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