patients with major extremity amputations. Osseointegration patients demonstrate encouraging improvements in quality of life and function. Patients report improvement in prosthetic use, prosthetic mobility, global health, and pain reduction on a variety of clinical assessment tools. Various implants have been developed for osseointegration for amputees. These implants use a variety of fixation strategies and surface augments to allow for successful integration into the host bone. Regardless of design, all OI implants face similar challenges, particularly infections. Other challenges include the inability to determine when integration has occurred and the inability to detect loss of integration. These challenges may be met by incorporating sensing systems into the implants. The percutaneous nature of the metal devices can be leveraged so that internal sensors need not be wireless, and can be interrogated by external monitoring systems, thus providing crucial, real-time information about the state of the implant. The purpose of this review is to (1) review the basic science behind osseointegration, (2) provide an overview of current implants, practice patterns, and clinical outcomes, and (3) preview sensor technologies which may prove useful in future generations of transdermal orthopaedic implants.
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Affiliation(s)
- A. L. Overmann
- Orthopaedics, USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - J. A. Forsberg
- Orthopaedics, USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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Myers H, Lu D, Gray SJ, Bruscino-Raiola F. Targeted muscle reinnervation to improve electromyography signals for advanced myoelectric prosthetic limbs: a series of seven patients. ANZ J Surg 2020; 90:591-596. [PMID: 31989741 DOI: 10.1111/ans.15664] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Upper limb amputation is a devastating injury. Patients may choose to use a passive prosthesis, a traditional body-powered prosthesis or a myoelectric prosthesis driven by electromyography (EMG) signals generated by underlying muscles. Targeted muscle reinnervation (TMR) aims to surgically create strong and reliable signals to permit the intuitive use of a myoelectric prosthesis with the greatest number of movements possible. We review the Alfred Hospital experience of using TMR to improve upper limb prosthesis control. METHODS A retrospective review of all cases of TMR performed at the Alfred Hospital was undertaken. Patient demographics, injury, surgical complications and outcomes were examined. Comparison was made to preoperative prosthesis use. RESULTS Seven patients have undergone TMR to improve upper limb prosthesis control at the Alfred Hospital between 2015 and 2018. Within the patient group, pre-TMR EMG signal numbers ranged from 1 to 2, and post-TMR signal numbers ranged from 3 to 5. Six patients were able to achieve six degrees of freedom post-operatively, and one patient achieved four degrees. No patients required the use of co-contraction to switch function post-operatively. There were no significant surgical complications. CONCLUSION The use of TMR to improve and increase the number of EMG signals has been successful in generating more degrees of freedom for upper limb amputees with myoelectric prostheses.
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Affiliation(s)
- Harley Myers
- Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - David Lu
- Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Steven J Gray
- Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Frank Bruscino-Raiola
- Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
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Abstract
Background The purpose of this study was to investigate residual rotation of patients with forearm amputation and the contribution of involved muscle to residual rotation. Methods Testing was performed using five fresh-frozen cadaveric specimens prepared by isolating muscles involved in forearm rotation. Amputation was implemented at 25 cm (wrist disarticulation), 18 cm, or 10 cm from the tip of olecranon. Supination and pronation in the amputation stump were simulated with traction of involved muscle (supinator, biceps brachii, pronator teres, pronator quadratus) using an electric actuator. The degree of rotation was examined at 30°, 60°, 90°, and 120° in flexion of elbow. Results Average rotation of 25 cm forearm stump was 148° (SD: 23.1). The rotation was decreased to 117.5° (SD: 26.6) at 18 cm forearm stump. It was further decreased to 63° (SD 31.5) at 10 cm forearm stump. Tendency of disorganized rotation was observed in close proximity of the amputation site to the elbow. Full residual pronation was achieved with traction of each pronator teres and pronator quadratus. Although traction of supinator could implement residual supination, the contribution of biceps brachii ranged from 4 to 88% according to the degree of flexion. Conclusions Close proximity of the amputation site to the elbow decreased the residual rotation significantly compared to residual rotation of wrist disarticulation. The preservation of pronosupination was 80% at 18 cm forearm stump. Although the pronator teres and the pronator quadratus could make a full residual pronation separately, the supinator was essential to a residual supination.
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Affiliation(s)
- Geon Lee
- Department of Electrical and Electronic Engineering, Hanyang University, Ansan, South Korea
| | - Sung-Jae Kim
- Department of Orthopaedic Surgery, Hallym University College of Medicine, Hwasung, South Korea
| | - Joo Hyung Ha
- Department of Orthopaedic Surgery, Eulji Medical Center, Eulji University College of Medicine, Seoul, South Korea
| | - Chang-Hun Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea.
| | - Young Jin Choi
- Department of Electrical and Electronic Engineering, Hanyang University, Ansan, South Korea
| | - Kwang-Hyun Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
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Hoyt BW, Walsh SA, Forsberg JA. Osseointegrated prostheses for the rehabilitation of amputees (OPRA): results and clinical perspective. Expert Rev Med Devices 2020; 17:17-25. [DOI: 10.1080/17434440.2020.1704623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ontario Health (Quality). Osseointegrated Prosthetic Implants for People With Lower-Limb Amputation: A Health Technology Assessment. Ont Health Technol Assess Ser 2019; 19:1-126. [PMID: 31911825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Osseointegrated prosthetic implants are biocompatible metal devices that are inserted into the residual bone to integrate with the bone and attach to the external prosthesis, eliminating the need for socket prostheses and the problems that may accompany their use. We conducted a health technology assessment of osseointegrated prosthetic implants, compared with conventional socket prostheses, for people with lower-limb amputation who experience chronic problems with their prosthetic socket, leading to prosthesis intolerance and reduced mobility. Our analysis included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding osseointegrated prosthetic implants, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence on the safety and effectiveness of the latest iterations of three implant systems: the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) Implant System, the Endo-Exo-Femur-Prosthesis, and the Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL). We assessed the risk of bias of individual studies and determined the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a lifetime horizon from a public payer perspective. We also analyzed the net budget impact of publicly funding osseointegrated prosthetic implants in Ontario. To contextualize the potential value of osseointegrated prosthetic implants, we spoke with people with lower-limb amputations. RESULTS We included nine studies in the clinical evidence review. All studies included patients with above-the-knee amputation who underwent two-stage surgery and mostly had short-term follow-up. With osseointegrated prosthetic implants, scores for functional outcomes improved significantly as measured by 6-Minute Walk Test (6MWT), Timed Up and Go (TUG) test, and Questionnaire for Persons with a Transfemoral Amputation (Q-TFA). The scores for quality of life measured by SF-36 showed significant improvement in the physical component summary but a nonsignificant decline for the mental component summary. The most frequently seen adverse event was superficial infection, occurring in about half of patients in some studies. Deep or bone infection was a serious adverse event, with variable rates among the studies depending on the length of follow-up. The treatment of deep or bone infection required long-term antibiotic use, surgical debridement, revision surgery, and implant extraction in some cases. Other adverse events included femoral bone fracture, implant breakage, issues with extramedullary parts that required replacement, and implant removal. Our assessment of the quality of the clinical evidence according to the GRADE criteria found low certainty in terms of improvement in functional outcomes, low certainty for quality of life, and high certainty of an increase in adverse events; all findings compared receiving an osseointegrated prosthetic implant with not receiving an osseointegrated prosthetic implant.In our economic model, osseointegrated prosthetic implants were found to be more effective and more expensive than having people remain users of an uncomfortable socket prosthesis. Our best estimate of the incremental cost-effectiveness ratio (ICER) for osseointegration, compared with an uncomfortable socket, was $94,987 per quality-adjusted life-year (QALY) gained. The probability of osseointegration being cost-effective was 54.2% at a willingness-to-pay value of $100,000 per QALY gained. The annual net budget impact of publicly funding osseointegrated prosthetic implants in Ontario over the next 5 years, for a small population of eligible candidates, would range from $1.5 million in year 1 to $0.6 million in year 5, for a 5-year total of $5.3 million.We interviewed 13 people with a lower-limb amputation; nine had experience with both a conventional socket prosthesis and an osseointegrated prosthetic implant, three had experience with a conventional socket prosthesis only, and one had only recently undergone amputation and had not yet chosen a prosthesis. People who had received an osseointegrated prosthetic implant said they had better mobility and quality of life than before receiving this implant but had concerns about the ongoing risk of infection and potential for problems with implant maintenance. People using a conventional socket prosthesis said cost was the only factor preventing them from undergoing an osseointegration procedure. CONCLUSIONS In the studies included in the clinical evidence review, most people who received osseointegrated prosthetic implants were followed for only a few years. Studies showed that functional outcomes and physical ability improved with osseointegrated prosthetic implants (GRADE: Low), but there was uncertainty about the impact of these implants on people's emotional health (GRADE: Low). Osseointegrated prosthetic implants can lead to serious adverse events such as bone infection and bone fracture in some patients, which may require additional surgeries (GRADE: High). The reference case of the primary economic evaluation represented a conservative estimate of cost-effectiveness and found osseointegration may be cost-effective, but there is a large degree of uncertainty given parameter uncertainty and the need to use proxy costs. Scenario analyses explored potential variations in approaches to modelling and parameter selection. Qualitative interviews with people with a lower-limb amputation and caregivers underscored the challenges of conventional socket prostheses, but cost remains an important barrier to pursuing osseointegrated prosthetic implantation.
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Abstract
Osseointegration is a surgical approach that permitted the direct attachment of an external prosthesis to the skeleton in some select patients with amputation, who had failed to tolerate conventional sockets, thereby obviating related issues such as discomfort, skin breakdown, and poor fit. In this specific population, osseointegration offers the potential for enhanced biomechanical advantage and rehabilitative potential. Multiple percutaneous implant systems exist for clinical use internationally, each attempting to create a stable bone-implant interface while avoiding complications such as infection and loosening. Prospective clinical trials are now underway in the United States. This article will review the history and biology of osseointegration, indications and contraindications for use of currently available implant systems, and reported outcomes. Future directions of orthopaedic osseointegration technology, including electronic systems capable of biomimetic bidirectional volitional motor control of, and sensory/proprioceptive feedback from, external prosthetic devices, will also be discussed.
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Lancashire HT, Al Ajam Y, Dowling RP, Pendegrass CJ, Blunn GW. Hard-wired Epimysial Recordings from Normal and Reinnervated Muscle Using a Bone-anchored Device. Plast Reconstr Surg Glob Open 2019; 7:e2391. [PMID: 31741811 PMCID: PMC6799399 DOI: 10.1097/gox.0000000000002391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/07/2019] [Indexed: 12/02/2022]
Abstract
A combined approach for prosthetic attachment and control using a transcutaneous bone-anchored device and implanted muscle electrodes can improve function for upper-limb amputees. The bone-anchor provides a transcutaneous feed-through for muscle signal recording. This approach can be combined with targeted muscle reinnervation (TMR) to further improve myoelectric control. METHODS A bone-anchored device was implanted trans-tibially in n = 8 sheep with a bipolar recording electrode secured epimysially to the peroneus tertius muscle. TMR was carried out in a single animal: the peroneus tertius was deinnervated and the distal portion of the transected nerve to the peroneus muscle was coapted to a transected nerve branch previously supplying the tibialis anterior muscle. For 12 weeks (TMR) or 19 weeks (standard procedure), epimysial muscle signals were recorded while animals walked at 2 km·h-1. RESULTS After 19 weeks implantation following standard procedure, epimysial recording signal-to-noise ratio (SNR) was 18.7 dB (± 6.4 dB, 95% CI) with typical recordings falling in the range 10-25 dB. Recoveries in gait and muscle signals were coincident 6 weeks post-TMR; initial muscle activity was identifiable 3 weeks post-TMR though with low signal amplitude and signal-to-noise ratio compared with normal muscle recordings. CONCLUSIONS Following recovery, muscle signals were recorded reliably over 19 weeks following implantation. In this study, targeted reinnervation was successful in parallel with bone-anchor implantation, with recovery identified 6 weeks after surgery.
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Affiliation(s)
- Henry T. Lancashire
- From the Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Yazan Al Ajam
- Research Department of Orthopaedics and Musculoskeletal Science, University College London, London, UK
- Royal Free Hospital, London, UK
| | - Robert P. Dowling
- Research Department of Orthopaedics and Musculoskeletal Science, University College London, London, UK
| | - Catherine J. Pendegrass
- Research Department of Orthopaedics and Musculoskeletal Science, University College London, London, UK
| | - Gordon W. Blunn
- Research Department of Orthopaedics and Musculoskeletal Science, University College London, London, UK
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Hansen RL, Langdahl BL, Jørgensen PH, Petersen KK, Søballe K, Stilling M. Does migration of osseointegrated implants for transfemoral amputees predict later revision? A prospective 2-year radiostereometric analysis with 5-years clinical follow-up. Orthop Traumatol Surg Res 2019; 105:1013-20. [PMID: 31255502 DOI: 10.1016/j.otsr.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/14/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The osseointegrated (OI) prosthesis is a treatment option for transfemoral amputees with a short residual femur and/or difficulties caused by using the prosthetic socket. Implant removal due to aseptic or septic loosening is not uncommon, but the association between implant migration patterns and the need for removal has not previously been studied. We conducted a prospective model-based radiostereometric analysis study to investigate: if the OI implant migration pattern 1) differs between later removed implants and non-removed implants, (2) predicts later implant removal, and (3) if the precision of the method is acceptable. HYPOTHESIS Model-based radiostereometric analysis of the OI implant migration pattern can be used to predict later OI implant removal. MATERIAL AND METHODS A prospective cohort of 17 consecutive transfemoral amputees suitable for surgery (11 males), mean age 50 (range 32-66) were treated with an OI implant (Integrum AB, Sweden). Postoperative stereoradiographs of the OI implant were obtained during 24-month follow-up. X, Y, and Z translations and total translations were evaluated using CAD-implant models. Implant survival was followed for up to 60 months. RESULTS Six total implant removals (fixture and abutment) and four partial removals (abutment) were conducted (10/17 (59%)), and one patient did not use the OI implant. The removed implants group migrated a mean (±standard deviation) 0.55mm±0.75mm (p=0.009) and the non-removed implants group migrated 0.31mm±0.51mm (p=0.22) in total translations from 3 months to last follow-up. Odds ratio for implant removal was 22.5 (95% CI: 1.6 to 314 (p=0.021)) if the OI implants migrated distally. CONCLUSION Later removed OI implants migrated from 3 months to last follow-up and more than the non-removed OI implants. Distal implant migration greatly increased the odds of implant removal. Ten out of 17 OI implants were removed within 5 years of follow-up. We advise to use OI implants with caution and close follow-up in consideration of the risk of complications. LEVEL OF EVIDENCE IV, Prospective study.
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Aman M, Festin C, Sporer ME, Gstoettner C, Prahm C, Bergmeister KD, Aszmann OC. Bionic reconstruction : Restoration of extremity function with osseointegrated and mind-controlled prostheses. Wien Klin Wochenschr 2019; 131:599-607. [PMID: 31201567 PMCID: PMC6908564 DOI: 10.1007/s00508-019-1518-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 05/22/2019] [Accepted: 05/25/2019] [Indexed: 12/17/2022]
Abstract
Background Loss of an extremity at any level has a major impact on a patient’s life. Using bionic reconstruction, extremity function can be restored and the patient reintegrated into daily life. Surgical procedures including selective nerve transfer and anchoring of prostheses into bone are combined with structured rehabilitation and modern prosthetic fitting. The patient is thereby able to use the prostheses intuitively and with multiple degrees of freedom. Methods This article presents the concept and approach for modern bionic reconstruction in detail and the relevant literature. The nerve transfer matrices for targeted muscle reinnervation (TMR) and the concept of osseointegration to optimally fit a patient with a modern prosthesis are described in detail. As a clinical example, the case of a patient who suffered from traumatic amputation and subsequently received TMR in combination with an osseointegrated implant and structured rehabilitation is presented. Results Using bionic reconstruction, basic hand functions can be restored and bimanual dexterity can expand the range of daily activities. Besides this approach to bionic reconstruction, its advantages and disadvantages are compared to hand transplantation. The limitations and perspectives of modern bionic reconstruction are also discussed. Conclusions Bionic reconstruction is a sophisticated method for restoring extremity function and nowadays can be considered a standard of care for all levels of upper extremity amputations. An interdisciplinary approach and structured rehabilitation are necessary to master prosthetic function to ultimately reintegrate patients into daily life.
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Affiliation(s)
- Martin Aman
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias E Sporer
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Clemens Gstoettner
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Cosima Prahm
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Konstantin D Bergmeister
- Division of Biomedical Research, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria. .,Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria. .,Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
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