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Prahm C, Bressler M, Heinzel J, Lauer H, Ritter J, Daigeler A, Kolbenschlag J. [Digital technologies and strategies in amputation medicine]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:637-643. [PMID: 39093447 DOI: 10.1007/s00113-024-01468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
Surgical techniques in amputation medicine did not change for a long time, while prosthesis technology underwent rapid development. The focus shifted to optimising the residual limb for prostheses use. At the same time, digital technologies such as gamification, virtual and mixed reality revolutionised rehabilitation. The use of gamification elements increases motivation and adherence to therapy, while immersive technologies enable realistic and interactive therapy experiences. This is particularly useful in the context of controlling modern prostheses and treating phantom pain. In addition, digital applications contribute to optimised documentation of symptoms and therapy successes. Overall, these technologies open up new, effective and personalised therapeutic approaches that can significantly improve the quality of life of amputation patients.
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Affiliation(s)
- Cosima Prahm
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland.
| | - Michael Bressler
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
| | - Johannes Heinzel
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
| | - Henrik Lauer
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
| | - Jana Ritter
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
| | - Adrien Daigeler
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
| | - Jonas Kolbenschlag
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland
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Flanagan W, Becraft K, Warren H, Stavrakis AI, Bernthal NM, Hardin TJ, Clites TR. Prosthetic Limb Attachment via Electromagnetic Attraction Through a Closed Skin Envelope. IEEE Trans Biomed Eng 2024; 71:1552-1564. [PMID: 38090864 DOI: 10.1109/tbme.2023.3342652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Current socket-based methods of prosthetic limb attachment are responsible for many of the dominant problems reported by persons with amputation. In this work, we introduce a new paradigm for attachment via electromagnetic attraction between a bone-anchored ferromagnetic implant and an external electromagnet. Our objective was to develop a design framework for electromagnetic attachment, and to evaluate this framework in the context of transfemoral amputation. METHODS We first used inverse dynamics to calculate the forces required to suspend a knee-ankle-foot prosthesis during gait. We then conducted cadaveric dissections to inform implant geometry and design a surgical methodology for covering the implant. We also developed an in silico framework to investigate how electromagnet design affects system performance. Simulations were validated against benchtop testing of a custom-built electromagnet. RESULTS The physical electromagnet matched simulations, with a root-mean-square percentage error of 4.2% between measured and predicted forces. Using this electromagnet, we estimate that suspension of a prosthesis during gait would require 33 W of average power. After 200 and 1000 steps of simulated walking, the temperature at the skin would increase 2.3 °C and 15.4 °C relative to ambient, respectively. CONCLUSION Our design framework produced an implant and electromagnet that could feasibly suspend a knee-ankle-foot prosthesis during short walking bouts. Future work will focus on optimization of this system to reduce heating during longer bouts. SIGNIFICANCE This work demonstrates the initial feasibility of an electromagnetic prosthetic attachment paradigm that has the potential to increase comfort and improve residual limb health for persons with amputation.
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Rubin N, Hinson R, Saul K, Filer W, Hu X, Huang H(H. Modified motor unit properties in residual muscle following transtibial amputation. J Neural Eng 2024; 21:10.1088/1741-2552/ad1ac2. [PMID: 38176027 PMCID: PMC11214693 DOI: 10.1088/1741-2552/ad1ac2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/04/2024] [Indexed: 01/06/2024]
Abstract
Objective.Neural signals in residual muscles of amputated limbs are frequently decoded to control powered prostheses. Yet myoelectric controllers assume muscle activities of residual muscles are similar to that of intact muscles. This study sought to understand potential changes to motor unit (MU) properties after limb amputation.Approach.Six people with unilateral transtibial amputation were recruited. Surface electromyogram (EMG) of residual and intacttibialis anterior(TA) andgastrocnemius(GA) muscles were recorded while subjects traced profiles targeting up to 20% and 35% of maximum activation for each muscle (isometric for intact limbs). EMG was decomposed into groups of MU spike trains. MU recruitment thresholds, action potential amplitudes (MU size), and firing rates were correlated to model Henneman's size principle, the onion-skin phenomenon, and rate-size associations. Organization (correlation) and modulation (rates of change) of relations were compared between intact and residual muscles.Main results.The residual TA exhibited significantly lower correlation and flatter slopes in the size principle and onion-skin, and each outcome covaried between the MU relations. The residual GA was unaffected for most subjects. Subjects trained prior with myoelectric prostheses had minimally affected slopes in the TA. Rate-size association correlations were preserved, but both residual muscles exhibited flatter decay rates.Significance.We showed peripheral neuromuscular damage also leads to spinal-level functional reorganizations. Our findings suggest models of MU recruitment and discharge patterns for residual muscle EMG generation need reparameterization to account for disturbances observed. In the future, tracking MU pool adaptations may also provide a biomarker of neuromuscular control to aid training with myoelectric prostheses.
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Affiliation(s)
- Noah Rubin
- UNC/NC State Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Robert Hinson
- UNC/NC State Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
- UNC/NC State Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Katherine Saul
- Department of Mechanical & Aerospace Engineering, North Carolina State University, Raleigh, NC 27695, United States of America
| | - William Filer
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
| | - Xiaogang Hu
- Department of Mechanical Engineering, Pennsylvania State University, University Park, PA 16802, United States of America
| | - He (Helen) Huang
- UNC/NC State Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States of America
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Mauch JT, Kao DS, Friedly JL, Liu Y. Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review. PM R 2023; 15:1457-1465. [PMID: 36965013 DOI: 10.1002/pmrj.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 01/28/2023] [Accepted: 03/10/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVE Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear. LITERATURE SURVEY A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried. METHODOLOGY Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation. SYNTHESIS Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing. CONCLUSIONS Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.
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Affiliation(s)
- Jaclyn T Mauch
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Dennis S Kao
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Yusha Liu
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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Schnack LL, Rodriguez-Collazo ER, Oexeman SA, Costa AJ. The Reset Neurotomy within a Nonidentifiable Zone of Injury after Trauma. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5316. [PMID: 37842076 PMCID: PMC10569763 DOI: 10.1097/gox.0000000000005316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 08/23/2023] [Indexed: 10/17/2023]
Abstract
Recent reconstructive approaches to peripheral nerve surgery have been directed toward active approaches; one such approach is nerve grafting the injured nerve segment. Addressing a nerve injury proximal to the zone of injury has demonstrated reproducible results in preventing symptomatic neuroma formation. A 53-year-old woman with a history of an ankle fracture presented with neuritic symptoms that interfered with her activities of daily living. Her intractable pain was significantly but temporarily relieved with in-office nerve blocks to the superficial peroneal nerve and sural nerve. There were no identifiable zones of injury in the nerve conduction study. Orthopedic etiology was ruled out. Nerve allografts, each 3 cm in length, were utilized with conduits and placed at the location proximal to the zone of maximum tenderness. Once the neurotomy was performed, the nerve allografts and conduits were coapted to each nerve. The patient's intractable neuritic pain was relieved even 15 months postoperatively. The visual analog scale went from eight of 10 preoperatively to two of 10 postoperatively. Additional nerve conduction studies were not needed, and the patient returned to daily activities once the skin incisions healed. The reset neurotomy is an option for the microsurgical surgeon to have for patients with a nonidentifiable zone of injury or no identifiable neuroma but presents with intractable nerve pain relieved by local anesthetic nerve blocks.
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Affiliation(s)
- Lauren L Schnack
- From the Department of Podiatric Medicine and Surgery, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Ill
| | - Edgardo R Rodriguez-Collazo
- Ascension-Saint Joseph Chicago Podiatry Residency Program, Chicago, Ill
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Ill
| | - Stephanie A Oexeman
- Ascension-Saint Joseph Chicago Podiatry Residency Program, Chicago, Ill
- Oexeman Foot and Ankle, PLLC, Chicago, Ill
| | - Andrew J Costa
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Ill
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Leach GA, Dean RA, Kumar NG, Tsai C, Chiarappa FE, Cederna PS, Kung TA, Reid CM. Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5127. [PMID: 37465283 PMCID: PMC10351954 DOI: 10.1097/gox.0000000000005127] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 07/20/2023]
Abstract
Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.
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Affiliation(s)
- Garrison A. Leach
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Riley A. Dean
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Nishant Ganesh Kumar
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Catherine Tsai
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Frank E. Chiarappa
- Department of Orthopedic Surgery, University of California San Diego, La Jolla, Calif
| | - Paul S. Cederna
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Theodore A. Kung
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Chris M. Reid
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
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Schwartz NA, von Glascoe CA. Adaptive sport as affirmation: "We focus on our strengths, not our disabilities". PLoS One 2023; 18:e0283842. [PMID: 37163489 PMCID: PMC10171584 DOI: 10.1371/journal.pone.0283842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/18/2023] [Indexed: 05/12/2023] Open
Abstract
This paper offers a counter-narrative to the stereotype of people with physical and cognitive impairments being less inclined to participate in athletic activities. It contributes to the affirmative model proposed by Swain and French, which posits a non-tragic view of disability that encompasses positive social identities. We employed the tools of ethnography and phenomenology to explore the adaptive athlete experience among individuals practicing various sports and exhibiting divergent levels of proficiency. Findings confirm the appropriateness of the affirmative model and provide examples of movement from the state of liminality to that of communitas as defined by Victor Turner.
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Affiliation(s)
- Norah Anita Schwartz
- Departamento de Estudios Poblacion, Secion de Salud Publica, El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico
| | - Christine Alysse von Glascoe
- Departamento de Estudios Poblacion, Secion de Salud Publica, El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico
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Eberlin KR, Brown DA, Gaston RG, Kleiber GM, Ko JH, Kovach SJ, Loeffler BJ, MacKay BJ, Potter BK, Roubaud MS, Souza JM, Valerio IL, Dumanian GA. A Consensus Approach for Targeted Muscle Reinnervation in Amputees. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4928. [PMID: 37035125 PMCID: PMC10079335 DOI: 10.1097/gox.0000000000004928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023]
Abstract
Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.
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Affiliation(s)
- Kyle R. Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - David A. Brown
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, N.C
| | - R. Glenn Gaston
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Grant M. Kleiber
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Jason H. Ko
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Stephen J. Kovach
- Division of Plastic Surgery, Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pa
| | - Bryan J. Loeffler
- OrthoCarolina Hand and Upper Extremity Department and Atrium Health Department of Orthopedic Surgery, Charlotte, N.C
| | - Brendan J. MacKay
- Department of Orthopedic Surgery, Texas Tech University Health Science Center, Lubbock, Tex
| | - Benjamin K. Potter
- Uniformed Services University – Walter Reed Department of Surgery, Bethesda, Md
| | - Margaret S. Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Jason M. Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ian L. Valerio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Gregory A. Dumanian
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Crandell D, Lozano-Calderon S, Mayerson J. Editorial: Advances in rehabilitation intervention after limb amputation. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1149001. [PMID: 36873819 PMCID: PMC9978791 DOI: 10.3389/fresc.2023.1149001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Affiliation(s)
- David Crandell
- Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, United States
| | | | - Joel Mayerson
- Wexner Medical Center, The Ohio State University, Columbus, OH, United States
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A Systematic Review of the Reported Complications Related to Facial and Upper Extremity Vascularized Composite Allotransplantation. J Surg Res 2023; 281:164-175. [PMID: 36162189 DOI: 10.1016/j.jss.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Twenty three years after the first successful upper extremity transplantation, the role of vascularized composite allotransplantation (VCA) in the world of transplantation remains controversial. Face and upper extremity reconstruction via transplantation have become successful options for highly selected patients with severe tissue and functional deficit when conventional reconstructive options are no longer available. Despite clear benefit in these situations, VCA has a significant potential for complications that are more frequent when compared to visceral organ transplantation. This study intended to perform an updated systematic review on such complications. MATERIALS AND METHODS MEDLINE database via PubMed, Embase and Cochrane Library were searched. Face and upper extremity VCA performed between 1998 and 2021 were included in the study. Relevant media and press conferences reports were also included. Complications related to face and upper extremity VCA were recorded and reviewed including their clinical characteristics and complications. RESULTS One hundred fifteen patients underwent facial (43%) or upper extremity (57%) transplantation. Overall, the surgical complication rate was 23%. Acute and chronic rejection was identified in 89% and 11% of patients, respectively. Fifty eight percent of patients experienced opportunistic infection. Impaired glucose metabolism was the most common immunosuppression-related complication other than infection. Nineteen percent of patients ultimately experienced partial or complete allograft loss. CONCLUSIONS Complications related to VCA are a significant source of morbidity and potential mortality. Incidence of such complications is higher than previously reported and should be strongly emphasized in patient consent process. Strict patient selection criteria, complex preoperative evaluation, consideration of alternatives, and thorough disclosure to patients should be routinely performed prior to VCA indication.
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Song H, Israel EA, Gutierrez-Arango S, Teng AC, Srinivasan SS, Freed LE, Herr HM. Agonist-antagonist muscle strain in the residual limb preserves motor control and perception after amputation. COMMUNICATIONS MEDICINE 2022; 2:97. [PMID: 35942078 PMCID: PMC9356003 DOI: 10.1038/s43856-022-00162-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/22/2022] [Indexed: 12/04/2022] Open
Abstract
Background Elucidating underlying mechanisms in subject-specific motor control and perception after amputation could guide development of advanced surgical and neuroprosthetic technologies. In this study, relationships between preserved agonist-antagonist muscle strain within the residual limb and preserved motor control and perception capacity are investigated. Methods Fourteen persons with unilateral transtibial amputations spanning a range of ages, etiologies, and surgical procedures underwent evaluations involving free-space mirrored motions of their lower limbs. Research has shown that varied motor control in biologically intact limbs is executed by the activation of muscle synergies. Here, we assess the naturalness of phantom joint motor control postamputation based on extracted muscle synergies and their activation profiles. Muscle synergy extraction, degree of agonist-antagonist muscle strain, and perception capacity are estimated from electromyography, ultrasonography, and goniometry, respectively. Results Here, we show significant positive correlations (P < 0.005-0.05) between sensorimotor responses and residual limb agonist-antagonist muscle strain. Identified trends indicate that preserving even 20-26% of agonist-antagonist muscle strain within the residuum compared to a biologically intact limb is effective in preserving natural motor control postamputation, though preserving limb perception capacity requires more (61%) agonist-antagonist muscle strain preservation. Conclusions The results suggest that agonist-antagonist muscle strain is a characteristic, readily ascertainable residual limb structural feature that can help explain variability in amputation outcome, and agonist-antagonist muscle strain preserving surgical amputation strategies are one way to enable more effective and biomimetic sensorimotor control postamputation.
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Affiliation(s)
- Hyungeun Song
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA USA
| | - Erica A. Israel
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
| | | | - Ashley C. Teng
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
- Mechanical Engineering Department, Massachusetts Institute of Technology, Cambridge, MA USA
| | - Shriya S. Srinivasan
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA USA
| | - Lisa E. Freed
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
| | - Hugh M. Herr
- K. Lisa Yang Center for Bionics, Massachusetts Institute of Technology, Cambridge, MA USA
- Harvard Medical School, Cambridge, MA USA
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Ahkami B, Mastinu E, Earley EJ, Ortiz-Catalan M. Extra-neural signals from severed nerves enable intrinsic hand movements in transhumeral amputations. Sci Rep 2022; 12:10218. [PMID: 35715459 PMCID: PMC9206000 DOI: 10.1038/s41598-022-13363-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 05/24/2022] [Indexed: 11/22/2022] Open
Abstract
Robotic prostheses controlled by myoelectric signals can restore limited but important hand function in individuals with upper limb amputation. The lack of individual finger control highlights the yet insurmountable gap to fully replacing a biological hand. Implanted electrodes around severed nerves have been used to elicit sensations perceived as arising from the missing limb, but using such extra-neural electrodes to record motor signals that allow for the decoding of phantom movements has remained elusive. Here, we showed the feasibility of using signals from non-penetrating neural electrodes to decode intrinsic hand and finger movements in individuals with above-elbow amputations. We found that information recorded with extra-neural electrodes alone was enough to decode phantom hand and individual finger movements, and as expected, the addition of myoelectric signals reduced classification errors both in offline and in real-time decoding.
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Affiliation(s)
- Bahareh Ahkami
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Enzo Mastinu
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Eric J Earley
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden. .,Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden. .,Operational Area 3, Sahlgrenska University Hospital, Mölndal, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Karczewski AM, Zeng W, Stratchko LM, Bachus KN, Poore SO, Dingle AM. Clinical Basis for Creating an Osseointegrated Neural Interface. Front Neurosci 2022; 16:828593. [PMID: 35495044 PMCID: PMC9039253 DOI: 10.3389/fnins.2022.828593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
As technology continues to improve within the neuroprosthetic landscape, there has been a paradigm shift in the approach to amputation and surgical implementation of haptic neural prosthesis for limb restoration. The Osseointegrated Neural Interface (ONI) is a proposed solution involving the transposition of terminal nerves into the medullary canal of long bones. This design combines concepts of neuroma formation and prevention with osseointegration to provide a stable environment for conduction of neural signals for sophisticated prosthetic control. While this concept has previously been explored in animal models, it has yet to be explored in humans. This anatomic study used three upper limb and three lower limb cadavers to assess the clinical feasibility of creating an ONI in humans. Anatomical measurement of the major peripheral nerves- circumference, length, and depth- were performed as they are critical for electrode design and rerouting of the nerves into the long bones. CT imaging was used for morphologic bone evaluation and virtual implantation of two osseointegrated implants were performed to assess the amount of residual medullary space available for housing the neural interfacing hardware. Use of a small stem osseointegrated implant was found to reduce bone removal and provide more intramedullary space than a traditional implant; however, the higher the amputation site, the less medullary space was available regardless of implant type. Thus the stability of the endoprosthesis must be maximized while still maintaining enough residual space for the interface components. The results from this study provide an anatomic basis required for establishing a clinically applicable ONI in humans. They may serve as a guide for surgical implementation of an osseointegrated endoprosthesis with intramedullary electrodes for prosthetic control.
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Affiliation(s)
- Alison M. Karczewski
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Weifeng Zeng
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Lindsay M. Stratchko
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Kent N. Bachus
- George E. Wahlen Department of Veterans Affairs Medical Center and the Department of Orthopaedics, University of Utah Orthopaedic Center, Salt Lake City, UT, United States
| | - Samuel O. Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Aaron M. Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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14
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Karczewski AM, Dingle AM, Poore SO. Osseointegration of Extremity Prostheses: A Primer for the Plastic Surgeon. Plast Reconstr Surg 2022; 149:150e-151e. [PMID: 34855705 DOI: 10.1097/prs.0000000000008644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Samuel O Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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15
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Abstract
Scientist and technologist have long sought to advance limb prostheses that connect directly to the peripheral nervous system, enabling a person with amputation to volitionally control synthetic actuators that move, stiffen and power the prosthesis, as well as to experience natural afferent sensations from the prosthesis. Recently, the agonist-antagonist myoneural interface (AMI) was developed, a mechanoneural transduction architecture and neural interface system designed to provide persons with amputation improved muscle-tendon proprioception and neuroprosthetic control. In this paper, we provide an overview of the AMI, including its conceptual framing and preclinical science, surgical techniques for its construction, and clinical efficacy related to pain mitigation, phantom limb range of motion, fascicle dynamics, central brain proprioceptive sensorimotor preservation, and prosthetic controllability. Following this broad overview, we end with a discussion of current limitations of the AMI and potential resolutions to such challenges.
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16
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Luft M, Klepetko J, Muceli S, Ibáñez J, Tereshenko V, Festin C, Laengle G, Politikou O, Maierhofer U, Farina D, Aszmann OC, Bergmeister KD. Proof of concept for multiple nerve transfers to a single target muscle. eLife 2021; 10:e71312. [PMID: 34596042 PMCID: PMC8530510 DOI: 10.7554/elife.71312] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Surgical nerve transfers are used to efficiently treat peripheral nerve injuries, neuromas, phantom limb pain, or improve bionic prosthetic control. Commonly, one donor nerve is transferred to one target muscle. However, the transfer of multiple nerves onto a single target muscle may increase the number of muscle signals for myoelectric prosthetic control and facilitate the treatment of multiple neuromas. Currently, no experimental models are available. This study describes a novel experimental model to investigate the neurophysiological effects of peripheral double nerve transfers to a common target muscle. In 62 male Sprague-Dawley rats, the ulnar nerve of the antebrachium alone (n=30) or together with the anterior interosseus nerve (n=32) was transferred to reinnervate the long head of the biceps brachii. Before neurotization, the motor branch to the biceps' long head was transected at the motor entry point. Twelve weeks after surgery, muscle response to neurotomy, behavioral testing, retrograde labeling, and structural analyses were performed to assess reinnervation. These analyses indicated that all nerves successfully reinnervated the target muscle. No aberrant reinnervation was observed by the originally innervating nerve. Our observations suggest a minimal burden for the animal with no signs of functional deficit in daily activities or auto-mutilation in both procedures. Furthermore, standard neurophysiological analyses for nerve and muscle regeneration were applicable. This newly developed nerve transfer model allows for the reliable and standardized investigation of neural and functional changes following the transfer of multiple donor nerves to one target muscle.
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Affiliation(s)
- Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Johanna Klepetko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Silvia Muceli
- Department of Electrical Engineering, Chalmers University of TechnologyGothenburgSweden
| | - Jaime Ibáñez
- Department of Bioengineering, Imperial College LondonLondonUnited Kingdom
- Department of Clinical and Movement Neuroscience, University College London, LondonLondonUnited Kingdom
- BSICoS Group, IIS Aragón, Universidad de ZaragozaZaragozaSpain
| | - Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Dario Farina
- Department of Bioengineering, Imperial College LondonLondonUnited Kingdom
- Department of Clinical and Movement Neuroscience, University College London, LondonLondonUnited Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
| | - Konstantin Davide Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
- Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and ReconstructiveSurgery, University Hospital St. PoeltenSt. PoeltenAustria
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17
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Nishikawa K, Huck TG. Muscle as a tunable material: implications for achieving muscle-like function in robotic prosthetic devices. J Exp Biol 2021; 224:272387. [PMID: 34605903 DOI: 10.1242/jeb.225086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An ideal prosthesis should perform as well as or better than the missing limb it was designed to replace. Although this ideal is currently unattainable, recent advances in design have significantly improved the function of prosthetic devices. For the lower extremity, both passive prostheses (which provide no added power) and active prostheses (which add propulsive power) aim to emulate the dynamic function of the ankle joint, whose adaptive, time-varying resistance to applied forces is essential for walking and running. Passive prostheses fail to normalize energetics because they lack variable ankle impedance that is actively controlled within each gait cycle. By contrast, robotic prostheses can normalize energetics for some users under some conditions. However, the problem of adaptive and versatile control remains a significant issue. Current prosthesis-control algorithms fail to adapt to changes in gait required for walking on level ground at different speeds or on ramps and stairs. A new paradigm of 'muscle as a tunable material' versus 'muscle as a motor' offers insights into the adaptability and versatility of biological muscles, which may provide inspiration for prosthesis design and control. In this new paradigm, neural activation tunes muscle stiffness and damping, adapting the response to applied forces rather than instructing the timing and amplitude of muscle force. A mechanistic understanding of muscle function is incomplete and would benefit from collaboration between biologists and engineers. An improved understanding of the adaptability of muscle may yield better models as well as inspiration for developing prostheses that equal or surpass the functional capabilities of biological limbs across a wide range of conditions.
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Affiliation(s)
- Kiisa Nishikawa
- Department of Biological Sciences, Northern Arizona University, Flagstaff, AZ 86011-5640, USA
| | - Thomas G Huck
- Department of Biological Sciences, Northern Arizona University, Flagstaff, AZ 86011-5640, USA
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18
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Neural interfacing architecture enables enhanced motor control and residual limb functionality postamputation. Proc Natl Acad Sci U S A 2021; 118:2019555118. [PMID: 33593940 PMCID: PMC7936324 DOI: 10.1073/pnas.2019555118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in prosthetic technologies, persons with amputation today suffer great diminution in mobility and quality of life. This is largely due to an outdated amputation paradigm that precludes efficacious communication between the residual limb and prosthesis. An amputation method utilizing agonist–antagonist myoneural interfaces (AMIs) constructs neuromuscular substrates in the residual limb to avail enhanced sensorimotor signaling. In our study, subjects with AMI amputation demonstrate improved motor control, phantom sensations, range of motion, and decreased pain when compared to patients with traditional amputation. With the demonstrated increases in motor coordination and position differentiation, our results suggest that patients with AMI amputation will be able to more efficaciously control bionic prostheses. Despite advancements in prosthetic technologies, patients with amputation today suffer great diminution in mobility and quality of life. We have developed a modified below-knee amputation (BKA) procedure that incorporates agonist–antagonist myoneural interfaces (AMIs), which surgically preserve and couple agonist–antagonist muscle pairs for the subtalar and ankle joints. AMIs are designed to restore physiological neuromuscular dynamics, enable bidirectional neural signaling, and offer greater neuroprosthetic controllability compared to traditional amputation techniques. In this prospective, nonrandomized, unmasked study design, 15 subjects with AMI below-knee amputation (AB) were matched with 7 subjects who underwent a traditional below-knee amputation (TB). AB subjects demonstrated significantly greater control of their residual limb musculature, production of more differentiable efferent control signals, and greater precision of movement compared to TB subjects (P < 0.008). This may be due to the presence of greater proprioceptive inputs facilitated by the significantly higher fascicle strains resulting from coordinated muscle excursion in AB subjects (P < 0.05). AB subjects reported significantly greater phantom range of motion postamputation (AB: 12.47 ± 2.41, TB: 10.14 ± 1.45 degrees) when compared to TB subjects (P < 0.05). Furthermore, AB subjects also reported less pain (12.25 ± 5.37) than TB subjects (17.29 ± 10.22) and a significant reduction when compared to their preoperative baseline (P < 0.05). Compared with traditional amputation, the construction of AMIs during amputation confers the benefits of enhanced physiological neuromuscular dynamics, proprioception, and phantom limb perception. Subjects’ activation of the AMIs produces more differentiable electromyography (EMG) for myoelectric prosthesis control and demonstrates more positive clinical outcomes.
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19
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Hoyt BW, Potter BK, Souza JM. Nerve Interface Strategies for Neuroma Management and Prevention: A Conceptual Approach Guided by Institutional Experience. Hand Clin 2021; 37:373-382. [PMID: 34253310 DOI: 10.1016/j.hcl.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this article, the authors propose a strategy to manage and prevent symptomatic neuromas using a combination of nerve interface approaches. By using a reconstructive paradigm, these procedures provide the components integral to organized nerve regeneration, conferring both improvements in pain and potential for myoelectric control of prostheses in the future. Given the lack of evidence at this point indicating the advantage of any single nerve interface procedure, the authors propose a management approach that maximizes physiologic restoration while limiting morbidity where possible.
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Affiliation(s)
- Benjamin W Hoyt
- USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD 20814, USA
| | - Benjamin K Potter
- USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD 20814, USA
| | - Jason M Souza
- Peripheral Nerve Program, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University, 8901 Wisconsin Avenue, Bethesda, MD 20814, USA.
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20
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Abstract
The agonist-antagonist myoneural interface is a novel surgical construct and neural interfacing approach designed to augment volitional control of adapted prostheses, preserve proprioception, and prevent limb atrophy in the setting of limb amputation.
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Affiliation(s)
- Matthew J Carty
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Hugh M Herr
- Center for Extreme Bionics, MIT Media Lab, Massachusetts Institute of Technology, 75 Amherst Street, Cambridge, MA 02139, USA
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21
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Karczewski AM, Dingle AM, Poore SO. The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements. Front Neurorobot 2021; 15:711028. [PMID: 34366820 PMCID: PMC8334559 DOI: 10.3389/fnbot.2021.711028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Over the last few decades there has been a push to enhance the use of advanced prosthetics within the fields of biomedical engineering, neuroscience, and surgery. Through the development of peripheral neural interfaces and invasive electrodes, an individual's own nervous system can be used to control a prosthesis. With novel improvements in neural recording and signal decoding, this intimate communication has paved the way for bidirectional and intuitive control of prostheses. While various collaborations between engineers and surgeons have led to considerable success with motor control and pain management, it has been significantly more challenging to restore sensation. Many of the existing peripheral neural interfaces have demonstrated success in one of these modalities; however, none are currently able to fully restore limb function. Though this is in part due to the complexity of the human somatosensory system and stability of bioelectronics, the fragmentary and as-yet uncoordinated nature of the neuroprosthetic industry further complicates this advancement. In this review, we provide a comprehensive overview of the current field of neuroprosthetics and explore potential strategies to address its unique challenges. These include exploration of electrodes, surgical techniques, control methods, and prosthetic technology. Additionally, we propose a new approach to optimizing prosthetic limb function and facilitating clinical application by capitalizing on available resources. It is incumbent upon academia and industry to encourage collaboration and utilization of different peripheral neural interfaces in combination with each other to create versatile limbs that not only improve function but quality of life. Despite the rapidly evolving technology, if the field continues to work in divided "silos," we will delay achieving the critical, valuable outcome: creating a prosthetic limb that is right for the patient and positively affects their life.
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Affiliation(s)
| | - Aaron M. Dingle
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin–Madison, Madison, WI, United States
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22
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Srinivasan SS, Tuckute G, Zou J, Gutierrez-Arango S, Song H, Barry RL, Herr HM. Agonist-antagonist myoneural interface amputation preserves proprioceptive sensorimotor neurophysiology in lower limbs. Sci Transl Med 2021; 12:12/573/eabc5926. [PMID: 33298564 DOI: 10.1126/scitranslmed.abc5926] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/22/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022]
Abstract
The brain undergoes marked changes in function and functional connectivity after limb amputation. The agonist-antagonist myoneural interface (AMI) amputation is a procedure that restores physiological agonist-antagonist muscle relationships responsible for proprioceptive sensory feedback to enable greater motor control. We compared results from the functional neuroimaging of individuals (n = 29) with AMI amputation, traditional amputation, and no amputation. Individuals with traditional amputation demonstrated a significant decrease in proprioceptive activity, measured by activation of Brodmann area 3a, whereas functional activation in individuals with AMIs was not significantly different from controls with no amputation (P < 0.05). The degree of proprioceptive activity in the brain strongly correlated with fascicle activity in the peripheral muscles and performance on motor tasks (P < 0.05), supporting the mechanistic basis of the AMI procedure. These results suggest that surgical techniques designed to restore proprioceptive peripheral neuromuscular constructs result in desirable central sensorimotor plasticity.
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Affiliation(s)
- Shriya S Srinivasan
- Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA. .,MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA 02129, USA
| | - Greta Tuckute
- MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Jasmine Zou
- MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Samantha Gutierrez-Arango
- MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA 02129, USA
| | - Hyungeun Song
- Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA 02129, USA
| | - Robert L Barry
- Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA. .,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA 02129, USA.,Department of Radiology, Harvard Medical School, Boston, MA 02115, USA
| | - Hugh M Herr
- MIT Center for Extreme Bionics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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23
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Dibbs RP, Ali K, Sarrami SM, Koshy JC. Revision Peripheral Nerve Surgery of the Upper Extremity. Semin Plast Surg 2021; 35:119-129. [PMID: 34121947 DOI: 10.1055/s-0041-1727290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.
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Affiliation(s)
- Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Kausar Ali
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - John C Koshy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
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24
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Spotlight in Plastic Surgery: July 2021. Plast Reconstr Surg 2021; 148:268-271. [PMID: 34086618 DOI: 10.1097/prs.0000000000008128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Felder JM, Skladman R. Translating Technique into Outcomes in Amputation Surgeries. MISSOURI MEDICINE 2021; 118:141-146. [PMID: 33840857 PMCID: PMC8029626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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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26
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Restoration of bilateral motor coordination from preserved agonist-antagonist coupling in amputation musculature. J Neuroeng Rehabil 2021; 18:38. [PMID: 33596960 PMCID: PMC7891024 DOI: 10.1186/s12984-021-00829-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background Neuroprosthetic devices controlled by persons with standard limb amputation often lack the dexterity of the physiological limb due to limitations of both the user’s ability to output accurate control signals and the control system’s ability to formulate dynamic trajectories from those signals. To restore full limb functionality to persons with amputation, it is necessary to first deduce and quantify the motor performance of the missing limbs, then meet these performance requirements through direct, volitional control of neuroprosthetic devices. Methods We develop a neuromuscular modeling and optimization paradigm for the agonist-antagonist myoneural interface, a novel tissue architecture and neural interface for the control of myoelectric prostheses, that enables it to generate virtual joint trajectories coordinated with an intact biological joint at full physiologically-relevant movement bandwidth. In this investigation, a baseline of performance is first established in a population of non-amputee control subjects (\documentclass[12pt]{minimal}
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\begin{document}$$n = 8$$\end{document}n=8). Then, a neuromuscular modeling and optimization technique is advanced that allows unilateral AMI amputation subjects (\documentclass[12pt]{minimal}
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\begin{document}$$n = 5$$\end{document}n=5) and standard amputation subjects (\documentclass[12pt]{minimal}
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\begin{document}$$n = 4$$\end{document}n=4) to generate virtual subtalar prosthetic joint kinematics using measured surface electromyography (sEMG) signals generated by musculature within the affected leg residuum. Results Using their optimized neuromuscular subtalar models under blindfolded conditions with only proprioceptive feedback, AMI amputation subjects demonstrate bilateral subtalar coordination accuracy not significantly different from that of the non-amputee control group (Kolmogorov-Smirnov test, \documentclass[12pt]{minimal}
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\begin{document}$$P \ge 0.052$$\end{document}P≥0.052) while standard amputation subjects demonstrate significantly poorer performance (Kolmogorov-Smirnov test, \documentclass[12pt]{minimal}
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\begin{document}$$P < 0.001$$\end{document}P<0.001). Conclusions These results suggest that the absence of an intact biological joint does not necessarily remove the ability to produce neurophysical signals with sufficient information to reconstruct physiological movements. Further, the seamless manner in which virtual and intact biological joints are shown to coordinate reinforces the theory that desired movement trajectories are mentally formulated in an abstract task space which does not depend on physical limb configurations. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-021-00829-z.
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27
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Abstract
Surgical resection with wide margins and perioperative radiation therapy is the standard treatment of extremity soft tissue sarcomas. This combination often results in complex wounds and functional compromise. Reconstructive surgery is integral to limb salvage after sarcoma resection. Advances in adjuvant therapy and reconstructive surgical techniques have made functional limb salvage, instead of amputation, possible for most patients. This article reviews key concepts in the multidisciplinary care of patients with extremity soft tissue sarcomas and details reconstructive surgical techniques, including locoregional and free tissue transfer, free functional muscle transfer, and vascularized bone transfer, to optimize functional limb restoration after sarcoma resection.
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Affiliation(s)
- Rajiv P Parikh
- Plastic and Reconstructive Surgical Service, Center for Advanced Reconstruction, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Suite 1150 NWT, St Louis, MO 63110, USA.
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28
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A cutaneous mechanoneural interface for neuroprosthetic feedback. Nat Biomed Eng 2021; 6:731-740. [PMID: 33526908 DOI: 10.1038/s41551-020-00669-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/26/2020] [Indexed: 01/16/2023]
Abstract
Amputation destroys sensory end organs and does not provide an anatomical interface for cutaneous neuroprosthetic feedback. Here, we report the design and a biomechanical and electrophysiological evaluation of the cutaneous mechanoneural interface consisting of an afferent neural system that comprises a muscle actuator coupled to a natively pedicled skin flap in a cuff-like architecture. Muscle is actuated through electrical stimulation to induce strains or oscillatory vibrations on the skin flap that are proportional to a desired contact duration or contact pressure. In rat hindlimbs, the mechanoneural interface elicited native dermal mechanotransducers to generate at least four levels of graded contact and eight distinct vibratory afferents that were not significantly different from analogous mechanical stimulation of intact skin. The application of different patterns of electrical stimulation independently engaged slowly adapting and rapidly adapting mechanotransducers, and recreated an array of cutaneous sensations. The cutaneous mechanoneural interface can be integrated with current prosthetic technologies for tactile feedback.
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Dumanian GA. Commentary on Targeted Muscle Reinnervation in the Oncologic Population: A Literature Review and Current Practice. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00270-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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