OsseointegrationNaomi Sheerman

Chris Horley

The Hills Private Hospital

Outline

History of Osseointegration

Who will Osseointegration benefit?

Stages of OsseointegrationThe decision-making processThe surgical processThe 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 ProtocolInitially only in Macquarie University Hospital –

more recently, 4 at Norwest -> the Hills Private.

#### patients so far

Osseointegration Conference Sydney November 2012Osseointegration Group of AustraliaMacquarie University HospitalOrthodynamics 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 clothingNo 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 weightGreater proprioception with the ground than with

conventional prosthesisReduced phantom painNo need to continually replace sockets -> cost-savingCan 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

SurgeryStage 1Stage 2

Loading

Prosthetic training

Decision-making ProcessInformation online + online enquiry form

http://www.osseointegrationaustralia.com.au/

QuestionnairePainCurrent activity levelsProsthetic comfort / fitGoals

Osseointegration Clinic:Meet & Greet, Q&A with peers and patients

who have had osseointegration

Decision-making ProcessMultidisciplinary Concurrent Assessment

SurgeonNUMProsthetistRehabilitation SpeciailistPhysiotherapist

Clinical Psychology Assessment

No advice given as to whether to have the surgery or not – impartial facts given

Team need to approve surgery candidate must be appropriate

Decision-making ProcessAssessment Includes:

Time and cause of amputation“k” classification and exercise toleranceGeneral healthPsychological wellbeing / motivationFamily and support networkBMICore and pelvic strengthPelvic dysfunctionHip ROMHip strength

Planning Process

Orthopaedic PlanningCT measurementsBMD measurementsCustom 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 StagesStage 1 Insertion of

Endo-Prosthesis Stage 2 Attachment of

Exo-Prosthesis

Stage 1

Stage 2

Integral Leg Prosthesis (ILP) SystemThis video has been removed from the presentation due to size. It can be viewed at:

http://www.osseointegrationaustralia.com.au/ (original hosts)

www.austpar.com/portals/acute_care/osseointegration.php (YouTube hosted)

Stage 1 Endo – Prosthesis

6/52 Late

r

Stage 2 Exo- Prosthesis

The Integral Leg Prosthesis:

PatentedSpongiosa-Metal® II surface. Osseointegration occurs within this three-dimensional grid structure, providing secure fixation of the prosthesis.

The Prosthesis

The ProsthesisA 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 restAnalgesia IceOedema management taught

self lymphatic drainageMobilise with crutches for 6/52 Monitor for hip contracturesHip strengthening exercisesTA + pelvic control exercises

After Stage 2

Bed restAnalgesia Stoma management / hygieneMinimum Day 5 Post-op commence

loadingMaximal axial loading of 20 kg for

30 mins x 2 / dayProgress 5-10 kg per dayOnce at 50 kg or 80 – 90% body weight

commence dynamic loading through prosthesisPWB 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 Prosthesis with crutches / walking sticks or wheelchair

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/CaseStudy1_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/CaseStudy1_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/CaseStu

dy1_J-Discharge1.mp4www.austpar.com/portals/acute_care/videos/CaseStu

dy1_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/CaseStu

dy2_A-Day1-ILP1.mp4www.austpar.com/portals/acute_care/videos/CaseStu

dy2_A-Day1-ILP2.mp4www.austpar.com/portals/acute_care/videos/CaseStu

dy2_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/CaseStu

dy3_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/CaseStu

dy3_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 lifeTo climb a mountainComplete 5 or 10 km fun run (walking)Wear high heelsRide 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/CaseStu

dy4_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/CaseStu

dy4_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/CaseStu

dy4_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/CaseStu

dy4_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