Osseointegration

Naomi Sheerman Chris Horley The Hills Private Hospital

Outline

 History of Osseointegration  Who will Osseointegration benefit?

 Stages of Osseointegration  The decision-making process  The surgical process  The rehab process  4 Case Studies  Q&A

History of Osseointegration

 Osseointegration in dentistry started in 1965 with Professor Per Ingvar Brånemark.

 In 1995 in Sweden, Brånemark (son) performed the first transcutaneous femoral intramedullary prosthesis on an above knee amputee with a 12cm screw-fixation titanium threaded device. A non-weight bearing period of 6 - 12 months was enforced to allow proper osseointegration.

 Germany 1999 Horst Heinrich Aschoff – femoral cement-free spongiosa implant  OPRA – Osseointegrated Prostheses for the Rehabilitation of Amputees – first 2 patients in Australia in 2000, at the Alfred Hospital, Melbourne.

 About 6 Centres Worldwide that perform osseointegration – Sweden, Germany, Menime, Holland, Chile, Sydney

OGAAP: Osseointegration Group of Australia Accelerated Protocol

 Initially only in Macquarie University Hospital – more recently, 4 at Norwest -> the Hills Private.

 #### patients so far  Osseointegration Conference Sydney November 2012    Osseointegration Group of Australia Macquarie University Hospital Orthodynamics Pty Ltd

Positives of Osseointegration

     Improved fit - the stump, which often fluctuates in volume and shape, is not forced into a predetermined form Speed – the exo-prosthesis can be attached and removed completely within a few seconds when seated. No skin irritations due to friction, sweat or heat, meaning the prosthesis can be worn for longer periods without pain or discomfort Less restrictions on clothing No movement – the prosthesis doesn’t need to be adjusted during the day such as getting out of a car

Positives

       More normalised mechanics, no pivoting and pistoning. Development of “normal” muscle tone + muscular strength -> greater control and less effort -> reduced energy consumption ROM is not restricted by the interfering edges of a prosthesis regardless of whether you are sitting, standing or walking Lighter components and improved perception of weight Greater proprioception with the ground than with conventional prosthesis Reduced phantom pain No need to continually replace sockets -> cost-saving Can sit on the toilet!

Negatives

 Cost  Permanent stoma: risk of infection  Swimming: public pools  Mechanical failure following a fall -> fracture or loosening, fear of falls  ?? High impact activities  Weight loading through the femur -> hip joint integrity, bone mineral density  ?? Lifespan

Who will Osseointegration benefit?

 Problems with socket  Pain / Rubbing      Skin breakdown / surgical intervention Stump size fluctuations   Falling off!!

Getting stuck on!

Weight of componentry Restriction / Limitations on clothes Impact on ADL’s and QOL from limited prosthesis use  Prosthetic user with nothing to lose / everything to gain  Money  very expensive surgery

Stages of Osseointegration

 Decision & Planning  Surgery  Stage 1  Stage 2  Loading  Prosthetic training

Decision-making Process

 Information online + online enquiry form  http://www.osseointegrationaustralia.com.au/  Questionnaire     Pain Current activity levels Prosthetic comfort / fit Goals  Osseointegration Clinic:  Meet & Greet, Q&A with peers and patients who have had osseointegration

Decision-making Process

  Multidisciplinary Concurrent Assessment  Surgeon     NUM Prosthetist Rehabilitation Speciailist Physiotherapist Clinical Psychology Assessment Team need to approve surgery  candidate must be appropriate  No advice given as to whether to have the surgery or not – impartial facts given

Decision-making Process

Assessment Includes:

 Time and cause of amputation  “k” classification and exercise tolerance   General health Psychological wellbeing / motivation    Family and support network BMI Core and pelvic strength    Pelvic dysfunction Hip ROM Hip strength

Planning Process

 Orthopaedic Planning  CT measurements  BMD measurements  Custom made implant  Prosthetic Planning  Not to wear prosthesis for 6/52 preop to rest the stump and allow any skin abrasions to heal

Surgical Process

 Two Stages  Stage 1  Insertion of Endo-Prosthesis  Stage 2  Attachment of Exo-Prosthesis

Stage 2 Stage 1

Integral Leg Prosthesis (ILP) System

This video has been removed from the presentation due to size. It can be viewed at:  http://www.osseointegrationaustralia.com.au/ hosts) (original  www.austpar.com/portals/acute_care/osseointegration.

php (YouTube hosted)

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The Prosthesis

The Integral Leg Prosthesis: Stage 1 Endo – Prosthesis Later Stage 2 Exo- Prosthesis  PatentedSpongiosa-Metal® II surface. Osseointegration occurs within this three-dimensional grid structure, providing secure fixation of the prosthesis.

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The Prosthesis

A dual adapter connects the endo and exo Prosthesis.

 The silicone cover is used to protect the stoma. The cone sleeve and the rotation disc serve as connection for the knee-lower leg prosthesis system.

 All other components (height adjusters, spinners) can be quickly and easily connected to the Endo-prosthesis using the knee connection adapter – tightened with an allen key.

After Stage 1

        Bed rest Analgesia Ice Oedema management  self lymphatic drainage taught Mobilise with crutches for 6/52 Monitor for hip contractures Hip strengthening exercises TA + pelvic control exercises

After Stage 2

        Bed rest Analgesia Stoma management / hygiene Minimum Day 5 Post-op commence loading Maximal axial loading of 20 kg for 30 mins x 2 / day Progress 5-10 kg per day Once at 50 kg or 80 – 90% body weight commence dynamic loading through prosthesis PWB for 3/12 post stage 2

Rehab process

 Gait re-training  Prosthetic adjustments  Knee-specific training  Stomal care  AVOID falls, rotational forces, infection

Rehab Process

 Gradual vertical loading

Rehab Process

 Core & limb strengthening

Rehab Process

 Generally, when at 80-90% WB, Prosthetist fits prosthesis

Rehab Process

 Prosthetic adjustments

Rehab Process

 Gait Retraining

Rehab Process

 Knee-specific training

Rehab Process

 Stoma care  AVOID falls, rotational forces, infection

Case Study 1: J

 32 y.o. male  Bilateral AKA – Car Accident – 2003  Wore socket prosthesis intermittently over past 9 years  Discarded previous prostheses due to discomfort  Prostheses: Genium  Previous mobility  wheelchair Prosthesis with crutches / walking sticks or  Goals : to walk with 1 x walking stick / unaided To take their dog for a walk

Case Study 1: J- Socket Prosthesis

This video was removed due to its size. It can be downloaded from:  www.austpar.com/portals/acute_care/videos/CaseStudy 1_J-SocketProsthesis.mp4

Case Study 1: J- Day 1 ILP

 This video shows J walking, day 1 with ILP.

 The video was removed due to size, and can be found at www.austpar.com/portals/acute_care/videos/CaseStudy 1_J-Day1-ILP.mp4

Case Study 1: J

Challenges  Bilateral Amputee  Previous brain injury  not responded well to physios in the past  Back / Hip / Leg / Bone pain  Self funded + international patient  Height adjustment of prosthesis  Shoes

Case Study 1: J - Discharge

 Two videos demonstrating J’s gait at discharge.

 The videos were removed from the presentation due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy1_ J-Discharge1.mp4

 www.austpar.com/portals/acute_care/videos/CaseStudy1_ J-Discharge2.mp4

Case Study 2: A

 39 y.o Feale  Hit by car 2 years ago  Left AKA  Phantom pain+++ related to bowel function and preventing functional prosthetic use  Prosthesis: C-Leg  Post MVA mobility  Canadian Crutches  Post traumatic stress & not returned to work  Goals : use a prosthesis without pain to participate more in kids’ lives

Case Study 2: A – D1 ILP

 These videos shows A walking, day 1 with ILP.

 The video was removed due to size, and can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy2_ A-Day1-ILP1.mp4

  www.austpar.com/portals/acute_care/videos/CaseStudy2_ A-Day1-ILP2.mp4

www.austpar.com/portals/acute_care/videos/CaseStudy2_ A-Day1-ILP3.mp4

Case Study 2: A

Challenges  Piriformis and gluts tenderness  Phantom pain  Fatigue  Stomal infection after discharge home -> AB’s

Case Study 3: D

 29 y.o Male  MBA 5 years ago: trail bike on private property  Right AKA  Wore socket prosthesis for ~ 3 months  Discarded previous prosthesis due to discomfort  Prosthesis: C-Leg  Post MBA mobility  Axillary Crutches  Goals : walk without walking aids to walk holding kids’ hands

Case Study 3: D- Day 1 ILP

 This video shows D’s gait on Day 1 with ILP.

 The video was removed due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy3_ D-Day1-ILP.mp4

Case Study 3: D

Challenges  Alignment  Tight hip flexors  Poor hip extensors  Poor Core Strength  Minimal weight bearing through prosthesis   confidence with prosthesis  Varying gait patterns  Self funded / Money

Case Study 3: D - Discharge

 This video shows D’s gait pattern at discharge.

 The video was removed from the presentation due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy3_ D-Discharge.mp4

Case Study 4: M

 25 y.o. female  R AKA  Congenital Amputation at 18 months   Malformation of Right Hip joint Malformation of thumb  index finger transplanted to thumb at ? 8 y.o.

 Highly functioning socket prosthetic user  Unaided prior to operation  Prosthesis: 3R60  Goals : Return to normal life To climb a mountain Complete 5 or 10 km fun run (walking) Wear high heels Ride a road bike

Case Study 4: M – X-Ray

Case Study 4: M-Socket Prosthesis

 This video shows M’s gait pattern with a socket prosthesis.

 The video was removed due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy4_ M-SocketProsthesis.mp4

Case Study 4: M- Day 1 ILP

 This video shows M’s gait pattern day 1 with ILP.

 The video was removed due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy4_ M-Day1-ILP.mp4

Case Study 4: M

Challenges  Congenital under development  Lack of Hip Joint / ROM / Strength  Expectations  Psychological Issues  Componentry  Hip Pain  Limitations of stoma: swimming  Limitations on assistance

Case Study 4: M – Week 3

 This video show M’s gait pattern at week 3.

 The video was removed from the presentation due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy4_ M-Week3-ILP.mp4

Case Study 4: M - Discharge

 This video show M’s gait pattern at discharge.

 The video was removed from the presentation due to size, but can be found at:  www.austpar.com/portals/acute_care/videos/CaseStudy4_ M-Discharge.mp4

Acknowledgements

 Dr Al Muderis and the Team at Macquarie University Hospital:      Sarah Benson, Physiotherapist Jennifer, NUM Dr Simon Chan, Rehab Consultant Stefan Laux, Prosthetist, APC Chris Bastien, Clinical Psychologist  Team at Norwest Private Hospital:  Natalie Tymoc-Campbell, Physiotherapist  www.almuderis.com.au/osseointegration  http://www.osseointegrationaustralia.com.au