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Osseo-Integrated Prosthesis for amputation
- 1. 1 Osseo-Integrated Prosthesis (OIP) Dr JoeAntony Physical medicine and rehabilitation
- 2. 2 Contents Introduction Implantmaterial Physiology of Osseo-Integration Implants Complications Rehabilitation Protocol Indications Advantages and disadvantages Contraindications Socket mounted vs OIP Functional evaluation of OIP Future directions
- 3. 3 Introduction Osseo-Integrated Prosthesis-An external prosthesis directly attached to appendicular skeleton transcutaneously by osseointegration using an intramedullary implant. Osseointegration- Direct bone anchorage to an implant body that can provide a bone foundation to support prosthesis. Pioneer design by Per-Ingvar Branemark, Professor of Biotechnology, university of Goteborg, Sweden. First human experiment 1990 in Sweden
- 4. 4 Implant material Factors deciding material Tissue reaction – Foreign body reaction Bio film formation- Glycocalyx biofilm formed by Gram positive bacteria preventing antibiotic penetration in conventional materials. Materials suited- Titanium and Chromium- cobalt- Molybdenum Advantages of Titanium Inert to corrosion (titanium oxide film on implant) Reduces foreign body reaction by deactivating inflammatory cells Doesn’t let biofilm to settle Titanium stimulate stem cells to differentiate to osteoblasts (improve osseointegration)
- 5. 5 Physiology of Osseo- Integration Initially,Woven bone formation over interphase- immature connective tissue over which a thin layer of bone is laid down Final phase- about 4 months of implant placement- lamellar bone formation Currently implant surface is coated with osteoconductive hydroxyapatite – stimulates bone growth into coating
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- 7. 7 Osseo Integrated Prosthesis for Rehabilitatio n of Amputee (OPRA) Introducedin 1998 Titanium with hydroxyapatite porous coating 3 parts 1. Fixture- threaded cylindrical implant that interdigitates into the stump bone. 2. Abutement- percutaneous component that press fits to the distal end of fixture 3. Abutement Screw- Connect fixture to abutement Minimum 12cm bone length is required for its fixation Suited for long bones and digits Weight bearing after 3 to 18 months
- 8. 8 Osseo Integrated Prosthesis for Rehabilitatio n of Amputee (OPRA) TwoSurgical Stages I. Fixture is fixed to medullary canal of stump bone. Left for 6 months for soft tissue closure and bone graft incorporation Can mobilize with socket mounted prosthesis with protection to implant II. A stoma is created for abutement to be fixed to fixture
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- 10. 10 OPRA For thumb amputation- Providespincer grasp as well as sensation through Osseo- perception
- 11. 11 Osseo- Perception Osseo-Perception isthe term used to describe the ability of patients with Osseo-integrated fixtures to identify tactile thresholds transmitted through their prostheses. Various studies have suggested the measured perception of vibration with an osseointegrated amputation prosthesis in place was generally comparable to that of the normal contralateral hand or foot.
- 12. 12 Rehabilitatio n protocol after OPRA Phase1 – management of pain and swelling Gentle residual limb massage for lymphatic drainage Positioning and strengthening exercises
- 13. 13 Rehabilitatio n protocol after OPRA Phase 2 – Prosthetic fitting and progressive weight bearing. Progressive weight bearing by axillary crutches followed by Canadian crutch Gait training with parallel bar Gradual increase in prosthetic time
- 14. 14 Rehabilitatio n protocol after OPRA Phase 3- Definite prosthesis
- 15. 15 Stoma Care Dailycleaning and covering with a clean gauze and cover with a silicone cap.
- 16. 16 Wet Stoma vs DryStoma Frölke JP, Leijendekkers RA, van de Meent H. Osseointegrated prosthesis for patients with an amputation : Multidisciplinary team approach in the Netherlands. Unfallchirurg. 2017 Apr;120(4):293-299.
- 17. 17 Other OIPs Integral leg prosthesis (ILP) Osseointegr ated Prosthetic Limb(OPL) IntraOsseous Transcutaenous Amputation Prosthesis (ITAP) Percutaneous Osseointegra ted Prosthesis (POP_ Material Cobalt Chromium Molybdenum Titanium Titanium Titanium Retention Press Fit Press Fit Press Fit Press Fit Anatomic Suitability Long bones Long Bones, Pelvis Femur Humerus,Fem ur Bone implant Interface Czech Hedgehog Plasma sprayed Porous coated Hydroxyapatit e Surgical Stages 2 1 2 1 Months from implant to full 2-3 2-3 Unspecified Unspecified
- 18. 18 Integral Leg Prosthesis juhnke DL,Beck JP, Jeyapalina S, Aschoff HH. Fifteen years of experience with Integral- Leg-Prosthesis: Cohort study of artificial limb attachment system. J Rehabil Res
- 19. 19 Indications Very shortstump Recurrent skin infection and ulceration Soft tissue scarring Volume fluctuation of stump Extensive skin scarring or grafts Skin allergies Conventional socket intolerable- Discomfort, pain, Poor suspension and excessive perspiration Age group 18-70 years
- 20. 20 Advantages vs Disadvantag es Advantages Disadvantages Osseo perception (Abilityof patients with OIPs to identify sensory thresholds through prosthesis) Poor availability No Socket fitting issues Expensive No issue with excessive perspiration Unexplained vague pain Skin irritation and pressure sores eliminated Osteomyelitis risk Easy donning and doffing
- 21. 21 Contraindicatio ns Age morethan 70 years Body weight more than 100 kg Severe PVDs Diabetes Osteopenia and osteoporosis Pregnancy Corticosteroid and immunosuppressant drug use Ongoing Chemotherapy Skeletal Immaturity Irradiated limbs Mental illness Questionable compliance
- 22. 22 Socket Mounted vs OIP Psychologicalbenefit- Patient feels the prosthesis is “part of me” Gait parameters- Duration of gait cycle, cadence etc is more close to normal people in OIPs compared to Socket mounted. Compliance- Prosthetic Compliance is much better in OIPs. Socket related problems negated- Skin problems, Balance issues, alignment issues, Degenerative arthritis due to malalignment ,skin break down etc
- 23. 23 Functional Evaluation of OIP Q-TFA-Questionnaires of persons with transfemoral amputation SF36- Short form 36 6 Minute Walk test Time up and Go test (TUG) Physiological cost index
- 24. 24 Future of osseointegrati on Currentresearch is directed towards OIPs for higher level amputations like hemipelvectomy or hip disarticulation. Techniques to prevent infections.
- 25. 25 Reference IAPMR textbookof PMR Juhnke DL, Beck JP, Jeyapalina S, Aschoff HH. Fifteen years of experience with Integral-Leg-Prosthesis: Cohort study of artificial limb attachment system. J Rehabil Res Frölke JP, Leijendekkers RA, van de Meent H. Osseointegrated prosthesis for patients with an amputation : Multidisciplinary team approach in the Netherlands. Unfallchirurg. 2017 Apr;120(4):293-299.