1
|
Berberoglu I, Burke KL, Gilman RH, Kasten S, Cederna PS, Kemp SW. 60 Years of Michigan Plastic Surgery. Semin Plast Surg 2024; 38:3-9. [PMID: 38495067 PMCID: PMC10942828 DOI: 10.1055/s-0043-1778035] [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] [Indexed: 03/19/2024]
Abstract
In 1964, the Section of Plastic and Reconstructive Surgery at the University of Michigan opened its doors to future surgeons and leaders in the field. Today, we are celebrating the 60-year history of the program and its significant contributions to the field. Beginning under the leadership of Reed O. Dingman, MD, DDS, the program began with three faculty members and two independent surgical residents. Since that time, it has expanded dramatically to include 24 faculty members and 28 integrated plastic surgery residents. The goals of the program have always been to achieve excellence in all three of our academic missions including clinical care, teaching, and research. Annually, the program sees an average of 35,000 outpatient clinic visits, 4,000 major operations, 200 peer-reviewed publications, $5,000,000 in research spending, and residents who are well trained and highly competitive for fellowships of their choosing every single year. Through scientific collaborations, academic exchanges, and medical missions, the program's influence has spread beyond Michigan, reaching the entire world. In addition to training world-renowned surgeons, Michigan's faculty and graduates have assumed leadership roles in prestigious professional organizations, scientific journals, and research foundations. In this article, we explore the roots of the program and reflect on six decades of impact, innovation, and inspiration.
Collapse
Affiliation(s)
- Ipek Berberoglu
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
| | - Katherine L. Burke
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
| | - Robert H. Gilman
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
| | - Steven Kasten
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
| | - Paul S. Cederna
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
- Department of Biomedical Engineering, The University of Michigan, Ann Arbor, Michigan
| | - Stephen W.P. Kemp
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan
- Department of Biomedical Engineering, The University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
2
|
Tian Y, Vaskov AK, Adidharma W, Cederna PS, Kemp SW. Merging Humans and Neuroprosthetics through Regenerative Peripheral Nerve Interfaces. Semin Plast Surg 2024; 38:10-18. [PMID: 38495064 PMCID: PMC10942838 DOI: 10.1055/s-0044-1779028] [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] [Indexed: 03/19/2024]
Abstract
Limb amputations can be devastating and significantly affect an individual's independence, leading to functional and psychosocial challenges in nearly 2 million people in the United States alone. Over the past decade, robotic devices driven by neural signals such as neuroprostheses have shown great potential to restore the lost function of limbs, allowing amputees to regain movement and sensation. However, current neuroprosthetic interfaces have challenges in both signal quality and long-term stability. To overcome these limitations and work toward creating bionic limbs, the Neuromuscular Laboratory at University of Michigan Plastic Surgery has developed the Regenerative Peripheral Nerve Interface (RPNI). This surgical construct embeds a transected peripheral nerve into a free muscle graft, effectively amplifying small peripheral nerve signals to provide enhanced control signals for a neuroprosthetic limb. Furthermore, the RPNI has the potential to provide sensory feedback to the user and facilitate neuroprosthesis embodiment. This review focuses on the animal studies and clinical trials of the RPNI to recapitulate the promising trajectory toward neurobionics where the boundary between an artificial device and the human body becomes indistinct. This paper also sheds light on the prospects of the improvement and dissemination of the RPNI technology.
Collapse
Affiliation(s)
- Yucheng Tian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Alex K. Vaskov
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stephen W.P. Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
3
|
Strong AL, Rohrich RJ, Tonnard PL, Vargo JD, Cederna PS. Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science. Plast Reconstr Surg 2024; 153:360-377. [PMID: 37159906 DOI: 10.1097/prs.0000000000010643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/11/2023]
Abstract
SUMMARY The scientific study of facial aging has transformed modern facial rejuvenation. As people age, fat loss in specific fat compartments is a major contributor to structural aging of the face. Autologous fat grafting is safe, abundant, readily available, and completely biocompatible, which makes it the preferred soft-tissue filler in the correction of facial atrophy. The addition of volume through fat grafting gives an aging face a more youthful, healthy, and aesthetic appearance. Harvesting and preparation with different cannula sizes and filter-cartridge techniques have allowed for fat grafts to be divided based on parcel size and cell type into three major subtypes: macrofat, microfat, and nanofat. Macrofat and microfat have the benefit of providing volume to restore areas of facial deflation and atrophy in addition to improving skin quality; nanofat has been shown to improve skin texture and pigmentation. In this article, the authors discuss the current opinions regarding fat grafting and how the evolving science of fat grafting has led to the clinical utility of each type of fat to optimize facial rejuvenation. The opportunity exists to individualize the use of autologous fat grafting with the various subtypes of fat for the targeted correction of aging in different anatomic areas of the face. Fat grafting has become a powerful tool that has revolutionized facial rejuvenation, and developing precise, individualized plans for autologous fat grafting for each patient is an important advancement in the evolution of facial rejuvenation.
Collapse
Affiliation(s)
- Amy L Strong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
| | - Rod J Rohrich
- Dallas Plastic Surgery Institute
- Baylor College of Medicine
| | | | - James D Vargo
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
| | - Paul S Cederna
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan
| |
Collapse
|
4
|
Gonzalez MA, Nwokeabia C, Vaskov AK, Vu PP, Lu CW, Patil PG, Cederna PS, Chestek CA, Gates DH. Electrical Stimulation of Regenerative Peripheral Nerve Interfaces (RPNIs) Induces Referred Sensations in People With Upper Limb Loss. IEEE Trans Neural Syst Rehabil Eng 2024; 32:339-349. [PMID: 38145529 PMCID: PMC10938368 DOI: 10.1109/tnsre.2023.3345164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
Individuals with upper limb loss lack sensation of the missing hand, which can negatively impact their daily function. Several groups have attempted to restore this sensation through electrical stimulation of residual nerves. The purpose of this study was to explore the utility of regenerative peripheral nerve interfaces (RPNIs) in eliciting referred sensation. In four participants with upper limb loss, we characterized the quality and location of sensation elicited through electrical stimulation of RPNIs over time. We also measured functional stimulation ranges (sensory perception and discomfort thresholds), sensitivity to changes in stimulation amplitude, and ability to differentiate objects of different stiffness and sizes. Over a period of up to 54 months, stimulation of RPNIs elicited sensations that were consistent in quality (e.g. tingling, kinesthesia) and were perceived in the missing hand and forearm. The location of elicited sensation was partially-stable to stable in 13 of 14 RPNIs. For 5 of 7 RPNIs tested, participants demonstrated a sensitivity to changes in stimulation amplitude, with an average just noticeable difference of 45 nC. In a case study, one participant was provided RPNI stimulation proportional to prosthetic grip force. She identified four objects of different sizes and stiffness with 56% accuracy with stimulation alone and 100% accuracy when stimulation was combined with visual feedback of hand position. Collectively, these experiments suggest that RPNIs have the potential to be used in future bi-directional prosthetic systems.
Collapse
|
5
|
Best CSW, Cederna PS, Kung TA. Regenerative Peripheral Nerve Interface (RPNI) Surgery for Mitigation of Neuroma and Postamputation Pain. JBJS Essent Surg Tech 2024; 14:e23.00009. [PMID: 38348364 PMCID: PMC10852375 DOI: 10.2106/jbjs.st.23.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Background A neuroma occurs when a regenerating transected peripheral nerve has no distal target to reinnervate. Symptomatic neuromas are a common cause of postamputation pain that can lead to substantial disability1-3. Regenerative peripheral nerve interface (RPNI) surgery may benefit patients through the use of free nonvascularized muscle grafts as physiologic targets for peripheral nerve reinnervation for mitigation of neuroma and postamputation pain. Description An RPNI is constructed by implanting the distal end of a transected peripheral nerve into a free nonvascularized skeletal muscle graft. The neuroma or free end of the affected nerve is identified, transected, and skeletonized. A free muscle graft is then harvested from the donor thigh or from the existing amputation site, and the distal end of each transected nerve is implanted into the center of the free muscle graft with use of 6-0 nonabsorbable suture. This can be done acutely at the time of amputation or as an elective procedure at any time postoperatively. Alternatives Nonsurgical treatments of neuromas include desensitization, chemical or anesthetic injections, biofeedback, transcutaneous electrical nerve stimulation, topical lidocaine, and/or other medications (e.g., antidepressants, anticonvulsants, and opioids). Surgical treatment of neuromas includes neuroma excision, nerve capping, excision with transposition into bone or muscle, nerve grafting, and targeted muscle reinnervation. Rationale Creation of an RPNI is a simple and reproducible surgical option to prevent neuroma formation that leverages several biologic processes and addresses many limitations of existing neuroma-treatment strategies. Given the understanding that neuromas will form when regenerating axons are not presented with end organs for reinnervation, any strategy that reduces the number of aimless axons within a residual limb should serve to reduce symptomatic neuromas. The use of free muscle grafts offers a vast supply of denervated muscle targets for regenerating nerve axons and facilitates the reestablishment of neuromuscular junctions without sacrificing denervation of any residual muscles. Expected Outcomes Articles describing RPNI surgery for postamputation pain have shown favorable outcomes, with significant reduction in neuroma pain and phantom pain scores at approximately 7 months postoperatively4,5. Neuroma pain scores were reduced by 71% and phantom pain scores were reduced by 53%4. Prophylactic RPNI surgery is also associated with substantially lower incidence of symptomatic neuromas (0% versus 13.3%) and a lower rate of phantom limb pain (51.1% versus 91.1%)5 compared with the rates in patients who did not undergo RPNI surgery. Important Tips Ask the patient preoperatively to point at the site of maximal tenderness, as this can serve as a guide for where the symptomatic neuroma may be located. The incision can be made either through the previous site of the amputation or directly over the site of maximal tenderness longitudinally. The pitfall of incising directly over the site is creating another incision with its attendant risk of wound infection.Excise the terminal neuroma with a knife until healthy-appearing axons are visualized.The free nonvascularized skeletal muscle graft can be obtained from local muscle (preferred) or from a separate donor site. A separate donor site can introduce donor-site morbidity and complications, including hematoma and pain.The harvested skeletal muscle graft should ideally be approximately 35 mm long, 20 mm wide, and 5 mm thick in order to ensure survivability and to prevent central necrosis. The harvesting can be performed with curved Mayo scissors.The peripheral nerve should be implanted parallel to the direction of the muscle fibers, and the epineurium should be secured to the free muscle graft at 1 or 2 places. One suture should be utilized to tack the distal end of the epineurium to the middle of the bed of the muscle graft. Another suture should be utilized to start the wrapping of the muscle graft around the nerve using a bite through the muscle, a bite through the epineurium of the proximal end of the nerve, and another bite through the other muscle edge in order to form a cylindrical wrap around the nerve.Wrap the entire muscle graft by taking only bites of muscle graft around the nerve to secure the muscle graft in a cylindrical structure using 2 to 4 more sutures.Avoid locating the RPNI near weight-bearing surfaces of the residual limb when closing. The RPNI should be in the muscular tissue, deep to the subcutaneous tissue and dermis.Do perform intraneural dissection for large-caliber nerves to create several (normally 2 to 4) distinct RPNIs, to avoid too many regenerating axons in a single free muscle graft.
Collapse
Affiliation(s)
- Christine SW. Best
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Paul S. Cederna
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Theodore A. Kung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
6
|
Ganesh Kumar N, Chestek CA, Cederna PS, Kung TA. Realizing Upper Extremity Bionic Limbs: Leveraging Neuroprosthetic Control Strategies. Plast Reconstr Surg 2023:00006534-990000000-02188. [PMID: 37927033 DOI: 10.1097/prs.0000000000011183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
SUMMARY Innovations in the fields of prosthetic devices and neuroprosthetic control strategies have opened new frontiers for the treatment and rehabilitation of individuals undergoing amputation. Commercial prosthetic devices are now available with sophisticated electrical and mechanical components that can closely replicate the functions of the human musculoskeletal system. However, to truly recognize the potential of such prosthetic devices and develop the next generation of bionic limbs, a highly reliable prosthetic device control strategy is required. In the past few years, refined surgical techniques have enabled neuroprosthetic control strategies to record efferent motor and stimulate afferent sensory action potentials from a residual limb with extraordinary specificity, signal quality, and long-term stability. As a result, such control strategies are now capable of facilitating intuitive, real-time, and naturalistic prosthetic experiences for patients with amputations. This article summarizes the current state of upper extremity neuroprosthetic devices and discusses the leading control strategies that are critical to the ongoing advancement of prosthetic development and implementation.
Collapse
Affiliation(s)
- Nishant Ganesh Kumar
- Section of Plastic Surgery, Department of Surgery University of Michigan Ann Arbor, MI
| | - Cynthia A Chestek
- Department of Biomedical Engineering and Computer Science University of Michigan Ann Arbor, MI
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery University of Michigan Ann Arbor, MI
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery University of Michigan Ann Arbor, MI
| |
Collapse
|
7
|
Kubiak CA, Lee JC, Hamill JB, Kim HM, Roth RS, Cederna PS, Geisser ME, Kung TA, Kemp SWP. Agreement between Patient-reported Pain Medication Use and Electronic Medical Record Data in Surgical Amputation Patients. Plast Reconstr Surg Glob Open 2023; 11:e5415. [PMID: 38025619 PMCID: PMC10681441 DOI: 10.1097/gox.0000000000005415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
Background Opioid misuse after surgery remains a public health crisis in the United States. Recent efforts have focused on tracking pain medication use in surgical populations. However, accurate interpretations of medication use remain quite challenging given inconsistent usage of different datasets. The purpose of this study was to investigate the agreement between electronic medical records (EMR) versus patient self-reported use of pain medications in a surgical amputation population. Methods Patients undergoing major lower extremity amputation or amputation-related procedures were included in this study. Both self-reported and EMR data for pain medication intake were obtained for each patient at three time points (preoperatively, 4 months postoperatively, and 12 months postoperatively). Percentage agreement and the kappa statistic were calculated for both usage (yes/no) and dose categories. Results Forty-five patients were included in this study, resulting in 108 pairs of self-reported and EMR datasets. Substantial levels of agreement (>70% agreement, kappa >0.61) for opioid use was seen at preoperative and 12 months postoperative. However, agreement dropped at 4 months postoperatively. Anticonvulsant medication showed high levels, whereas acetaminophen showed lower levels of agreements at all time points. Conclusions Either self-reported or EMR data may be used in research and clinical settings for preoperative or 12-month postoperative patients with little concern for discrepancies. However, at time points immediately following the expected end of acute surgical pain, self-reported data may be needed for more accurate medication reporting. With these findings in mind, usage of datasets should be driven by study objectives and the dataset's strength (eg, accuracy, ease, lack of bias).
Collapse
Affiliation(s)
- Carrie A Kubiak
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Jennifer C Lee
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Jennifer B Hamill
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
| | - H Myra Kim
- Center for Statistical Consulting & Research, The University of Michigan, Ann Arbor, Mich
| | - Randy S Roth
- Department of Physical Medicine and Rehabilitation, The University of Michigan, Ann Arbor, Mich
| | - Paul S Cederna
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
- Department of Biomedical Engineering, The University of Michigan, Ann Arbor, Mich
| | - Michael E Geisser
- Department of Physical Medicine and Rehabilitation, The University of Michigan, Ann Arbor, Mich
| | - Theodore A Kung
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Stephen W P Kemp
- From the Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, Mich
- Center for Statistical Consulting & Research, The University of Michigan, Ann Arbor, Mich
| |
Collapse
|
8
|
Dehdashtian A, Timek JH, Svientek SR, Risch MJ, Bratley JV, Riegger AE, Kung TA, Cederna PS, Kemp SWP. Sexually Dimorphic Pattern of Pain Mitigation Following Prophylactic Regenerative Peripheral Nerve Interface (RPNI) in a Rat Neuroma Model. Neurosurgery 2023; 93:1192-1201. [PMID: 37227138 DOI: 10.1227/neu.0000000000002548] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/13/2022] [Accepted: 04/06/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Treating neuroma pain is a clinical challenge. Identification of sex-specific nociceptive pathways allows a more individualized pain management. The Regenerative Peripheral Nerve Interface (RPNI) consists of a neurotized autologous free muscle using a severed peripheral nerve to provide physiological targets for the regenerating axons. OBJECTIVE To evaluate prophylactic RPNI to prevent neuroma pain in male and female rats. METHODS F344 rats of each sex were assigned to neuroma, prophylactic RPNI, or sham groups. Neuromas and RPNIs were created in both male and female rats. Weekly pain assessments including neuroma site pain and mechanical, cold, and thermal allodynia were performed for 8 weeks. Immunohistochemistry was used to evaluate macrophage infiltration and microglial expansion in the corresponding dorsal root ganglia and spinal cord segments. RESULTS Prophylactic RPNI prevented neuroma pain in both sexes; however, female rats displayed delayed pain attenuation when compared with males. Cold allodynia and thermal allodynia were attenuated exclusively in males. Macrophage infiltration was mitigated in males, whereas females showed a reduced number of spinal cord microglia. CONCLUSION Prophylactic RPNI can prevent neuroma site pain in both sexes. However, attenuation of both cold allodynia and thermal allodynia occurred in males exclusively, potentially because of their sexually dimorphic effect on pathological changes of the central nervous system.
Collapse
Affiliation(s)
- Amir Dehdashtian
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Jagienka H Timek
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Shelby R Svientek
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Mary Jane Risch
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Jared V Bratley
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Anna E Riegger
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
| | - Paul S Cederna
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
- Department of Biomedical Engineering, The University of Michigan, Ann Arbor , Michigan , USA
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor , Michigan , USA
- Department of Biomedical Engineering, The University of Michigan, Ann Arbor , Michigan , USA
| |
Collapse
|
9
|
Affiliation(s)
- Victor Agbafe
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Nusaiba Baker
- Section of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Paul S Cederna
- Section of Plastic Surgery, University of Michigan Health System; and Department of Biomedical Engineering, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
10
|
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. Plast Reconstr Surg Glob Open 2023; 11:e5127. [PMID: 37465283 PMCID: PMC10351954 DOI: 10.1097/gox.0000000000005127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 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.
Collapse
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
| |
Collapse
|
11
|
Frecentese GI, Roche AD, Cederna PS. Chronic Exertional Compartment Syndrome Requiring Bilateral Fasciotomy: An Atypical Complication of Familial Stiff Skin Syndrome in a Father and Son. Ann Plast Surg 2023; 90:631-635. [PMID: 37115944 DOI: 10.1097/sap.0000000000003529] [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: 04/30/2023]
Abstract
ABSTRACT Stiff skin syndrome (SSS) is a rare cutaneous disorder characterized by cutaneous fibrosis resulting in the early onset of thickened and indurated skin, joint mobility restrictions, and contractures. We describe a father and son with familial SSS who presented with bilateral exertional pain and a confirmed diagnosis of chronic exertional compartment syndrome on 4-compartment pressure testing. Patients experienced restored functionality with bilateral 4-compartment fasciotomy. Chronic exertional compartment syndrome should be considered in the differential diagnosis of patients with SSS and chronic pain of the lower limbs.
Collapse
Affiliation(s)
| | | | - Paul S Cederna
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| |
Collapse
|
12
|
Jordan A, Tashmia A, Wang S, Cederna PS, Kauffman CA. Where Have All the Rhinoplasties Gone? A Call to Action for Academic Plastic Surgeons to Focus on Increasing Rhinoplasty Procedures Before It Is Too Late. Ann Plast Surg 2023:00000637-990000000-00241. [PMID: 37115851 DOI: 10.1097/sap.0000000000003531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND The armamentarium of a plastic surgeon is vast, consisting of an array of surgical procedures from head to toe. Unfortunately, plastic surgeons have been losing portions of their operative domain to other surgical subspecialties for years. The number of subspecialties invading our niche is bothersome, but more concerning is the fact that losing the reins of these core procedures results in less surgical exposure and competency for plastic surgery residents.Lately, in academic institutions, otolaryngologists seem to be performing most rhinoplasty procedures, resulting in fewer surgeries performed by plastic surgeons. Trainees must perform 10 rhinoplasties to fulfill graduation requirements but, more importantly, residents should graduate feeling competent and confident performing rhinoplasties. The aims of this study are to determine the number of rhinoplasties being performed at academic centers each year and to evaluate the trend with regard to which specialties are performing these procedures. METHODS Three academic institutions with plastic surgery and otolaryngology residency programs searched medical records for rhinoplasty Current Procedural Terminology codes from January 1, 2009, to December 31, 2019. The total numbers of rhinoplasties performed each year, by each specialty, were tallied. RESULTS Growth rate in rhinoplasty volume among participating institutions ranged from 27% to 149%. At these institutions, plastic surgeons performed less than one third of all rhinoplasties. In 2009, 10% of rhinoplasties were performed by plastic surgeons at institution 1, 22% at institution 2, and 18% at institution 3. In 2019, the volume of rhinoplasties performed by plastic surgeons was 5%, 12%, and 27%, respectively. The 3 ENT departments had statistically significant increasing trends in rhinoplasty volume. Institutions 1 and 2's plastic surgery departments showed that negative volume trends, however, were not statistically significant. Institution 3's plastic surgery department has had an increasing trend, which was statistically significant. CONCLUSIONS Otolaryngology is performing most rhinoplasties at several academic institutions. This is concerning for the education of plastic surgery trainees. Academic plastic surgeons must focus on increasing the number of rhinoplasties performed to adequately train residents this core procedure. If rhinoplasties are not made a priority now, this surgery may become a historic operation instead of a vital skill in plastic surgeons' armamentarium.
Collapse
Affiliation(s)
- Ashley Jordan
- From the Department of Plastic and Reconstructive Surgery, Geisinger Medical Center, Danville PA
| | | | - Shengxuan Wang
- Department of Population Health Sciences, Geisinger Medical Center, Danville, PA
| | - Paul S Cederna
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Christian A Kauffman
- From the Department of Plastic and Reconstructive Surgery, Geisinger Medical Center, Danville PA
| |
Collapse
|
13
|
Vu PP, Vaskov AK, Lee C, Jillala RR, Wallace DM, Davis AJ, Kung T, Kemp SWP, Gates DH, Chestek CA, Cederna PS. Long-term upper-extremity prosthetic control using Regenerative Peripheral Nerve Interfaces and implanted EMG electrodes. J Neural Eng 2023; 20. [PMID: 37023743 PMCID: PMC10126717 DOI: 10.1088/1741-2552/accb0c] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 04/06/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Extracting signals directly from the motor system poses challenges in obtaining both high amplitude and sustainable signals for upper-limb neuroprosthetic control. To translate neural interfaces into the clinical space, these interfaces must provide consistent signals and prosthetic performance. APPROACH Previously, we have demonstrated that the Regenerative Peripheral Nerve Interface (RPNI) is a biologically stable, bioamplifier of efferent motor action potentials. Here, we assessed the signal reliability from electrodes surgically implanted in RPNIs and residual innervated muscles in humans for long-term prosthetic control. MAIN RESULTS RPNI signal quality, measured as signal-to-noise ratio, remained greater than 15 for up to 276 and 1054 days in participant 1 (P1), and participant 2 (P2), respectively. Electromyography from both RPNIs and residual muscles was used to decode finger and grasp movements. Though signal amplitude varied between sessions, P2 maintained real-time prosthetic performance above 94% accuracy for 604 days without recalibration. Additionally, P2 completed a real-world multi-sequence coffee task with 99% accuracy for 611 days without recalibration. SIGNIFICANCE This study demonstrates the potential of RPNIs and implanted EMG electrodes as a long-term interface for enhanced prosthetic control.
Collapse
Affiliation(s)
- Philip P Vu
- Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Alex K Vaskov
- Robotics, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Christina Lee
- Biomedical Engineering, University of Michigan, 830 N University Ave, Ann Arbor, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Ritvik R Jillala
- Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Dylan M Wallace
- Robotics, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Alicia J Davis
- Phyiscal Medicine and Rehabilitation, University of Michigan Michigan Medicine, 2850 S. Industrial Hwy. Suite 400, Ann Arbor, Ann Arbor, Michigan, 48104, UNITED STATES
| | - Theodore Kung
- Section of Plastic Surgery, University of Michigan Michigan Medicine, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109-5000, UNITED STATES
| | | | - Deanna H Gates
- School of Kinesiology, University of Michigan, 830 N University Ave, Ann Arbor, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109-1382, UNITED STATES
| | - Paul S Cederna
- Section of Plastic Surgery, University of Michigan Michigan Medicine, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109-5000, UNITED STATES
| |
Collapse
|
14
|
Roche AD, Bailey ZK, Gonzalez M, Vu PP, Chestek CA, Gates DH, Kemp SWP, Cederna PS, Ortiz-Catalan M, Aszmann OC. Upper limb prostheses: bridging the sensory gap. J Hand Surg Eur Vol 2023; 48:182-190. [PMID: 36649123 PMCID: PMC9996795 DOI: 10.1177/17531934221131756] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/18/2023]
Abstract
Replacing human hand function with prostheses goes far beyond only recreating muscle movement with feedforward motor control. Natural sensory feedback is pivotal for fine dexterous control and finding both engineering and surgical solutions to replace this complex biological function is imperative to achieve prosthetic hand function that matches the human hand. This review outlines the nature of the problems underlying sensory restitution, the engineering methods that attempt to address this deficit and the surgical techniques that have been developed to integrate advanced neural interfaces with biological systems. Currently, there is no single solution to restore sensory feedback. Rather, encouraging animal models and early human studies have demonstrated that some elements of sensation can be restored to improve prosthetic control. However, these techniques are limited to highly specialized institutions and much further work is required to reproduce the results achieved, with the goal of increasing availability of advanced closed loop prostheses that allow sensory feedback to inform more precise feedforward control movements and increase functionality.
Collapse
Affiliation(s)
- Aidan D Roche
- College of Medicine, The Queen's Medical Research Institute, Edinburgh, UK.,Department of Plastic Surgery, NHS Lothian, Livingston, UK
| | - Zachary K Bailey
- Department of Bioengineering, Imperial College London, South Kensington Campus, UK
| | | | - Philip P Vu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.,Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H Gates
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - Stephen W P Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul S Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Sweden.,Operational Area 3, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Oskar C Aszmann
- Department of Plastic & Reconstructive Surgery, Medical University of Vienna, Austria.,Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| |
Collapse
|
15
|
Lee C, Vaskov AK, Gonzalez MA, Vu PP, Davis AJ, Cederna PS, Chestek CA, Gates DH. Use of regenerative peripheral nerve interfaces and intramuscular electrodes to improve prosthetic grasp selection: a case study. J Neural Eng 2022; 19:10.1088/1741-2552/ac9e1c. [PMID: 36317254 PMCID: PMC9942093 DOI: 10.1088/1741-2552/ac9e1c] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Received: 05/17/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Objective.Advanced myoelectric hands enable users to select from multiple functional grasps. Current methods for controlling these hands are unintuitive and require frequent recalibration. This case study assessed the performance of tasks involving grasp selection, object interaction, and dynamic postural changes using intramuscular electrodes with regenerative peripheral nerve interfaces (RPNIs) and residual muscles.Approach.One female with unilateral transradial amputation participated in a series of experiments to compare the performance of grasp selection controllers with RPNIs and intramuscular control signals with controllers using surface electrodes. These experiments included a virtual grasp-matching task with and without a concurrent cognitive task and physical tasks with a prosthesis including standardized functional assessments and a functional assessment where the individual made a cup of coffee ('Coffee Task') that required grasp transitions.Main results.In the virtual environment, the participant was able to select between four functional grasps with higher accuracy using the RPNI controller (92.5%) compared to surface controllers (81.9%). With the concurrent cognitive task, performance of the virtual task was more consistent with RPNI controllers (reduced accuracy by 1.1%) compared to with surface controllers (4.8%). When RPNI signals were excluded from the controller with intramuscular electromyography (i.e. residual muscles only), grasp selection accuracy decreased by up to 24%. The participant completed the Coffee Task with 11.7% longer completion time with the surface controller than with the RPNI controller. She also completed the Coffee Task with 11 fewer transition errors out of a maximum of 25 total errors when using the RPNI controller compared to surface controller.Significance.The use of RPNI signals in concert with residual muscles and intramuscular electrodes can improve grasp selection accuracy in both virtual and physical environments. This approach yielded consistent performance without recalibration needs while reducing cognitive load associated with pattern recognition for myoelectric control (clinical trial registration number NCT03260400).
Collapse
Affiliation(s)
- Christina Lee
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Alex K. Vaskov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Philip P. Vu
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Alicia J. Davis
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H. Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
16
|
Vaskov AK, Vu PP, North N, Davis AJ, Kung TA, Gates DH, Cederna PS, Chestek CA. Surgically Implanted Electrodes Enable Real-Time Finger and Grasp Pattern Recognition for Prosthetic Hands. IEEE T ROBOT 2022; 38:2841-2857. [PMID: 37193351 PMCID: PMC10168021 DOI: 10.1109/tro.2022.3170720] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Currently available prosthetic hands are capable of actuating anywhere from five to 30 degrees of freedom (DOF). However, grasp control of these devices remains unintuitive and cumbersome. To address this issue, we propose directly extracting finger commands from the neuromuscular system. Two persons with transradial amputations had bipolar electrodes implanted into regenerative peripheral nerve interfaces (RPNIs) and residual innervated muscles. The implanted electrodes recorded local electromyography with large signal amplitudes. In a series of single-day experiments, participants used a high speed movement classifier to control a virtual prosthetic hand in real-time. Both participants transitioned between 10 pseudo-randomly cued individual finger and wrist postures with an average success rate of 94.7% and trial latency of 255 ms. When the set was reduced to five grasp postures, metrics improved to 100% success and 135 ms trial latency. Performance remained stable across untrained static arm positions while supporting the weight of the prosthesis. Participants also used the high speed classifier to switch between robotic prosthetic grips and complete a functional performance assessment. These results demonstrate that pattern recognition systems can use intramuscular electrodes and RPNIs for fast and accurate prosthetic grasp control.
Collapse
Affiliation(s)
- Alex K Vaskov
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109 USA
| | - Philip P Vu
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Naia North
- Mechanical Engineering department at University of Michigan, Ann Arbor, MI 48109 USA
| | - Alicia J Davis
- Department of Physical Medicine and Rehabilitation at the University of Michigan, Ann Arbor, MI 48109 USA
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Deanna H Gates
- School of Kinesiology, University of Michigan, Ann Arbor, MI 48109 USA
| | - Paul S Cederna
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109 USA
| |
Collapse
|
17
|
Adidharma W, Khouri AN, Lee JC, Vanderboll K, Kung TA, Cederna PS, Kemp SWP. Sensory nerve regeneration and reinnervation in muscle following peripheral nerve injury. Muscle Nerve 2022; 66:384-396. [PMID: 35779064 DOI: 10.1002/mus.27661] [Citation(s) in RCA: 5] [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: 08/19/2021] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 11/11/2022]
Abstract
Sensory afferent fibers are an important component of motor nerves and compose the majority of axons in many nerves traditionally thought of as "pure" motor nerves. These sensory afferent fibers innervate special sensory end organs in muscle, including muscle spindles that respond to changes in muscle length and Golgi tendons that detect muscle tension. Both play a major role in proprioception, sensorimotor extremity control feedback, and force regulation. After peripheral nerve injury, there is histological and electrophysiological evidence that sensory afferents can reinnervate muscle, including muscle that was not the nerve's original target. Reinnervation can occur after different nerve injury and muscle models, including muscle graft, crush, and transection injuries, and occurs in a nonspecific manner, allowing for cross-innervation to occur. Evidence of cross-innervation includes the following: muscle spindle and Golgi tendon afferent-receptor mismatch, vagal sensory fiber reinnervation of muscle, and cutaneous afferent reinnervation of muscle spindle or Golgi tendons. There are several notable clinical applications of sensory reinnervation and cross-reinnervation of muscle, including restoration of optimal motor control after peripheral nerve repair, flap sensation, sensory protection of denervated muscle, neuroma treatment and prevention, and facilitation of prosthetic sensorimotor control. This review focuses on sensory nerve regeneration and reinnervation in muscle, and the clinical applications of this phenomena. Understanding the physiology and limitations of sensory nerve regeneration and reinnervation in muscle may ultimately facilitate improvement of its clinical applications.
Collapse
Affiliation(s)
- Widya Adidharma
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Alexander N Khouri
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Jennifer C Lee
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Kathryn Vanderboll
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Theodore A Kung
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan.,Department of Biomedical Engineering, Ann Arbor, Michigan
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan.,Department of Biomedical Engineering, Ann Arbor, Michigan
| |
Collapse
|
18
|
Gonzalez MA, Vu PP, Vaskov AK, Cederna PS, Chestek CA, Gates DH. Characterizing sensory thresholds and intensity sensitivity of Regenerative Peripheral Nerve Interfaces: A Case Study . IEEE Int Conf Rehabil Robot 2022; 2022:1-6. [PMID: 36176116 DOI: 10.1109/icorr55369.2022.9896481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current prosthetic limbs offer little to no sensory feedback. Developments in peripheral nerve interfaces provide opportunities to restore some level of tactile feedback that is referred to the prosthetic limb. One such method is a Regenerative Peripheral Nerve Interface (RPNI), composed of a muscle graft wrapped around a free nerve ending. Here, we characterize perception and discomfort thresholds, as well as sensitivity to stimulation through two-alternative forced choice discrimination tasks. One person with transradial amputation who had one RPNI constructed from the median nerve and two constructed from the ulnar nerve participated. Average perception thresholds across all RPNIs were between 950 and 1120 nC with variance of less than 350 nC over a 36-month period. Discomfort thresholds were from 3880 nC to 9770 nC across all RPNIs. The just noticeable difference for the Median RPNI was 520 nC, larger than either the Ulnar-1 or Ulnar-2 RPNIs (210 nC, 470 nC, respectively). We also calculated Weber fractions to compare sensitivity between different RPNIs and relate our results to previous studies. Weber fractions for each of the Median, Ulnar-1, and Ulnar-2 RPNIs were 0.134, 0.088, 0.087, respectively. This work is the first to quantify the functional stimulation range and sensitivity of RPNIs in a human participant. Future work will focus on characterizing RPNI sensation in additional individuals to determine if these findings are generalizable to the amputee population.
Collapse
|
19
|
Vu PP, Lu CW, Vaskov AK, Gates DH, Gillespie RB, Kemp SW, Patil PG, Chestek CA, Cederna PS, Kung TA. Restoration of Proprioceptive and Cutaneous Sensation Using Regenerative Peripheral Nerve Interfaces in Humans with Upper Limb Amputations. Plast Reconstr Surg 2022; 149:1149e-1154e. [PMID: 35404335 PMCID: PMC9133017 DOI: 10.1097/prs.0000000000009153] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY Without meaningful and intuitive sensory feedback, even the most advanced prosthetic limbs remain insensate and impose an enormous cognitive burden during use. The regenerative peripheral nerve interface can serve as a novel bidirectional motor and sensory neuroprosthetic interface. In previous human studies, regenerative peripheral nerve interfaces demonstrated stable high-amplitude motor electromyography signals with excellent signal-to-noise ratio for prosthetic control. In addition, they can treat and prevent postamputation pain by mitigating neuroma formation. In this study, the authors investigated whether electrical stimulation applied to regenerative peripheral nerve interfaces could produce appreciable proprioceptive and/or tactile sensations in two participants with upper limb amputations. Stimulation of the interfaces resulted in both participants reporting proprioceptive sensations in the phantom hand. Specifically, stimulation of participant 1's median nerve regenerative peripheral nerve interface activated a flexion sensation in the thumb or index finger, whereas stimulation of the ulnar nerve interface evoked a flexion sensation of the ring or small finger. Likewise, stimulation of one of participant 2's ulnar nerve interfaces produced a sensation of flexion at the ring finger distal interphalangeal joint. In addition, stimulation of participant 2's other ulnar nerve interface and the median nerve interface resulted in perceived cutaneous sensations that corresponded to each nerve's respective dermatome. These results suggest that regenerative peripheral nerve interfaces have the potential to restore proprioceptive and cutaneous sensory feedback that could significantly improve prosthesis use and embodiment.
Collapse
Affiliation(s)
- Philip P. Vu
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Charles W. Lu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Alex K. Vaskov
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H. Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - R. Brent Gillespie
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Stephen W.P Kemp
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Parag G. Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | - Paul S. Cederna
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Theodore A. Kung
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
20
|
Khouri AN, Adidharma W, MacEachern M, Haase SC, Waljee JF, Cederna PS, Strong AL. The Current State of Fat Grafting in the Hand: A Systematic Review for Hand Diseases. Hand (N Y) 2022; 18:543-552. [PMID: 35130761 DOI: 10.1177/15589447211066347] [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: 11/17/2022]
Abstract
Autologous fat grafting (AFG) has traditionally been used for facial rejuvenation and soft tissue augmentation, but in recent years, its use has expanded to treat diseases of the hand. Autologous fat grafting is ideal for use in the hand because it is minimally invasive, can restore volume, and has regenerative capabilities. This review summarizes the emerging evidence regarding the safety and efficacy of AFG to the hand in several conditions, including systemic sclerosis, Dupuytren disease, osteoarthritis, burns, and traumatic fingertip injuries. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature search on the use of AFG in hand pathologies was performed on October 8, 2020, in Ovid MEDLINE, Elsevier Embase, Clarivate Web of Science, and Wiley Cochrane Central Register of Controlled Trials. The retrieved hits were screened and reviewed by 2 independent reviewers and a third reviewer adjudicated when required. Reviewers identified 919 unique hits. Screening of the abstracts identified 22 manuscripts which described the use of AFG to treat an identified hand condition. Studies suggest AFG in the hands is a safe, noninvasive option for the management of systemic sclerosis, Dupuytren contracture, osteoarthritis, burns, and traumatic fingertip injuries. While AFG is a promising therapeutic option for autoimmune, inflammatory, and fibrotic disease manifestations in the hand, further studies are warranted to understand its efficacy and to establish more robust clinical guidelines. Studies to date show the regenerative, immunomodulatory, and volume-filling properties of AFG that facilitate wound healing and restoration of hand function with limited complications.
Collapse
|
21
|
Yoon JP, Cederna PS, Dehdashtian A, Min S, Kim KR, Chung KC, Kemp SWP. Comparison of Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Versus Nerve Grafting for Neonatal Brachial Plexus Injury. Orthopedics 2022; 45:7-12. [PMID: 34734774 DOI: 10.3928/01477447-20211101-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Neonatal brachial plexus injuries may cause critical limitations of upper extremity function. The optimal surgical approach to address neonatal brachial plexus injuries has not been defined. In this systematic review, we compare clinical results after spinal accessory to suprascapular nerve transfer and nerve graft techniques among patients with neonatal brachial plexus injury. [Orthopedics. 2022;45(1):7-12.].
Collapse
|
22
|
Svientek SR, Wisely JP, Dehdashtian A, Bratley JV, Cederna PS, Kemp SWP. The Muscle Cuff Regenerative Peripheral Nerve Interface for the Amplification of Intact Peripheral Nerve Signals. J Vis Exp 2022. [DOI: 10.3791/63222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
23
|
Santosa KB, Cederna PS. Commentary on: Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training. Aesthet Surg J 2021; 41:1468-1470. [PMID: 33599726 DOI: 10.1093/asj/sjab005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Katherine B Santosa
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
24
|
Kubiak CA, Adidharma W, Kung TA, Kemp SWP, Cederna PS, Vemuri C. "Decreasing Postamputation Pain with the Regenerative Peripheral Nerve Interface (RPNI)". Ann Vasc Surg 2021; 79:421-426. [PMID: 34656720 DOI: 10.1016/j.avsg.2021.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 03/06/2021] [Revised: 06/06/2021] [Accepted: 08/14/2021] [Indexed: 11/01/2022]
Abstract
Over 185,000 limb amputations are performed in the United States annually, many of which are due to the sequelae of peripheral vascular disease. Symptomatic neuromas remain a significant source of postamputation morbidity and contribute to both phantom limb (PLP) and residual limb pain (RLP). While many interventions have been proposed for the treatment of symptomatic neuromas, conventional methods lead to a high incidence of neuroma recurrence. Furthermore, these existing methods do not facilitate an ability to properly interface with myoelectric prosthetic devices. The Regenerative Peripheral Nerve Interface (RPNI) was developed to overcome these limitations. The RPNI consists of an autologous free muscle graft secured around the end of a transected nerve. The muscle graft provides regenerating axons with end organs to reinnervate, thereby preventing neuroma formation. We have shown that this simple, reproducible, and safe surgical technique successfully treats and prevents neuroma formation in major limb amputations. In this paper, we describe RPNI surgery in the setting of major limb amputation and highlight the promising results of RPNIs in our animal and clinical studies.
Collapse
Affiliation(s)
- Carrie A Kubiak
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Widya Adidharma
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI.
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Chandu Vemuri
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| |
Collapse
|
25
|
Kubiak CA, Svientek SR, Dehdashtian A, Lawera NG, Nadarajan V, Bratley JV, Kung TA, Cederna PS, Kemp SWP. Physiologic signaling and viability of the muscle cuff regenerative peripheral nerve interface (MC-RPNI) for intact peripheral nerves. J Neural Eng 2021; 18. [PMID: 34359056 DOI: 10.1088/1741-2552/ac1b6b] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/06/2021] [Indexed: 11/11/2022]
Abstract
Background. Robotic exoskeleton devices have become a promising modality for restoration of extremity function in individuals with limb loss or functional weakness. However, there exists no consistent or reliable way to record efferent motor action potentials from intact peripheral nerves to control device movement. Peripheral nerve motor action potentials are similar in amplitude to that of background noise, producing an unfavorable signal-to-noise ratio (SNR) that makes these signals difficult to detect and interpret. To address this issue, we have developed the muscle cuff regenerative peripheral nerve interface (MC-RPNI), a construct consisting of a free skeletal muscle graft wrapped circumferentially around an intact peripheral nerve. Over time, the muscle graft regenerates, and the intact nerve undergoes collateral axonal sprouting to reinnervate the muscle. The MC-RPNI amplifies efferent motor action potentials by several magnitudes, thereby increasing the SNR, allowing for higher fidelity signaling and detection of motor intention. The goal of this study was to characterize the signaling capabilities and viability of the MC-RPNI over time.Methods. Thirty-seven rats were randomly assigned to one of five experimental groups (Groups A-E). For MC-RPNI animals, their contralateral extensor digitorum longus (EDL) muscle was harvested and trimmed to either 8 mm (Group A) or 13 mm (Group B) in length, wrapped circumferentially around the intact ipsilateral common peroneal (CP) nerve, secured, and allowed to heal for 3 months. Additionally, one 8 mm (Group C) and one 13 mm (Group D) length group had an epineurial window created in the CP nerve immediately preceding MC-RPNI creation. Group E consisted of sham surgery animals. At 3 months, electrophysiologic analyses were conducted to determine the signaling capabilities of the MC-RPNI. Additionally, electromyography and isometric force analyses were performed on the CP-innervated EDL to determine the effects of the MC-RPNI on end organ function. Following evaluation, the CP nerve, MC-RPNI, and ipsilateral EDL muscle were harvested for histomorphometric analysis.Results. Study endpoint analysis was performed at 3 months post-surgery. All rats displayed visible muscle contractions in both the MC-RPNI and EDL following proximal CP nerve stimulation. Compound muscle action potentials were recorded from the MC-RPNI following proximal CP nerve stimulation and ranged from 3.67 ± 0.58 mV to 6.04 ± 1.01 mV, providing efferent motor action potential amplification of 10-20 times that of a normal physiologic nerve action potential. Maximum tetanic isometric force (Fo) testing of the distally-innervated EDL muscle in MC-RPNI groups producedFo(2341 ± 114 mN-2832 ± 102 mN) similar to controls (2497 ± 122 mN), thus demonstrating that creation of MC-RPNIs did not adversely impact the function of the distally-innervated EDL muscle. Overall, comparison between all MC-RPNI sub-groups did not reveal any statistically significant differences in signaling capabilities or negative effects on distal-innervated muscle function as compared to the control group.Conclusions. MC-RPNIs have the capability to provide efferent motor action potential amplification from intact nerves without adversely impacting distal muscle function. Neither the size of the muscle graft nor the presence of an epineurial window in the nerve had any significant impact on the ability of the MC-RPNI to amplify efferent motor action potentials from intact nerves. These results support the potential for the MC-RPNI to serve as a biologic nerve interface to control advanced exoskeleton devices.
Collapse
Affiliation(s)
- Carrie A Kubiak
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Shelby R Svientek
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Amir Dehdashtian
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Nathan G Lawera
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Vidhya Nadarajan
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Jarred V Bratley
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Theodore A Kung
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America
| | - Paul S Cederna
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America.,Department of Biomedical Engineering, The University of Michigan, Ann Arbor, MI, United States of America
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, 1150 W Medical Center Drive, Medical Sciences Research Building II, Rm.A570A, Ann Arbor, MI 48109-5456, United States of America.,Department of Biomedical Engineering, The University of Michigan, Ann Arbor, MI, United States of America
| |
Collapse
|
26
|
Abstract
The quest to find the ideal prosthetic device interface that enables intuitive control has motivated several recent innovations. Although current prosthetic device control strategies have advanced the field of neuroprosthetic control, they are limited in their ability to generate reliable, stable, and specific signals to replicate the complex movements of the upper extremity. The regenerative peripheral nerve interface (RPNI) is a promising solution to enhance prosthetic device control. This article describes the development of RPNIs and summarizes its successful use in the control of advanced prosthetic devices in patients with upper extremity amputations.
Collapse
Affiliation(s)
- Nishant Ganesh Kumar
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
27
|
Cederna PS, Kung TA. Neuroma, Neural Interface, and Prosthetics. Hand Clin 2021; 37:xiii-xiv. [PMID: 34253319 DOI: 10.1016/j.hcl.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Paul S Cederna
- Section of Plastic Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| |
Collapse
|
28
|
Vu PP, Vaskov AK, Irwin ZT, Henning PT, Lueders DR, Laidlaw AT, Davis AJ, Nu CS, Gates DH, Gillespie RB, Kemp SWP, Kung TA, Chestek CA, Cederna PS. A regenerative peripheral nerve interface allows real-time control of an artificial hand in upper limb amputees. Sci Transl Med 2021; 12:12/533/eaay2857. [PMID: 32132217 DOI: 10.1126/scitranslmed.aay2857] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/28/2019] [Accepted: 12/27/2019] [Indexed: 11/02/2022]
Abstract
Peripheral nerves provide a promising source of motor control signals for neuroprosthetic devices. Unfortunately, the clinical utility of current peripheral nerve interfaces is limited by signal amplitude and stability. Here, we showed that the regenerative peripheral nerve interface (RPNI) serves as a biologically stable bioamplifier of efferent motor action potentials with long-term stability in upper limb amputees. Ultrasound assessments of RPNIs revealed prominent contractions during phantom finger flexion, confirming functional reinnervation of the RPNIs in two patients. The RPNIs in two additional patients produced electromyography signals with large signal-to-noise ratios. Using these RPNI signals, subjects successfully controlled a hand prosthesis in real-time up to 300 days without control algorithm recalibration. RPNIs show potential in enhancing prosthesis control for people with upper limb loss.
Collapse
Affiliation(s)
- Philip P Vu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alex K Vaskov
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA
| | - Zachary T Irwin
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Phillip T Henning
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel R Lueders
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ann T Laidlaw
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alicia J Davis
- University of Michigan Hospital Orthotics and Prosthetics Center, Ann Arbor, MI 48109, USA
| | - Chrono S Nu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Deanna H Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA.,Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - R Brent Gillespie
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephen W P Kemp
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA. .,Robotics Institute, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI 48109, USA.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul S Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA. .,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| |
Collapse
|
29
|
Cho HE, Huynh KA, Corriere MA, Chung KC, Cederna PS. Developing Strategies for Targeted Improvement of Perioperative Education for Postbariatric Surgery Body-Contouring Patients. Ann Plast Surg 2021; 86:463-468. [PMID: 32694462 PMCID: PMC10230510 DOI: 10.1097/sap.0000000000002471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/18/2022]
Abstract
BACKGROUND The quality of perioperative patient education impacts surgical outcomes, patient experiences, and resources needed to address patient concerns and unplanned visits. We examined patient inquiries and education materials to assess the quality of perioperative education and identify areas of targeted improvement for postbariatric surgery body-contouring procedures. METHODS We examined 100 consecutive postbariatric procedures at an academic center. Themes of patient-generated calls, e-mails, and electronic medical record portal messages during the perioperative period were identified via qualitative analysis. Understandability and actionability of perioperative educational resources were assessed using the Patient Education Materials Assessment Tool (PEMAT). RESULTS Among 212 communications identified, 167 (79%) were postoperative. Common themes were concerns regarding the surgical site (38%), medications (10%), and activity restrictions (10%). One hundred thirty inquiries were resolved through patient re-education (57%), but 36 (16%) required in-person evaluation including 4 unplanned emergency department visits and 3 readmissions for surgical-site concerns. The PEMAT scores for institutional materials were fair for understandability (69%) and actionability (60%). American Society of Plastic Surgeons materials were more understandable (84%) but less actionable (40%). CONCLUSIONS Patient queries can be leveraged as a source of qualitative data to identify gaps in perioperative education. High-yield topics, such as education regarding the surgical site and medications, can be targeted for quality improvement through better communication and potentially reduce the number of unnecessary visits. Using the PEMAT, we also identified how directly the education materials can be revised. Improving perioperative education can promote mutual understanding between patients and surgeons, better outcomes, and efficient resource utilization.
Collapse
Affiliation(s)
- Hoyune E. Cho
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Kristine A. Huynh
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Matthew A. Corriere
- Section of Vascular Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Paul S. Cederna
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI
| |
Collapse
|
30
|
Wroblewski OM, Vega-Soto EE, Nguyen MH, Cederna PS, Larkin LM. Impact of Human Epidermal Growth Factor on Tissue-Engineered Skeletal Muscle Structure and Function. Tissue Eng Part A 2021; 27:1151-1159. [PMID: 33203338 DOI: 10.1089/ten.tea.2020.0255] [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] [Indexed: 01/03/2023] Open
Abstract
Skeletal muscle tissue engineering technologies have the potential to treat volumetric muscle loss (VML) by growing exogenous muscle tissue. However, there has been limited success in engineering human cell-sourced skeletal muscle with structure and function comparable to native adult human muscle. The use of growth factors at optimal concentrations and delivery times is critical in enhancing the in vitro myogenesis of satellite cells used in engineered skeletal muscle. The mitogenic protein human epidermal growth factor (hEGF) is of particular interest because it enhances satellite cell proliferation and sarcomeric structure formation in myogenic cell cultures. In this study, we used our scaffold-free tissue-engineered skeletal muscle units (SMUs) to examine the effects of hEGF on the structure and function of human cell-sourced engineered skeletal muscle. During our established SMU fabrication process, human muscle cell isolates were exposed to media treated with 7.5 nM hEGF at three different time spans during the 21-day cell culture period: 0 to 6 days postseeding (hEGF-treated Muscle Growth Media [MGM] Only), 7 to 21 days postseeding (hEGF-treated Muscle Differentiation Media (MDM) Only), and 0 to 21 days postseeding (hEGF-treated MGM+MDM). Control cell cultures were fed standard MGM and MDM (no hEGF treatment). During the fabrication process, light microscopy was used to examine proliferation and differentiation of myogenic cells in the monolayer. After SMU formation, the three-dimensional constructs underwent tetanic force production measurements to evaluate contractile function and immunohistochemical staining to examine SMU structure. Results indicated that hEGF administration impacted myogenesis, by increasing myotube diameter in hEGF-treated MGM only and hEGF-treated MDM-only cell cultures, and by increasing myotube density in hEGF-treated MGM+MDM cultures. The exposure of myogenic cells to hEGF during any time period of the fabrication process led to a significant increase in SMU myosin heavy-chain content. SMUs exposed to hEGF-treated MDM and hEGF-treated MGM+MDM exhibited greater cross-sectional areas and more organized sarcomeric structure. Furthermore, hEGF-treated MGM+MDM SMUs displayed significantly enhanced contractile function compared with controls, indicating advanced functional maturation. In conclusion, hEGF supplementation in human primary myogenic cell cultures advances tissue-engineered skeletal muscle structural and functional characteristics. Impact statement Our research suggests that human epidermal growth factor (hEGF) serves as a critical growth factor in enhancing in vitro skeletal muscle cell proliferation and differentiation during myogenesis and advances human skeletal muscle engineered tissues toward a more native adult skeletal muscle phenotype. Understanding the impact of hEGF on engineered skeletal muscle function and structure is valuable in determining the optimal culture conditions for the development of tissue engineering-based therapies for volumetric muscle loss.
Collapse
Affiliation(s)
- Olga M Wroblewski
- Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Emmanuel E Vega-Soto
- Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew H Nguyen
- Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul S Cederna
- Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa M Larkin
- Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA.,Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
31
|
Santosa KB, Cederna PS. Commentary on: Trends and Challenges of Telehealth in an Academic Institution: The Unforeseen Benefits of the COVID-19 Global Pandemic. Aesthet Surg J 2021; 41:119-121. [PMID: 33079130 PMCID: PMC7665368 DOI: 10.1093/asj/sjaa272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Katherine B Santosa
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| |
Collapse
|
32
|
Hu Y, Ursu DC, Sohasky RA, Sando IC, Ambani SLW, French ZP, Mays EA, Nedic A, Moon JD, Kung TA, Cederna PS, Kemp SWP, Urbanchek MG. Regenerative peripheral nerve interface free muscle graft mass and function. Muscle Nerve 2020; 63:421-429. [PMID: 33290586 DOI: 10.1002/mus.27138] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 04/16/2020] [Revised: 11/26/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Regenerative peripheral nerve interfaces (RPNIs) transduce neural signals to provide high-fidelity control of neuroprosthetic devices. Traditionally, rat RPNIs are constructed with ~150 mg of free skeletal muscle grafts. It is unknown whether larger free muscle grafts allow RPNIs to transduce greater signal. METHODS RPNIs were constructed by securing skeletal muscle grafts of various masses (150, 300, 600, or 1200 mg) to the divided peroneal nerve. In the control group, the peroneal nerve was transected without repair. Endpoint assessments were conducted 3 mo postoperatively. RESULTS Compound muscle action potentials (CMAPs), maximum tetanic isometric force, and specific muscle force were significantly higher for both the 150 and 300 mg RPNI groups compared to the 600 and 1200 mg RPNIs. Larger RPNI muscle groups contained central areas lacking regenerated muscle fibers. CONCLUSIONS Electrical signaling and tissue viability are optimal in smaller as opposed to larger RPNI constructs in a rat model.
Collapse
Affiliation(s)
- Yaxi Hu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Groningen, Groningen, The Netherlands
| | - Daniel C Ursu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Racquel A Sohasky
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ian C Sando
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shoshana L W Ambani
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary P French
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth A Mays
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrej Nedic
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jana D Moon
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Melanie G Urbanchek
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
33
|
Dehdashtian A, Bratley JV, Svientek SR, Kung TA, Awan TM, Cederna PS, Kemp SW. Autologous fat grafting for nerve regeneration and neuropathic pain: current state from bench-to-bedside. Regen Med 2020; 15:2209-2228. [PMID: 33264053 DOI: 10.2217/rme-2020-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 12/13/2022] Open
Abstract
Despite recent advances in microsurgical techniques, functional recovery following peripheral nerve injury remains slow and inadequate. Poor peripheral nerve regeneration not only leaves patients with significant impairments, but also commonly leads to the development of debilitating neuropathic pain. Recent research has demonstrated the potential therapeutic benefits of adipose-derived stem cells, to enhance nerve regeneration. However, clinical translation remains limited due to the current regulatory burdens of the US FDA. A reliable and immediately translatable alternative is autologous fat grafting, where native adipose-derived stem cells present in the transferred tissue can potentially act upon regenerating axons. This review presents the scope of adipose tissue-based therapies to enhance outcomes following peripheral nerve injury, specifically focusing on their role in regeneration and ameliorating neuropathic pain.
Collapse
Affiliation(s)
- Amir Dehdashtian
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jarred V Bratley
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Shelby R Svientek
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Tariq M Awan
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul S Cederna
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephen Wp Kemp
- Department of Surgery, Section of Plastic & Reconstructive Surgery, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| |
Collapse
|
34
|
Svientek SR, Kemp SWP, Cederna PS, Kung TA. The clinical significance of a swollen neuroma: a meaningful distinction or an incidental finding? Ann Palliat Med 2020; 9:4412-4415. [PMID: 33183022 DOI: 10.21037/apm-20-1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/17/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Shelby R Svientek
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Stephen W P Kemp
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Paul S Cederna
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Theodore A Kung
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
35
|
Vaskov AK, Vu PP, North N, Davis AJ, Kung TA, Gates DH, Cederna PS, Chestek CA. Surgically Implanted Electrodes Enable Real-Time Finger and Grasp Pattern Recognition for Prosthetic Hands. medRxiv 2020:2020.10.28.20217273. [PMID: 33173910 PMCID: PMC7654906 DOI: 10.1101/2020.10.28.20217273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Currently available prosthetic hands are capable of actuating anywhere from five to 30 degrees of freedom (DOF). However, grasp control of these devices remains unintuitive and cumbersome. To address this issue, we propose directly extracting finger commands from the neuromuscular system via electrodes implanted in residual innervated muscles and regenerative peripheral nerve interfaces (RPNIs). Two persons with transradial amputations had RPNIs created by suturing autologous free muscle grafts to their transected median, ulnar, and dorsal radial sensory nerves. Bipolar electrodes were surgically implanted into their ulnar and median RPNIs and into their residual innervated muscles. The implanted electrodes recorded local electromyography (EMG) with Signal-to-Noise Ratios ranging from 23 to 350 measured across various movements. In a series of single-day experiments, participants used a high speed pattern recognition system to control a virtual prosthetic hand in real-time. Both participants were able to transition between 10 pseudo-randomly cued individual finger and wrist postures in the virtual environment with an average online accuracy of 86.5% and latency of 255 ms. When the set was reduced to five grasp postures, average metrics improved to 97.9% online accuracy and 135 ms latency. Virtual task performance remained stable across untrained static arm positions while supporting the weight of the prosthesis. Participants also used the high speed classifier to switch between robotic prosthetic grips and complete a functional performance assessment. These results demonstrate that pattern recognition systems can use the high-quality EMG afforded by intramuscular electrodes and RPNIs to provide users with fast and accurate grasp control. SUMMARY Surgically implanted electrodes recorded finger-specific electromyography enabling reliable finger and grasp control of an upper limb prosthesis.
Collapse
|
36
|
Rodriguez BL, Vega-Soto EE, Kennedy CS, Nguyen MH, Cederna PS, Larkin LM. A tissue engineering approach for repairing craniofacial volumetric muscle loss in a sheep following a 2, 4, and 6-month recovery. PLoS One 2020; 15:e0239152. [PMID: 32956427 PMCID: PMC7505427 DOI: 10.1371/journal.pone.0239152] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/31/2020] [Indexed: 01/02/2023] Open
Abstract
Volumetric muscle loss (VML) is the loss of skeletal muscle that results in significant and persistent impairment of function. The unique characteristics of craniofacial muscle compared trunk and limb skeletal muscle, including differences in gene expression, satellite cell phenotype, and regenerative capacity, suggest that VML injuries may affect craniofacial muscle more severely. However, despite these notable differences, there are currently no animal models of craniofacial VML. In a previous sheep hindlimb VML study, we showed that our lab’s tissue engineered skeletal muscle units (SMUs) were able to restore muscle force production to a level that was statistically indistinguishable from the uninjured contralateral muscle. Thus, the goals of this study were to: 1) develop a model of craniofacial VML in a large animal model and 2) to evaluate the efficacy of our SMUs in repairing a 30% VML in the ovine zygomaticus major muscle. Overall, there was no significant difference in functional recovery between the SMU-treated group and the unrepaired control. Despite the use of the same injury and repair model used in our previous study, results showed differences in pathophysiology between craniofacial and hindlimb VML. Specifically, the craniofacial model was affected by concomitant denervation and ischemia injuries that were not exhibited in the hindlimb model. While clinically realistic, the additional ischemia and denervation likely created an injury that was too severe for our SMUs to repair. This study highlights the importance of balancing the use of a clinically realistic model while also maintaining control over variables related to the severity of the injury. These variables include the volume of muscle removed, the location of the VML injury, and the geometry of the injury, as these affect both the muscle’s ability to self-regenerate as well as the probability of success of the treatment.
Collapse
Affiliation(s)
- Brittany L. Rodriguez
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Emmanuel E. Vega-Soto
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Christopher S. Kennedy
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Matthew H. Nguyen
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Lisa M. Larkin
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| |
Collapse
|
37
|
Vu PP, Chestek CA, Nason SR, Kung TA, Kemp SW, Cederna PS. The future of upper extremity rehabilitation robotics: research and practice. Muscle Nerve 2020; 61:708-718. [PMID: 32413247 PMCID: PMC7868083 DOI: 10.1002/mus.26860] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Received: 12/05/2019] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 01/14/2023]
Abstract
The loss of upper limb motor function can have a devastating effect on people's lives. To restore upper limb control and functionality, researchers and clinicians have developed interfaces to interact directly with the human body's motor system. In this invited review, we aim to provide details on the peripheral nerve interfaces and brain-machine interfaces that have been developed in the past 30 years for upper extremity control, and we highlight the challenges that still remain to transition the technology into the clinical market. The findings show that peripheral nerve interfaces and brain-machine interfaces have many similar characteristics that enable them to be concurrently developed. Decoding neural information from both interfaces may lead to novel physiological models that may one day fully restore upper limb motor function for a growing patient population.
Collapse
Affiliation(s)
- Philip P. Vu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cynthia A. Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Robotics Institute, University of Michigan, Ann Arbor, Michigan
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
- Neuroscience Graduate Program, University of Michigan, Ann Arbor, Michigan
| | - Samuel R. Nason
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Theodore A. Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stephen W.P. Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
38
|
Santosa KB, Oliver JD, Cederna PS, Kung TA. Regenerative Peripheral Nerve Interfaces for Prevention and Management of Neuromas. Clin Plast Surg 2020; 47:311-321. [DOI: 10.1016/j.cps.2020.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
39
|
Hwang C, Marini S, Huber AK, Lee S, Stepien DM, Kubiak CA, Meyers C, Sorkin M, Pagani CA, Rehse T, Visser ND, Garada MA, Rasheed H, Greenstein JA, Khatib ZN, Kotha P, Vasquez K, Lisiecki J, Cederna PS, Kemp SW, James AW, Levi B. Abstract 7. Plast Reconstr Surg Glob Open 2020. [PMCID: PMC7224784 DOI: 10.1097/01.gox.0000667092.81976.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
40
|
Mironov S, Hwang CD, Nemzek J, Li J, Ranganathan K, Butts JT, Cholok DJ, Dolgachev VA, Wang SC, Hemmila M, Cederna PS, Morris MD, Berenfeld O, Levi B. Short-wave infrared light imaging measures tissue moisture and distinguishes superficial from deep burns. Wound Repair Regen 2020; 28:185-193. [PMID: 31675450 PMCID: PMC8513689 DOI: 10.1111/wrr.12779] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 04/28/2024]
Abstract
Existing clinical approaches and tools to measure burn tissue destruction are limited resulting in misdiagnosis of injury depth in over 40% of cases. Thus, our objective in this study was to characterize the ability of short-wave infrared (SWIR) imaging to detect moisture levels as a surrogate for tissue viability with resolution to differentiate between burns of various depths. To accomplish our aim, we constructed an imaging system consisting of a broad-band Tungsten light source; 1,200-, 1,650-, 1,940-, and 2,250-nm wavelength filters; and a specialized SWIR camera. We initially used agar slabs to provide a baseline spectrum for SWIR light imaging and demonstrated the differential absorbance at the multiple wavelengths, with 1,940 nm being the highest absorbed wavelength. These spectral bands were then demonstrated to detect levels of moisture in inorganic and in vivo mice models. The multiwavelength SWIR imaging approach was used to diagnose depth of burns using an in vivo porcine burn model. Healthy and injured skin regions were imaged 72 hours after short (20 seconds) and long (60 seconds) burn application, and biopsies were extracted from those regions for histologic analysis. Burn depth analysis based on collagen coagulation histology confirmed the formation of superficial and deep burns. SWIR multispectral reflectance imaging showed enhanced intensity levels in long burned regions, which correlated with histology and distinguished between superficial and deep burns. This SWIR imaging method represents a novel, real-time method to objectively distinguishing superficial from deep burns.
Collapse
Affiliation(s)
- Sergey Mironov
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan
| | - Charles D Hwang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jean Nemzek
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan
| | - John Li
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Jonathan T Butts
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David J Cholok
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael D Morris
- Department of Chemistry, University of Michigan, Ann Arbor, Michigan
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Levi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
41
|
Svientek SR, Ursu DC, Cederna PS, Kemp SWP. Fabrication of the Composite Regenerative Peripheral Nerve Interface (C-RPNI) in the Adult Rat. J Vis Exp 2020. [PMID: 32176203 DOI: 10.3791/60841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Recent advances in neuroprosthetics have enabled those living with extremity loss to reproduce many functions native to the absent extremity, and this is often accomplished through integration with the peripheral nervous system. Unfortunately, methods currently employed are often associated with significant tissue damage which prevents prolonged use. Additionally, these devices often lack any meaningful degree of sensory feedback as their complex construction dampens any vibrations or other sensations a user may have previously depended on when using more simple prosthetics. The composite regenerative peripheral nerve interface (C-RPNI) was developed as a stable, biologic construct with the ability to amplify efferent motor nerve signals while providing simultaneous afferent sensory feedback. The C-RPNI consists of a segment of free dermal and muscle graft secured around a target mixed sensorimotor nerve, with preferential motor nerve reinnervation of the muscle graft and sensory nerve reinnervation of the dermal graft. In rats, this construct has demonstrated the generation of compound muscle action potentials (CMAPs), amplifying the target nerve's signal from the micro- to milli-volt level, with signal to noise ratios averaging approximately 30-50. Stimulation of the dermal component of the construct generates compound sensory nerve action potentials (CSNAPs) at the proximal nerve. As such, this construct has promising future utility towards the realization of the ideal, intuitive prosthetic.
Collapse
Affiliation(s)
- Shelby R Svientek
- Department of Surgery, Division of Plastic Surgery, University of Michigan, Ann Arbor;
| | - Dan C Ursu
- Department of Surgery, Division of Plastic Surgery, University of Michigan, Ann Arbor
| | - Paul S Cederna
- Department of Surgery, Division of Plastic Surgery, University of Michigan, Ann Arbor; Department of Biomedical Engineering, University of Michigan, Ann Arbor
| | - Stephen W P Kemp
- Department of Surgery, Division of Plastic Surgery, University of Michigan, Ann Arbor; Department of Biomedical Engineering, University of Michigan, Ann Arbor
| |
Collapse
|
42
|
Ranganathan K, Mouch CA, Chung M, Mathews IB, Cederna PS, Raja Sabapathy S, Raghavendran K, Singhal M. Geospatial Mapping as a Guide for Resource Allocation Among Burn Centers in India. J Burn Care Res 2019; 41:853-858. [PMID: 31875220 DOI: 10.1093/jbcr/irz210] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Timely treatment is essential for optimal outcomes after burn injury, but the method of resource distribution to ensure access to proper care in developing countries remains unclear. We therefore sought to examine access to burn care and the presence/absence of resources for burn care in India. We surveyed all eligible burn centers (n = 67) in India to evaluate burn care resources at each facility. We then performed a cross-sectional geospatial analysis using geocoding software (ArcGIS 10.3) and publicly available hospital-level data (WorldStreetMap, WorldPop database) to predict the time required to access care at the nearest burn center. Our primary outcome was the time required to reach a burn facility within India. Descriptive statistics were used to present our results. Of the 67 burn centers that completed the survey, 45% were government funded. More than 1 billion (75.1%) Indian citizens live within 2 hours of a burn center, but only 221.9 million (15.9%) live within 2 hours of a burn center with both an intensive care unit (ICU) and a skin bank. Burn units are staffed primarily by plastic surgeons (n = 62, 93%) with an average of 5.8 physicians per unit. Most burn units (n = 53, 79%) have access to hemodialysis. While many Indian citizens live within 2 hours of a burn center, most centers do not offer ICU and skin bank services that are essential for modern burn care. Reallocation of resources to improve transportation and availability of ICU and skin bank services is necessary to improve burn care in India.
Collapse
Affiliation(s)
- Kavitha Ranganathan
- Center for Global Surgery, Department of Surgery, Ann Arbor, Michigan.,Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Charles A Mouch
- Center for Global Surgery, Department of Surgery, Ann Arbor, Michigan.,Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Michael Chung
- Department of Otolaryngology Head and Neck Surgery, Wayne State University, Detroit, MI
| | | | - Paul S Cederna
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - S Raja Sabapathy
- Department of Plastic Surgery, Hand, Reconstructive, and Burn Surgery, Ganga Hospital, Coimbatore, India
| | - Krishnan Raghavendran
- Center for Global Surgery, Department of Surgery, Ann Arbor, Michigan.,Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Maneesh Singhal
- Department of Plastic, Reconstructive and Burns Surgery and JPN Apex Trauma Centre, All India Institute of Medical Science, New Delhi, India
| |
Collapse
|
43
|
Kubiak CA, Grochmal J, Kung TA, Cederna PS, Midha R, Kemp SWP. Stem-cell-based therapies to enhance peripheral nerve regeneration. Muscle Nerve 2019; 61:449-459. [PMID: 31725911 DOI: 10.1002/mus.26760] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 10/31/2019] [Accepted: 11/12/2019] [Indexed: 12/13/2022]
Abstract
Peripheral nerve injury remains a major cause of morbidity in trauma patients. Despite advances in microsurgical techniques and improved understanding of nerve regeneration, obtaining satisfactory outcomes after peripheral nerve injury remains a difficult clinical problem. There is a growing body of evidence in preclinical animal studies demonstrating the supportive role of stem cells in peripheral nerve regeneration after injury. The characteristics of both mesoderm-derived and ectoderm-derived stem cell types and their role in peripheral nerve regeneration are discussed, specifically focusing on the presentation of both foundational laboratory studies and translational applications. The current state of clinical translation is presented, with an emphasis on both ethical considerations of using stems cells in humans and current governmental regulatory policies. Current advancements in cell-based therapies represent a promising future with regard to supporting nerve regeneration and achieving significant functional recovery after debilitating nerve injuries.
Collapse
Affiliation(s)
- Carrie A Kubiak
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joey Grochmal
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Midha
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
44
|
Ives GC, Kung TA, Nghiem BT, Ursu DC, Brown DL, Cederna PS, Kemp SWP. Current State of the Surgical Treatment of Terminal Neuromas. Neurosurgery 2019; 83:354-364. [PMID: 29053875 DOI: 10.1093/neuros/nyx500] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/10/2017] [Indexed: 12/15/2022] Open
Abstract
Painful terminal neuromas resulting from nerve injury following amputation are common. However, there is currently no universally accepted gold standard of treatment for this condition. A comprehensive literature review is presented on the treatment of terminal neuromas. Four categories of terminal neuroma surgical procedures are assessed: epineurial closure; nerve transposition with implantation; neurorrhaphy, and alternate target reinnervation. Significant patient and case studies are highlighted in each section, focusing on surgical technique and patient outcome metrics. Studies presented consisted of a PubMed search for "terminal neuromas," without year limitation. The current available research supports the use of implantation into muscle for the surgical treatment of terminal neuromas. However, this technique has several fundamental flaws that limit its utility, as it does not address the underlying physiology behind neuroma formation. Regenerative peripheral nerve interfaces and targeted muscle reinnervation are 2 techniques that seem to offer the most promise in preventing and treating terminal neuroma formation. Both techniques are also capable of generating control signals which can be used for both motor and sensory prosthetic control. Such technology has the potential to lead to the future restoration of lost limb function in amputees. Further clinical research employing larger patient groups with high-quality control groups and reproducible outcome measures is needed to determine the most effective and beneficial surgical treatment for terminal neuromas. Primary focus should be placed on investigating techniques that most closely approximate the theoretically ideal neuroma treatment, including targeted muscle reinnervation and regenerative peripheral nerve interfaces.
Collapse
Affiliation(s)
- Graham C Ives
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bao Tram Nghiem
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel C Ursu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - David L Brown
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
45
|
Hanwright PJ, Rath JL, Guionneau N, Harris TG, Sarhane KA, Kemp SW, Hoke A, Cederna PS, Tuffaha SH. Stimulated grip strength measurement: Validation of a novel method for functional assessment. Muscle Nerve 2019; 60:437-442. [DOI: 10.1002/mus.26646] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Philip J. Hanwright
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Jennifer L. Rath
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Nicholas Guionneau
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Thomas G.W Harris
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Karim A. Sarhane
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| | - Stephen W.P. Kemp
- Section of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Michigan Ann Arbor Michigan
| | - Ahmet Hoke
- Department of NeurologyJohns Hopkins University School of Medicine Baltimore Maryland
| | - Paul S. Cederna
- Section of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of Michigan Ann Arbor Michigan
| | - Sami H. Tuffaha
- Department of Plastic and Reconstructive SurgeryJohns Hopkins University School of Medicine Baltimore Maryland
| |
Collapse
|
46
|
Ballard TNS, Hill S, Nghiem BT, Lysikowski JR, Brandt K, Cederna PS, Kenkel JM. Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data. Aesthet Surg J 2019; 39:615-623. [PMID: 30052760 DOI: 10.1093/asj/sjy176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. OBJECTIVES The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. METHODS A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. RESULTS There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. CONCLUSIONS Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- Tiffany N S Ballard
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Sean Hill
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bao Tram Nghiem
- Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY
| | - Jerzy R Lysikowski
- Director of Academic Evaluation, Quality Education, and Simulation Analytics, Office of Medical Education, UT Southwestern Medical Center, Dallas, TX
| | - Keith Brandt
- Division of Plastic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Paul S Cederna
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Jeffrey M Kenkel
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX
| |
Collapse
|
47
|
Vu PP, Irwin ZT, Bullard AJ, Ambani SW, Sando IC, Urbanchek MG, Cederna PS, Chestek CA. Closed-Loop Continuous Hand Control via Chronic Recording of Regenerative Peripheral Nerve Interfaces. IEEE Trans Neural Syst Rehabil Eng 2019; 26:515-526. [PMID: 29432117 DOI: 10.1109/tnsre.2017.2772961] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Loss of the upper limb imposes a devastating interruption to everyday life. Full restoration of natural arm control requires the ability to simultaneously control multiple degrees of freedom of the prosthetic arm and maintain that control over an extended period of time. Current clinically available myoelectric prostheses do not provide simultaneous control or consistency for transradial amputees. To address this issue, we have implemented a standard Kalman filter for continuous hand control using intramuscular electromyography (EMG) from both regenerative peripheral nerve interfaces (RPNI) and an intact muscle within non-human primates. Seven RPNIs and one intact muscle were implanted with indwelling bipolar intramuscular electrodes in two rhesus macaques. Following recuperations, function-specific EMG signals were recorded and then fed through the Kalman filter during a hand-movement behavioral task to continuously predict the monkey's finger position. We were able to reconstruct continuous finger movement offline with an average correlation of and a root mean squared error (RMSE) of 0.12 between actual and predicted position from two macaques. This finger movement prediction was also performed in real time to enable closed-loop neural control of a virtual hand. Compared with physical hand control, neural control performance was slightly slower but maintained an average target hit success rate of 96.70%. Recalibration longevity measurements maintained consistent average correlation over time but had a significant change in RMSE ( ). Additionally, extracted single units varied in amplitude by a factor of +18.65% and -25.85% compared with its mean. This is the first demonstration of chronic indwelling electrodes being used for continuous position control via the Kalman filter. Combining these analyses with our novel peripheral nerve interface, we believe that this demonstrates an important step in providing patients with more naturalistic control of their prosthetic limbs.
Collapse
|
48
|
Ursu D, Cederna PS. Discussion: Contralateral Botulinum Toxin Improved Functional Recovery after Tibial Nerve Repair in Rats. Plast Reconstr Surg 2018; 142:1520-1522. [PMID: 30489525 DOI: 10.1097/prs.0000000000005075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Daniel Ursu
- From the Section of Plastic Surgery and the Department of Biomedical Engineering, University of Michigan
| | - Paul S Cederna
- From the Section of Plastic Surgery and the Department of Biomedical Engineering, University of Michigan
| |
Collapse
|
49
|
Frost CM, Ursu DC, Flattery SM, Nedic A, Hassett CA, Moon JD, Buchanan PJ, Brent Gillespie R, Kung TA, Kemp SWP, Cederna PS, Urbanchek MG. Regenerative peripheral nerve interfaces for real-time, proportional control of a Neuroprosthetic hand. J Neuroeng Rehabil 2018; 15:108. [PMID: 30458876 PMCID: PMC6245539 DOI: 10.1186/s12984-018-0452-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/31/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Regenerative peripheral nerve interfaces (RPNIs) are biological constructs which amplify neural signals and have shown long-term stability in rat models. Real-time control of a neuroprosthesis in rat models has not yet been demonstrated. The purpose of this study was to: a) design and validate a system for translating electromyography (EMG) signals from an RPNI in a rat model into real-time control of a neuroprosthetic hand, and; b) use the system to demonstrate RPNI proportional neuroprosthesis control. METHODS Animals were randomly assigned to three experimental groups: (1) Control; (2) Denervated, and; (3) RPNI. In the RPNI group, the extensor digitorum longus (EDL) muscle was dissected free, denervated, transferred to the lateral thigh and neurotized with the residual end of the transected common peroneal nerve. Rats received tactile stimuli to the hind-limb via monofilaments, and electrodes were used to record EMG. Signals were filtered, rectified and integrated using a moving sample window. Processed EMG signals (iEMG) from RPNIs were validated against Control and Denervated group outputs. RESULTS Voluntary reflexive rat movements produced signaling that activated the prosthesis in both the Control and RPNI groups, but produced no activation in the Denervated group. Signal-to-Noise ratio between hind-limb movement and resting iEMG was 3.55 for Controls and 3.81 for RPNIs. Both Control and RPNI groups exhibited a logarithmic iEMG increase with increased monofilament pressure, allowing graded prosthetic hand speed control (R2 = 0.758 and R2 = 0.802, respectively). CONCLUSION EMG signals were successfully acquired from RPNIs and translated into real-time neuroprosthetic control. Signal contamination from muscles adjacent to the RPNI was minimal. RPNI constructs provided reliable proportional prosthetic hand control.
Collapse
Affiliation(s)
- Christopher M. Frost
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - Daniel C. Ursu
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
- University of Michigan Department of Mechanical Engineering, Ann Arbor, MI USA
| | | | - Andrej Nedic
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - Cheryl A. Hassett
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - Jana D. Moon
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - Patrick J. Buchanan
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - R. Brent Gillespie
- University of Michigan Department of Mechanical Engineering, Ann Arbor, MI USA
| | - Theodore A. Kung
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| | - Stephen W. P. Kemp
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Paul S. Cederna
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Melanie G. Urbanchek
- University of Michigan Department of Surgery, Section of Plastic Surgery, 570 MSRB II Level A, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-5456 USA
| |
Collapse
|
50
|
Loder SJ, Agarwal S, Chung MT, Cholok D, Hwang C, Visser N, Vasquez K, Sorkin M, Habbouche J, Sung HH, Peterson J, Fireman D, Ranganathan K, Breuler C, Priest C, Li J, Bai X, Li S, Cederna PS, Levi B. Characterizing the Circulating Cell Populations in Traumatic Heterotopic Ossification. Am J Pathol 2018; 188:2464-2473. [PMID: 30142335 DOI: 10.1016/j.ajpath.2018.07.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/08/2018] [Accepted: 07/26/2018] [Indexed: 12/23/2022]
Abstract
Heterotopic ossification (HO) occurs secondary to trauma, causing pain and functional limitations. Identification of the cells that contribute to HO is critical to the development of therapies. Given that innate immune cells and mesenchymal stem cells are known contributors to HO, we sought to define the contribution of these populations to HO and to identify what, if any, contribution circulating populations have to HO. A shared circulation was obtained using a parabiosis model, established between an enhanced green fluorescent protein-positive/luciferase+ donor and a same-strain nonreporter recipient mouse. The nonreporter mouse received Achilles tendon transection and dorsal burn injury to induce HO formation. Bioluminescence imaging and immunostaining were performed to define the circulatory contribution of immune and mesenchymal cell populations. Histologic analysis showed circulating cells present throughout each stage of the developing HO anlagen. Circulating cells were present at the injury site during the inflammatory phase and proliferative period, with diminished contribution in mature HO. Immunostaining demonstrated that most early circulatory cells were from the innate immune system; only a small population of mesenchymal cells were present in the HO. We demonstrate the time course of the participation of circulatory cells in trauma-induced HO and identify populations of circulating cells present in different stages of HO. These findings further elucidate the relative contribution of local and systemic cell populations to HO.
Collapse
Affiliation(s)
- Shawn J Loder
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shailesh Agarwal
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael T Chung
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David Cholok
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Charles Hwang
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Noelle Visser
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kaetlin Vasquez
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Sorkin
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joe Habbouche
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hsiao H Sung
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joshua Peterson
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David Fireman
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kavitha Ranganathan
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Christopher Breuler
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Caitlin Priest
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - John Li
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Xue Bai
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shuli Li
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S Cederna
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Levi
- Burn/Wound and Regenerative Medicine Laboratory, Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|