bionic reconstruction (oi – tmr ) - · pdf filepartim bionic reconstruction (oi –...
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![Page 1: Bionic reconstruction (OI – TMR ) - · PDF filepartim Bionic reconstruction (OI – TMR ) Dr. Wim Vanhove , Dr. Sofie Vertriest, Dr Sybille Geers . Created Date: 6/26/2016 5:33:03](https://reader036.vdocuments.site/reader036/viewer/2022082217/5a76e71c7f8b9a93088d7951/html5/thumbnails/1.jpg)
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 )
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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
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- 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
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Titanium anchors prosthesis securely
First TRA in 1992
osseointegration
Preserves active ELBOW ROM
presented in 1998 …
“can I have the Swedish prosthesis ?”
Issue 1995
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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)
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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
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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
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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 !
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TMR = only way to fit functional prosthesis in glenohumeral / forequarter amputation 6 electrodes
Courtesy Dr O.Aszmann Vienna
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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
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♂ – °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
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Suspension difficult Loss of shoulder ROM Unstable electrode contact Difficult control of
prosthesis
2 Myo Signals Pect M & L Dorsi
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TMR - the principle
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TMR - the principle
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TMR - the principle
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Targeted muscle reinnervation
TMR - the principle
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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
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Rehabilitation 1. phase of radio silence
Experiment every action
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Rehabilitation 2. Muscle twitching ( 10-15 wks )
bilateral training to recruite increase duration of contraction &
number of repetitions
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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
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Training ADL
Training socket ( signals move and vary in time )
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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
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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
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OI + TMR 15 – 18 mos 18 mos
20 mos
r T r S1 r S2 r
} TMR
OI S1 OI S2
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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
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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
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not so distant FUTURE
BETTER Myo signal transfer
Blue tooth implant myo-electrodes IMES
coil
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not so distant FUTURE
SENSOR HAND implant electrodes
presented at IASPT , Chicago, May 2016
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not so distant FUTURE
BETTER Myo signal transfer implant myo-electrodes coming out via abutment
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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