Post on 04-Feb-2018
DEPT. ORTHOPAEDIC SURGERY, PHYSICAL MEDICINE AND REHABILITATION
UNIVERSITY HOSPITAL GHENT BELGIUM
Dr. Wim Vanhove , Dr. Sofie Vertriest, Dr Sybille Geers
Prof J. Victor , Prof G. Vanderstraeten, Dr. S. Rimbaut
17/06/ 2016
Amputee rehabilitation program partim
Bionic reconstruction (OI – TMR )
Zorgproces AMPUTATIE met vaste actoren (exclusief tenen en vingers : zie diabetische voet en handchirurgie)
BASIS AMPUTATIE ZORG volgens protocol STOMP REVISIE CHIRURGIE / KLASSIEKE RECONSTRUCTIE
BIONISCHE RECONSTRUCTIE OI (Osseo-integratie) : transfemoral - transhumeral TMR (Targeted Muscle Reinnervation ) : elleboog amputatie en hoger
HAND TRANSPLANTATIE potentieel voor bilaterale distale onderarm amputatie
- Stump revision surgery
osteoplastic procedures adductorplasty neuroma surgery soft tissue revision – ‘stump lift’
- Reconstructive surgery free vascularised toe transfer
free flap surgery …
Vilkki
Marquardt humerus
Morrison
ALT
Titanium anchors prosthesis securely
First TRA in 1992
osseointegration
Preserves active ELBOW ROM
presented in 1998 …
“can I have the Swedish prosthesis ?”
Issue 1995
Long rehab
FEATURES that mattered to us
OPRA
MOST EXPERIENCED and RESEARCHED SYSTEM development in 50’s , 1965 teeth, 1977 ear, 1990 limb,
STANDARDISED since 1999
PATIENT SAFETY - Maximum bone stock preservation
implant short (6-8 cm) and minimally agressive
- Efficient exteriorisation technique : implant contained in living bone - Bone covered by thin and immobile skin perforation zone stable and dry (= non inflamed)
COMPLICATIONS MANAGEABLE
‘back to start’ possible (also ‘redo’ ) - NO reamputations VERSATILITY very short stumps + osteoporosis COMBINATION with implant electrodes (TMR & sensory)
Free ROM of both shoulders In full control of exoprosthesis
pre
post
male , born 1993 injury nov. 2008
OI 2010 - 2011
picture 2012
only 1 myosignal …
viaGOOGLE:‘osseoïntegra3eugent’
15 – 18 mos
T. Kuiken , Chicago, 2002 O. Aszmann, Vienna , 2006
‘Targeted muscle reinnervation’ - TMR
treatment of Neuromas & Phantom pain by plexular reafferentiation surgery
Ottobock, 2010 Dynamic Arm
6 DOF
More & better (‘orthorepresentative’ ) myosignals
In amputation at elbow or more proximal
- ROUTINE for all PRIMARY AMPUTATIONS as delayed procedure (within 6 to 9 mos of trauma)
- As ELECTIVE procedure within BIONIC RECONSTRUCTION ( less than 10 yrs following amputation, pref. < 5 yrs )
viaGOOGLE:‘tmruzgent’
DON’T RESECT loose nerve ends !
TMR = only way to fit functional prosthesis in glenohumeral / forequarter amputation 6 electrodes
Courtesy Dr O.Aszmann Vienna
Incidence of limb amputation by level (A. Esquanazi – 2004)
UEA LEA
ca 15-30 per year in Belgium ? major UEA Upper Extremity Amputation
TMR
OI
♂ – °1993 RTA april 2013 THA – dominant side
Very short stump Ipsilateral brachial plexus lesion
Deltoid muscle palsy No triceps & biceps Recovered supra- & infraspinatus Good pectoral & Lat dorsi
h"p://deredac+e.be/cm/vrtnieuws/videozone/programmas/journaal/2.40948?video=1.2439797
Suspension difficult Loss of shoulder ROM Unstable electrode contact Difficult control of
prosthesis
2 Myo Signals Pect M & L Dorsi
TMR - the principle
TMR - the principle
TMR - the principle
Targeted muscle reinnervation
TMR - the principle
TMR treatment cycle Referal by physician in rehabilitation medicine or by surgeon
SELECTION : Ergo - rehab & prosthetic assessment / EMG – NCV – MEP – US counseling psychiatry/psychology radiology (MRI – fMRI ) Coordination & financial planning of treatment
SURGERY
REHAB
FOLLOW UP
0 – 3 m reinnervation
imaginary recruitment general rehab
3 – 15 m signal training praxis of signal transfer
12 – 24 m prosthesis training prosthesis assembly & fitting
Rehabilitation 1. phase of radio silence
Experiment every action
Rehabilitation 2. Muscle twitching ( 10-15 wks )
bilateral training to recruite increase duration of contraction &
number of repetitions
Rehabilitation 3. Signal finding & training
(as from 3-6 mos ) patterns → discrete muscle contractions
– which command best signal ?
separation of signals
practice with training socket + trial prosthesis
4 . Final prosthetic fitting
12-18 mos
attachment socket - OI components – terminal device
Casus: EMG 5 mos Good control 10 mos
Training ADL
Training socket ( signals move and vary in time )
TMR 4 DoF
Utah arm 1000 g (myoelectric elbow)
Battery 230 g Myoelectric hand 515 g -------------
Total weight 1745 g
Ergo arm plus 600 g (mechanic elbow) Battery 50 g Myoelectric hand 515 g ------------Total weight 1165 g
more & better signals for seamless sequential and simultaneous intuitive control
Improved functional motor outcome
on average 198% motor improvement over standard prostheses (Agnew, Kuiken 2011)
Prevention of neuroma & phantom pain ± 25% of all major limb amputees develop chronic localized pain due to
neuromas in the residual limb
In Traumatic amputations as high as 71% (Souza, Kuiken, 2014)
But : TMR induces temporary increase in phantom limb pain
www.ric.org/research/centers/bionic-medicine/newscbm/
TMR
OI + TMR 15 – 18 mos 18 mos
20 mos
r T r S1 r S2 r
} TMR
OI S1 OI S2
NEXT
TMR in other amputation sites
- in LEA for neuroma & phantom pain
- UEA below elbow also for improved prosthetic control
Courtesy B. Loeffler
Posterior aspect long TFA
NEXT
Aszmann et al., The Lancet, Feb. 2015
TMR in other pathology e.g. Brachial plexus with C8-T1 avulsion but
reasonable recovery C5-6(-7) : ‘useless hand’
Courtesy Dr O.Aszmann Vienna
not so distant FUTURE
BETTER Myo signal transfer
Blue tooth implant myo-electrodes IMES
coil
not so distant FUTURE
SENSOR HAND implant electrodes
presented at IASPT , Chicago, May 2016
not so distant FUTURE
BETTER Myo signal transfer implant myo-electrodes coming out via abutment
DEPT. ORTHOPAEDIC SURGERY, PHYSICAL MEDICINE AND REHABILITATION
UNIVERSITY HOSPITAL GHENT BELGIUM
osseointegratie @ ugent . be t m r - rehabilitation - amputee @ ugent . be
01/12/ 2015
Amputee rehabilitation program partim Bionic reconstruction
(OI – TMR )
Dr. Wim Vanhove , Dr. Sofie Vertriest, Dr Sybille Geers