Chris Horley The Hills Private Hospital Outline History of Osseointegration Who will O sseointegration benefit Stages of Osseointegration The decisionmaking process The surgical process ID: 1033879
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1. OsseointegrationNaomi SheermanChris HorleyThe Hills Private Hospital
2. OutlineHistory of OsseointegrationWho will Osseointegration benefit?Stages of OsseointegrationThe decision-making processThe surgical processThe rehab process4 Case StudiesQ&A
3. History of OsseointegrationOsseointegration 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 implantOPRA – 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 ProtocolInitially only in Macquarie University Hospital – more recently, 4 at Norwest -> the Hills Private.#### patients so farOsseointegration Conference Sydney November 2012Osseointegration Group of AustraliaMacquarie University HospitalOrthodynamics Pty Ltd
5. Positives of OsseointegrationImproved fit - the stump, which often fluctuates in volume and shape, is not forced into a predetermined formSpeed – 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 discomfortLess restrictions on clothingNo 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 consumptionROM is not restricted by the interfering edges of a prosthesis regardless of whether you are sitting, standing or walkingLighter 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!
7. NegativesCostPermanent stoma: risk of infectionSwimming: public poolsMechanical failure following a fall -> fracture or loosening, fear of falls?? High impact activitiesWeight loading through the femur -> hip joint integrity, bone mineral density?? Lifespan
8. Who will Osseointegration benefit?Problems with socketPain / Rubbing Skin breakdown / surgical intervention Stump size fluctuationsFalling off!!Getting stuck on!Weight of componentryRestriction / Limitations on clothes Impact on ADL’s and QOL from limited prosthesis useProsthetic user with nothing to lose / everything to gainMoney very expensive surgery
9. Stages of OsseointegrationDecision & PlanningSurgeryStage 1Stage 2LoadingProsthetic training
10. Decision-making ProcessInformation online + online enquiry formhttp://www.osseointegrationaustralia.com.au/QuestionnairePainCurrent activity levelsProsthetic comfort / fitGoalsOsseointegration Clinic:Meet & Greet, Q&A with peers and patients who have had osseointegration
11. Decision-making ProcessMultidisciplinary Concurrent Assessment SurgeonNUMProsthetistRehabilitation SpeciailistPhysiotherapistClinical Psychology AssessmentNo advice given as to whether to have the surgery or not – impartial facts givenTeam need to approve surgery candidate must be appropriate
12. 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
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14. Planning ProcessOrthopaedic PlanningCT measurementsBMD measurementsCustom made implantProsthetic PlanningNot to wear prosthesis for 6/52 preop to rest the stump and allow any skin abrasions to heal
15. Surgical ProcessTwo StagesStage 1 Insertion of Endo-Prosthesis Stage 2 Attachment of Exo-Prosthesis
16. Stage 1Stage 2
17. 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)
18. The Integral Leg Prosthesis:PatentedSpongiosa-Metal® II surface. Osseointegration occurs within this three-dimensional grid structure, providing secure fixation of the prosthesis.The Prosthesis
19. 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.
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21. After Stage 1Bed restAnalgesia IceOedema management taught self lymphatic drainageMobilise with crutches for 6/52 Monitor for hip contracturesHip strengthening exercisesTA + pelvic control exercises
22. After Stage 2Bed 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
23. Rehab processGait re-trainingProsthetic adjustmentsKnee-specific trainingStomal careAVOID falls, rotational forces, infection
24. Rehab ProcessGradual vertical loading
25. Rehab ProcessCore & limb strengthening
26. Rehab ProcessGenerally, when at 80-90% WB, Prosthetist fits prosthesis
27. Rehab ProcessProsthetic adjustments
28. Rehab ProcessGait Retraining
29. Rehab ProcessKnee-specific training
30. Rehab ProcessStoma careAVOID falls, rotational forces, infection
31. Case Study 1: J32 y.o. maleBilateral AKA – Car Accident – 2003Wore socket prosthesis intermittently over past 9 yearsDiscarded previous prostheses due to discomfortProstheses: GeniumPrevious mobility Prosthesis with crutches / walking sticks or wheelchairGoals : to walk with 1 x walking stick / unaided To take their dog for a walk
32. Case Study 1: J- Socket ProsthesisThis video was removed due to its size. It can be downloaded from:www.austpar.com/portals/acute_care/videos/CaseStudy1_J-SocketProsthesis.mp4
33. Case Study 1: J- Day 1 ILPThis 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
34. Case Study 1: JChallengesBilateral AmputeePrevious brain injury not responded well to physios in the past Back / Hip / Leg / Bone painSelf funded + international patientHeight adjustment of prosthesisShoes
35. Case Study 1: J - DischargeTwo 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.mp4www.austpar.com/portals/acute_care/videos/CaseStudy1_J-Discharge2.mp4
36. Case Study 2: A39 y.o FealeHit by car 2 years agoLeft AKAPhantom pain+++ related to bowel function and preventing functional prosthetic useProsthesis: C-LegPost MVA mobility Canadian CrutchesPost traumatic stress & not returned to workGoals : use a prosthesis without pain to participate more in kids’ lives
37. Case Study 2: A – D1 ILPThese 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.mp4www.austpar.com/portals/acute_care/videos/CaseStudy2_A-Day1-ILP2.mp4www.austpar.com/portals/acute_care/videos/CaseStudy2_A-Day1-ILP3.mp4
38. Case Study 2: AChallengesPiriformis and gluts tendernessPhantom painFatigueStomal infection after discharge home -> AB’s
39. Case Study 3: D29 y.o MaleMBA 5 years ago: trail bike on private propertyRight AKAWore socket prosthesis for ~ 3 monthsDiscarded previous prosthesis due to discomfortProsthesis: C-LegPost MBA mobility Axillary CrutchesGoals : walk without walking aids to walk holding kids’ hands
40. Case Study 3: D- Day 1 ILPThis 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
41. Case Study 3: DChallengesAlignmentTight hip flexorsPoor hip extensorsPoor Core StrengthMinimal weight bearing through prosthesis confidence with prosthesisVarying gait patternsSelf funded / Money
42. Case Study 3: D - DischargeThis 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
43. Case Study 4: M25 y.o. femaleR AKACongenital Amputation at 18 monthsMalformation of Right Hip jointMalformation of thumb index finger transplanted to thumb at ? 8 y.o.Highly functioning socket prosthetic userUnaided prior to operationProsthesis: 3R60Goals : Return to normal life To climb a mountain Complete 5 or 10 km fun run (walking) Wear high heels Ride a road bike
44. Case Study 4: M – X-Ray
45. Case Study 4: M-Socket ProsthesisThis 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
46. Case Study 4: M- Day 1 ILPThis 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
47. Case Study 4: MChallengesCongenital under developmentLack of Hip Joint / ROM / StrengthExpectationsPsychological IssuesComponentryHip Pain Limitations of stoma: swimmingLimitations on assistance
48. Case Study 4: M – Week 3This 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
49. Case Study 4: M - DischargeThis 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
50. AcknowledgementsDr Al Muderis and the Team at Macquarie University Hospital:Sarah Benson, PhysiotherapistJennifer, NUMDr Simon Chan, Rehab ConsultantStefan Laux, Prosthetist, APCChris Bastien, Clinical PsychologistTeam at Norwest Private Hospital:Natalie Tymoc-Campbell, Physiotherapistwww.almuderis.com.au/osseointegrationhttp://www.osseointegrationaustralia.com.au