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Osseointegration

Osseointegration. Naomi Sheerman Chris Horley The Hills Private Hospital. Outline. History of Osseointegration Who will O sseointegration benefit? Stages of Osseointegration The decision-making process The surgical process The rehab process 4 Case Studies Q&A.

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Osseointegration

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  1. Osseointegration Naomi Sheerman Chris Horley The Hills Private Hospital

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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!

  7. 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

  8. 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 userwith nothing to lose / everything to gain • Money  very expensive surgery

  9. Stages of Osseointegration • Decision & Planning • Surgery • Stage 1 • Stage 2 • Loading • Prosthetic training

  10. 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

  11. Decision-making Process • Multidisciplinary Concurrent Assessment • Surgeon • NUM • Prosthetist • Rehabilitation Speciailist • Physiotherapist • 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

  12. 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

  13. 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

  14. Surgical Process • Two Stages • Stage 1 Insertion of Endo-Prosthesis • Stage 2  Attachment of Exo-Prosthesis

  15. Stage 1 Stage 2

  16. 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/ (original hosts) • www.austpar.com/portals/acute_care/osseointegration.php (YouTube hosted)

  17. The Prosthesis • The Integral Leg Prosthesis: • PatentedSpongiosa-Metal® II surface. Osseointegration occurs within this three-dimensional grid structure, providing secure fixation of the prosthesis.

  18. The Prosthesis • A dual adapter connects the endo and exoProsthesis. • 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.

  19. After Stage 1 • Bed rest • Analgesia • Ice • Oedema management taught self lymphatic drainage • Mobilise with crutches for 6/52 • Monitor for hip contractures • Hip strengthening exercises • TA + pelvic control exercises

  20. 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

  21. Rehab process • Gait re-training • Prosthetic adjustments • Knee-specific training • Stomal care • AVOID falls, rotational forces, infection

  22. Rehab Process • Gradual vertical loading

  23. Rehab Process • Core & limb strengthening

  24. Rehab Process • Generally, when at 80-90% WB, Prosthetistfits prosthesis

  25. Rehab Process • Prosthetic adjustments

  26. Rehab Process • Gait Retraining

  27. Rehab Process • Knee-specific training

  28. Rehab Process • Stoma care • AVOID falls, rotational forces, infection

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. Case Study 2: A • 39 y.oFeale • 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

  35. 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

  36. Case Study 2: A Challenges • Piriformis and gluts tenderness • Phantom pain • Fatigue • Stomal infection after discharge home -> AB’s

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. Case Study 4: M – X-Ray

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

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