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Osseointegration Naomi Sheerman Chris Horley The Hills Private Hospital.

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Presentation on theme: "Osseointegration Naomi Sheerman Chris Horley The Hills Private Hospital."— Presentation transcript:

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 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 user with 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 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

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14 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

15 Surgical Process Two Stages Stage 1  Insertion of Endo-Prosthesis Stage 2  Attachment of Exo-Prosthesis

16 Stage 1 Stage 2

17 Integral Leg Prosthesis (ILP) System This video has been removed from the presentation due to size. It can be viewed at: (original hosts) php (YouTube hosted) php

18 Stage 1 Endo – Prosthesis 6/52 Later 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

19 A 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 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

22 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

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

24 Rehab Process Gradual vertical loading

25 Rehab Process Core & limb strengthening

26 Rehab Process Generally, when at 80-90% WB, Prosthetist fits prosthesis

27 Rehab Process Prosthetic adjustments

28 Rehab Process Gait Retraining

29 Rehab Process Knee-specific training

30 Rehab Process Stoma care AVOID falls, rotational forces, infection

31 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

32 Case Study 1: J- Socket Prosthesis This video was removed due to its size. It can be downloaded from: 1_J-SocketProsthesis.mp4 1_J-SocketProsthesis.mp4

33 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 1_J-Day1-ILP.mp4 1_J-Day1-ILP.mp4

34 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

35 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: J-Discharge1.mp4 J-Discharge1.mp4 J-Discharge2.mp4 J-Discharge2.mp4

36 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

37 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: A-Day1-ILP1.mp4 A-Day1-ILP1.mp4 A-Day1-ILP2.mp4 A-Day1-ILP2.mp4 A-Day1-ILP3.mp4 A-Day1-ILP3.mp4

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

39 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

40 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: D-Day1-ILP.mp4 D-Day1-ILP.mp4

41 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

42 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: D-Discharge.mp4 D-Discharge.mp4

43 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

44 Case Study 4: M – X-Ray

45 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: M-SocketProsthesis.mp4 M-SocketProsthesis.mp4

46 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: M-Day1-ILP.mp4 M-Day1-ILP.mp4

47 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

48 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: M-Week3-ILP.mp4 M-Week3-ILP.mp4

49 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: M-Discharge.mp4 M-Discharge.mp4

50 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


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