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