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Shelby Johnson

on 16 October 2012

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Transcript of Osseointegration

An Upcoming Procedure Osseointegration: 1990: First bilateral transfemoral and upper limb application Rehab Protocol Originally designed for:
Transfemoral amputees w/ socket complications Candidates The ability by patients with osseointegrated fixtures to identify tactile thresholds transmitted through their prostheses Osseoperception No sweating or skin irritation
No pain, pressure or discomfort in socket
Easy to don/doff
Good suspension
No restriction of hip movement
Increased comfort in sitting Longer Rehab process
Risk of infection
Risk of Fracture or loosening
Poor cosmesis
No high impact activities permitted
Daily care of abutment skin required Osteoporosis
Peripheral vascular disease
Excess weight (>242lbs)
>70 years of age
Haven't reached full skeletal maturity
Not physically and mentally suitable for surgery
Chemotherapy/corticosteroid use
Pregnancy Early Feasibility Study Rational: secondary to nerve ingrowth into remodeling bone Direct anchorage of an implant by
the formation of bony tissues around
the implant without the growth of fibrous
tissue at the bone-implant interface Definition Recognize the current challenges of prosthetic wear
To understand the history of OI
To explain the OI surgical procedure
To comprehend the concept of osseoperception
To identify current transfemoral OI research Objectives Sweating (72%)
Socket discomfort (44%)
Skin sores/breakdown (62%)
Improper fit
Difficulty donning/doffing prosthesis
Poor suspension
Mobility deficits Current problems w/
Conventional Socket Use 1952: Implantation of a titanium chamber to testing blood flow in rabbits (Dr. Branemark) Ears, nose and hearing Aids Finger and thumb replacements Titanium fixture is threaded into medullary cavity of residual femur
Wound is completely closed
Once healed pt can use conventional socket Fixture is re-exposed
Abundant inserted into distal end of fixture
(fail proof mechanism)
Wound closed w/ abundant penetrating skin  No Protocol (prior to 1994)
Normal Protocol: 12 months
Half-speed Protocol: 18 months
Individual Protocol Safety guidelines:
VAS level 2-3 considered safe
VAS >5 should be avoided Rehab Protocol Case Study History Summary References Current Practice Advantages of OI Disadvantages of OI Contraindications Procedure: Stage 1 Procedure: Stage 2 Case Study 1965: Dental implants Rehab Protocol Hagberg K, Branemark R. One hundred patients treated with osseointegrated transfemoral
amputation prostheses--rehabilitation perspective. J Rehabil Res Dev. 2009;46(3):331-344.

Hagberg K, Branemark R, Gunterberg B, Rydevik B. Osseointegrated trans-femoral amputation
prostheses: Prospective results of general and condition-specific quality of life in 18 patients at 2-year follow-up. Prosthet Orthot Int. 2008;32(1):29-41.

Jacobs et al., Evaluation of the psychophysical detection threshold level for vibrotactile and
pressure stimulation of prosthetic limbs using bone anchorage or soft tissue support. Prosthet Orthot Int. 2000 Aug;24(2):133-42.

Lundberg M, Hagberg K, Bullington J. My prosthesis as a part of me: A qualitative analysis of
living with an osseointegrated prosthetic limb. Prosthet Orthot Int. 2011;35(2):207-214.

Sahlgrenska University Hospital. Direct bone anchoring of amputation prosthesis.

Sullivan J, Uden M, Robinson KP, Sooriakumaran S. Rehabilitation of the trans-femoral
amputee with an osseointegrated prosthesis: The united kingdom experience. Prosthet Orthot Int. 2003;27(2):114-120.

Tranberg R, Zugner R, Karrholm J. Improvements in hip- and pelvic motion for patients with
osseointegrated trans-femoral prostheses. Gait Posture. 2011;33(2):165-168. One Hundred Patients Treated with Osseointegrated
Transfemoral amputation Prosthesis Branemark et al. Aim: Describe current rehabilitation protocol and overview the results
Subjects: 100 patients w/ transfemoral amputations
Inclusion/Exclusion criteria: General Sweden
United Kingdom
United States (coming soon) Non-use: Phantom limb pain, osteomyelitis, contralateral limb disability Case Study Female, 58 years old Amputation: 1977 (osteosarcoma)
Prosthetic use score: ~75
complications: pain, sweating, sitting discomfort, sores/skin irritation, difficulty donning, poor suspension Osseointegration S1: 1992 (S2 3 months later)
Pt experienced loosening resulting in implant removal
Re-implantation S1: 1995 (S2 12 months later)
Prosthetic use score: 100
Complication: superficial infection Female, 62 years old Amputation: 1995
Wear time: half day
Prosthetic use score: ~50
Complications: decreased ROM, skin breakdown, discomfort in sitting, pain and poor suspension Osseointegration: 1998 (S2 8 months later)
Half speed protocol: 20 months
Prosthetic use score: 100
No complications noted Male, 36 years old Amputation: 1995 (trauma)
Prosthetic use score: 9 Osseointegration: 1999
Wear time: 15 hours/day
Prosthetic use score: 100
Complications: mechanical, 3 abundant replacements Early Feasibility Study Veteran Affairs, SLC Subjects: 10 patients w/ trans-femoral amputation
2 stage procedure
S2 performed 6 weeks after S1
1+ year follow up
1 surgical team (Dr.Kubiak) @ VAMC-SLC Age 18-55
Veteran or active military status
Unilateral trans-femoral amputation
Minimum 6 months post-op
Adequate cognitive abilities for informed consent
K2 or K3 ambulator
Tolerate prosthetic wear >3 hours/day Early Feasibility Study Early Feasibility Study Residual limb characteristics
Active residual limb breakdown
Active or prior hx osteomyelitis
Active HO
Phantom limb pain prohibiting prosthetic use
General medical considerations
Obesity (BMI >30/ Wt >250lbs)
Contralateral limb disability
High fall risk (Berg balance <30) Outcome measures Exclusion Criteria Inclusion Criteria 4 weeks pre-op
12 weeks post-op
6 months post-op
12 months post-op Activity
LCI-5: measure bi-pedal ambulation
Prosthetic don/doff time and effort measure
Gait analysis
GARS: self cares assessment Early Feasibility Study Impairment
Berg balance scale
Chronic pain grade
Psychosocial adjustment subscale
TAPES: activity restriction subscale
SWLS: satisfaction w/ life
SF-36: medical outcome
TAPES: prosthetic satisfaction subscale Outcome measures Timeline: Cons:
Currently unaware of long term results
OI has potential risks and complications
Little research supporting a rehab protocol Pros:
Potential to reduce complications of current prosthetic wear w/ OI
Potential to improve QOL and mobility
Osseoperception Osseoperception Osseoperception Evaluation of the psychophysical detection threshold level for vibrotactile and pressure stimulation of prosthetic limbs using bone anchorage or soft tissue support Jacobs et al. 32 subjects
16 UE amputees, 16 LE amputees
2 groups: OI (17) vs. Conventional socket (15)
Control: non-prosthetic limb
Detection threshold for vibration and pressure stimulation Pressure Vibration Osseoperception Vibration
Conventional socket: 20% increase
OI prosthesis: similar
Conventional socket: 60% increase
OI prosthesis: 40% increase Results: Results: Results: QUESTIONS Rehab Protocol
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