osseointegration for amputees - subacute care · osseointegration for amputees at scgh . selection...
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OSSEOINTEGRATION FOR AMPUTEES SCGH SERVICE and REHABILITATION
Beck Hefferon
Snr Physiotherapist Amputee Rehabilitation
Sir Charles Gairdner Hospital, WA
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What is it? Benefits and Risks Different Systems Who it is for SCGH Service
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What is Osseointegration? • From Latin ossum "bone" and
integrare "to make whole"
• Direct structural and functional connection btw living bone and the surface of a load-bearing artificial implant.
• Invented in Sweden by Per-Ingvar Branemårk 1952 for dental implants
• Rickard Branemårk first to carry out surgery in amputees
• For amputees - functional prosthetic limb can be connected directly without a socket.
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Implant systems OPRA - Sweden OGAP-OPL - Australia
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Benefits • Improved Quality of Life due to;
• Increased range of motion improves gait efficiency
• Eliminates socket pain and skin breakdown
• Eliminates weight/volume change & sweating problems
• Quick, easy & accurate attachment and detachment
• Improved ‘osseo-perception’ (direct sensory feedback via bone)
• All day comfort, even sitting
• Mechanical advantage for short residual limbs
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Negatives
• 2 main risks are Infection and Implant failure
• Permanent ’stoma’ increases infection risk
• Individual- PVD/Diabetes
• External- Poor hygiene, swimming
• High impact activities ↑risk of implant failure -
• Running, contact sport
• Long rehab programme; 6-18 mths commitment
• Cosmesis- extrusion of implant is permanent.
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Who is suitable and who isn’t?
Those unable to use a socket prosthesis Over 18yrs/skeletal maturity No diabetic or vascular pathology (?) Body Weight <100 kg Adequate bone density Cognitively, physically and medically suitable for surgery Compliant with Rehab protocol
Major comorbidities/musculoskeletal disease Obesity (>100kg) Insufficient bone density Insufficient physical capacity Significant joint contractures Psychological, behavioural or social red/yellow flags
compromise ability to comply with restrictions of rehab & life with an OI implant
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How is Surgery Performed? • Traditionally 2 stages; in stage one
• Surgery 1: bone implant » 6mths to heal (osseointegration)
• Surgery 2: Stoma created & endo-exo prosthetic connector attached » 4-6 wks to heal
• Rehabilitation » Progressive loading through short then full length prosthesis follows
• Single stage surgery (1&2 combined) is becoming more common- not yet in WA
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Interim Rehab
Amputee Rehab Initial Assessment
Patient screening and education
Pre op Physio – strengthening, baseline OMs Psych, Prosthetic OT screening
Surgical Planning- Ortho OMs, XR, Bone density test
S1
REHAB 1- 3-6mths
No prosthetic mobility, Physio to ↑trunk/hip stability/mobility
Full wound Healing
S2 Creation of stoma and permanent attachment stem for prosthetic limb
REHAB 2 6-12mths
4-6 wks Healing
Gentle AROM, torso stability ex Repeat OMs. Prosthetic Prescription
Short prosthesis loading NO rotation! →to long prosthesis once 80% bodyweight tolerated ~ 4mths 2ECs.
Orthopaedics and Infectious Diseases monitoring
Orthopaedics
Transition to 1 EC as tolerated Repeat OMs with both 1 and 2 ECs Prosthetic reviews as required
REHAB 3 12-18mths
Orthopaedics F/up, OMs and XR, monitor foe infection
SCGH OI PATHWAY
Advance mobility skills- slopes, stairs Repeat OMs
Orthopaedics F/up, OMs and XR, monitor foe infection
~3mths healing
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Is the amputee interested in OI? • YES-Referral to SCGH Amputee MDT
• →Does the person meet selection criteria?
• YES- Education on surgical, rehab and prosthetic pathways
• →Does the person wish to proceed?
• YES- Amputee Clinic OI Assessments – Cognition, Psych & QoL and Functional Mobility OMs if
required
• →Referral to Professor Carey-Smith once suitability confirmed
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Orthopaedic OI Team Review attended by Prosthetist and Amputee PT if possible-
1. Surgical suitability confirmed
2. Education: implant systems, pros, cons, risks
3. Surgical plan & timeframe confirmed
4. Rehabilitation Programme explained Patient consents to proceed with OI
5. Surgical plan fed back to Amps MDT
6. Physio, Psych, Prosthetist and OT input as appropriate
7. Patient doesn’t consent →return to standard amputee care
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Timeline 0-6 weeks 6-12 12-18 18-24 30 36>
OI referral
to RCS and
SCGH
MDT
S1 to S2
Rehab phase
1
At SCGH
Rehab phase
2
At SCGH
RC-S and
Amps MDT
follow up
RC-S and
Amps MDT
annual
follow up
Patient
identified
and
eligibility
criteria
met
3-6 months
Can use
socket if pain
free
Short
prosthesis
loading
Long
prosthesis
training
OMs
collected
OMS
collected
annually
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Axial Loading Progression through Short Prosthesis
Loading is then increased under supervision by a max of 10kg a week until 80% to full bodyweight is achieved.
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Extended Physiotherapy • 6mths -12mths: progress to closed chain
exercises, introduce rotation, change of direction, and single crutch support
• Reintroduce alternative surfaces • Stairs • Slopes • Increasing closed chain loads • Stationary bike • Swimming (salt water pool or ocean) if
no infections and prior clearance by RCS
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Follow up
Patient
SCGH Amputee
MDT
Prosthetics
SCGH ID Team
SCGH Pain Team
SCGH Ortho Team
• Annual follow up by SCGH Amps MDT • OMs at 3,6,12,18 mths • Regular monitoring by SCGH
Orthopaedics - OMs at 3,6,12,18 mths • Ongoing prosthetic management as
advised -changes in componentry to be documentation through SCGH Amputee MDT notes
• Established OI recipients eligible for gait retraining and amputee physio through SCGH when required
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Infections
• Most patients will experience infection at stoma site • Most common in first 2 years, most superficial • IMMEDIATE action needed to reduce risk of progressing
to bone • STOP prosthetic use and HEP- NWB until authorised by
Orthopaedic Team • Contact Prof Carey Smith’s Team directly
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Implant Failure
• Implants and components have potential to, come lose, break and fail due to infection, excessive force and general wear
• Connectors have inbuilt safety mechanisms to protect patient’s limb but not invincible!
• Require regular maintenance by prosthetist • IMMEDIATE action to reduce risk of injury/fall- they can fall
out! • STOP prosthetic use and HEP- NWB until authorised by
Orthopaedic Team • Contact Prof Carey Smith’s Team directly
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Complications Checklist • Has patient received education to recognise signs of infection/inflammation?
• Is there increased pain, bleeding or exudate?
• Has the limb become swollen, red, hot/painful to touch or look infected/inflamed?
• Do they have fever or other systemic symptoms?
• Is there abnormal movement or noise within componentry?
• Is their gait affected?
• If the answer is YES to any of above refer directly and immediately to Prof Carey-Smith for review and liaison with ID and pain teams
• Notify SCGH Amputee MDT immediately
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Future Development? • SCGH OI specific Clinic • MDT upskilling initiatives • Introduction of OPRA system?? • Simple checklist guides:
– Pre operative Planning – Surgical and Acute Care – Amputee MDT Care – Prosthetic Management – Rehab Programme – Physiotherapy Protocol – Complications
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Osseointegration for Amputees at
SCGH
Selection Criteria
Contraindications Patient Referral
Patient Education
Surgical Plan Rehabilitation Plan
Long-term Follow up
Action Plan for Complications
• Collaboration between Orthopaedics (surgical) and Amputee MDT Rehab Service
• Supported by OPH YAR, SCGH Pain Services and SCGH Infectious Diseases
• Suitable LL amputees
• 2 year Rehab programme
SCGH SERVICE
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THANK YOU! • The CARE Team at Sahlgrenska University, Sweden
• The Amputee Rehab Team at St Mary’ Hospital , London • The Osseointegration Team at UCSF • Churchill Trust of Australia • SCGH Orthopaedics and Amputee Rehab Team