1. (aka Osseointegration)
Osteointegration
(aka Osseointegration)
Present topic and relevance to PT (the cases, what it is, causes, prevalence, how it works, who it affects, clinical ramifications etc.
12 mins 3 mins questions
Just from looking online, I think that osteointegration and osseointegration are the same thing, so I think we are good!
Also, I searched Osseointegration on the APTA and got two results, but you have to be a member to view them...

2. What is Osteointegration?
A direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant.
There is no progressive relative movement between the implant and the bone with which it has direct contact.
Daniel

3. How did osteointegration start?
First used in dental implants
Bone is directly attached to implant
Alex
This method is years old
Fun Fact: the man who originally developed this technique is from Sweden (Branemark)...his son is the one who took the technique and applied it to prosthetics (keeping it in the family)

4. How does this apply to P&O?
Process of Osteointegration :
Surgery #1: limb is amputated and implant is fitted into medullary canal
Surgery #2: incision is reopened, and the external component of the implant that protrudes from the skin is placed
The external component is then used to connect to the external prosthetic limb
Alex
Note: In 1990, Rickard Brånemark, MD, PhD, and his colleagues became the first to achieve clinical success with this procedure.
P&O in Clinical Practice Book
Maybe show this video?

5. Why do we use Osteointegration?
Provides an alternative for people who cannot use conventional socket prostheses.
Daniel Http
Daniel ://

6. Indications for Osteointegration
Recurrent skin infections and/or ulceration in socket contact area
Short residual limb
Volume fluctuation of the residual limb
Soft-tissue scarring
Extensive skin grafting
Socket retention problems due to excessive perspiration
Heterotopic bone ossification that cannot be managed with modification to the socket
Daniel sp

7. Benefits of osteointegration for prosthesis
The prosthetic attachment:
Does not apply pressure to the soft tissue of the residual limb
Does not loosen with perspiration
Can be performed on residual limbs too short for sockets.
Alex
Image: s&tbm=isch&sa=X&ved=0ahUKEwiwtaKptN3NAhVL8mMKHUPHDXQQ_AUIBigB#tbm=isch& q=osseointegration+x-ray&imgrc=ZclbFjwAuLS7aM%3A

8. What goes into using an osteointegrated prosthetic?
Safety mechanisms - to protect the bone/implant interface.
The Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) uses a RotaSafe as a connection and safety device designed to protect the osseointegrated implant from excessive rotational forces.
Soft tissue supports - to minimize motion and consequent inflammation around the skin/implant interface (often made of Zirconia or titanium).
Acts as a buffer between skin and prosthetic
Daniel sp
The Axor will replace the RotaSafe when it becomes commercially available. More mobility options, but also more torque resistnace.
Axor protects the bone/implant interface from both rotational and bending forces and does not require a tool for donning and doffing the prosthesis.
For this slide and the next slide, how can we incorporate this info into a presentation- friendly format?
Also, let’s take a look at this! It might give us a few additional resources
Track2.pdf

9. Tools involved in osteointegration for prosthetic attachment
Patients use a tool (5mm Allen key) to don and doff the prosthesis from the RotaSafe.
The alignment process is the same for people with osseointegrated implants and people with sockets.
The exit angle of the implant would affect the definitive alignment.
Daniel

10. But does it actually work?
There are three groups abroad who have performed and published clinical studies:
The Swedish Group:
Prosthetic use, prosthetic functions, and global quality of life were all significantly improved and prosthetic problems were reduced.
Results from the Questionnaire for Persons with a Transfemoral Amputation demonstrated relief from prosthetic problems, with respondents reporting increased comfort when sitting with a prosthesis and reduced heat and sweating on the residual limb.
The UK Group:
This group published a case study on a transhumeral amputee using an implant they call intraosseous transcutaneous amputation prosthesis
Surgeons performed the implantation in one surgery. Rehabilitation after surgery took approximately ten months. The procedure improved the patient's range of motion and arm function. After a two-year follow-up, the patient reported no infection.
Daniel sp

11. But does it actually work?
The German Group
The implant is called the Endo-Exo-Femur Prosthesis and requires a two-stage surgical procedure.
Rehabilitation usually takes between ten and 14 months with this procedure.
Between 1999 and 2010, this group treated 54 patients.
Thirty-two out of 54 had revisions, mainly due to soft-tissue problems caused by the implant protruding through the skin. The latest design reduced revisions. None of the recipients of the last 24 procedures have shown evidence of infection in the two years following the operations
Daniel

12. Osteointegration in the US
Osteointegration was approved by the FDA one year ago
UCSF was the first medical center in the US to proceed with the Osseoanchored Prosthesis for the Rehabilitation of Amputees (OPRA) Program
Walter Reed National Military Medical Center
Department of Defense Osteointegration Program
Goal: Make the technology available for:
Military personnel with combat-related injury
Limb loss secondary to tumors
Civilian Trauma
Alex
UCSF=University of California San Francisco
The first procedure was completed the first pt in May, and the second procedure is to be performed in the fall
This might also be a useful article to mention...the first center in the US to have an OPRA program, and it was from this year!
--Walter Reed
--DOD

13. Risk Factors? Infection Bone Loss from stress-shielding of bone
Stress shielding refers to the reduction in bone density (osteopenia) as a result of removal of typical stress from the bone by an implant (for instance, the femoral component of a hip prosthesis).
Bone Fractures
Complications like these may lead to revision surgeries where a new implant is inserted and rehabilitation must be repeated
Alex
Stress Shielding: osteopenia of bone b/c force through prosthetic-implant-bone is different from force through natural limb-->Wolff’s Law of decreased stress-->bone will become weaker sp

14. Clinical Ramifications
Osteointegration makes ambulation possible for patients with potentially more severe amputations (i.e. shorter residual limbs)
Similar exercises needed for a patient with a traditional prosthetic, but we must consider how the load through the bone changes:
Stress shielding → osteopenia?
Possible changes in gait, depending on the patient, length of residual limb, etc.
Example of Exercises to do with a patient:
Daniel sp
I found this case study article that has a section on the rehabilitative process of a bilateral osseointegrated prosthesis fixation, the result is an increased QOL
Ooh look at this one too! It even has PT pictures!!
“The goals of physical therapy with the external limb prosthesis were to improve endurance and strength while continuing to work on balance. A prescribed exercise program with the prosthesis was designed to work through gait on level surfaces, uneven surfaces, stairs, and curbs with a long-term goal of ambulation without any assistive device.”
And perhaps if there is time, we could also show a couple minutes of this!

15. Case Study: Meet our Patient
Patient: 65 y.o. Female healthcare worker
Received osteointegration implant for R femur
Had no significant complications from surgery
Completed intensive therapy program before receiving prosthesis
Continued with physical therapy after receiving prosthesis
What types of exercises would be good for our patient pre-prosthesis?
What exercises would be good post-prosthesis?
Alex
Include initial eval, why pt was qualified for osteointegration surgery, any functional outcome measures
A few surgery points to mention: pain managed by hydrocodone, ceased by 5th wk; phantom limb pain resolved before 2nd surgery; drainage around stoma; pt experienced emotional distress/anxiety during recovery from 2nd surgery, but was informally counseled by a peer who had same surgery previously

16. Case Study: Pre-Prosthetic Coupling Goals
Maximize residual limb strength & flexibility
Maximize sound limb strength, flexibility
Improve overall balance & proprioception
Increase aerobic capacity
Alex
--Residual limb strength: Isotonic hip abduction and extension exercises with resistance applied through cuff weights or TheraBand™ in both the laying and standing
--Sound limb strength: resistance exercises on the leg press
--Balance: single limb standing on both stable and unstable surfaces without upper extremity support to maximize limb proprioception
--Aerobic fitness was improved through a program of upper body ergometry and recumbent cycling.

17. Case Study: Post-Prosthetic Coupling Goals
Gait training on even, uneven surfaces, stairs and curbs
Improve endurance & strength
Improve balance
Long-Term Goal: ambulate without any assistive device and return to work
Alex
4 months following 2nd surgery...
--Took 1st steps in parallel bars w/o problems
--initially reported cramping/pain in hip musculature
--more informal counseling/encouragement from peer (these sensations are normal)
--prosthetic originally set to 0/0 (no rotational or offset correction)
----pt reported feeling medial off-balance sensation during SLS on R side → 5mm lateral offset eliminated this sensation

18. Case Study: What were the Results?
Progressed to using prosthesis at home w/support from furniture or walker
Gait: fluid heel-to-toe motion
Microprocessor unit being trained, but not being used regularly
Pain controlled by NSAIDs
Experiencing “osteoperception”
Daniel
These are the finals results collected for the publication of this paper
“Osteoperception”--skeletal vibrations felt during heel strike of prosthetic on floor (reported in other cases of osteointegration)

19. References
Rosenbaum-Chou (April 2013). Update on osseointegration for prosthetic attachment. The Academy Today: Vol. 9, No. 2. Retrieved from
Mavrogenis AF et al (2009). Biology of implant osseointegration. JMNI: Vol. 9, No. 2. Retrieved from
Hillock RW, et al (June 2014). Osseointegration implant post coupling with external prosthetic limb. JISRF: Reconstructive Review, Vol. 4, No. 2. Retrieved from
May BJ, Lockard MA (2011). Prosthetics & orthotics in clinical practice: A case study approach. Philadelphia: F.A. Davis Company
Scott M (May 3, 2016). Osseointegration surgery at UCSF is first of its kind in U.S. University of California San Francisco. Retrieved from first-its-kind-us.
Here are the other three websites together that we could use! I didn’t include them in references since they aren’t officially in our presentation yet

20. Questions?
Daniel :)