Osseointegration
Naomi Sheerman
Chris Horley
The Hills Private Hospital
Outline
 History of Osseointegration
 Who will Osseointegration benefit?
 Stages of Osseointegration
 The decision-making process
 The surgical process
 The rehab process
 4 Case Studies
 Q&A
History of Osseointegration
 Osseointegration in dentistry started in 1965 with Professor PerIngvar Brånemark.
 In 1995 in Sweden, Brånemark (son) performed the first
transcutaneous femoral intramedullary prosthesis on an above
knee amputee with a 12cm screw-fixation titanium threaded
device. A non-weight bearing period of 6 - 12 months was
enforced to allow proper osseointegration.
 Germany 1999 Horst Heinrich Aschoff – femoral cement-free
spongiosa implant
 OPRA – Osseointegrated Prostheses for the Rehabilitation of
Amputees – first 2 patients in Australia in 2000, at the Alfred
Hospital, Melbourne.
 About 6 Centres Worldwide that perform osseointegration –
Sweden, Germany, Menime, Holland, Chile, Sydney
OGAAP: Osseointegration Group
of Australia Accelerated Protocol
 Initially only in Macquarie University Hospital – more
recently, 4 at Norwest -> the Hills Private.
 #### patients so far
 Osseointegration Conference Sydney November 2012
 Osseointegration Group of Australia
 Macquarie University Hospital
 Orthodynamics Pty Ltd
Positives of Osseointegration
 Improved fit - the stump, which often fluctuates in volume
and shape, is not forced into a predetermined form
 Speed – the exo-prosthesis can be attached and removed
completely within a few seconds when seated.
 No skin irritations due to friction, sweat or heat, meaning the
prosthesis can be worn for longer periods without pain or
discomfort
 Less restrictions on clothing
 No movement – the prosthesis doesn’t need to be adjusted
during the day such as getting out of a car
Positives
 More normalised mechanics, no pivoting and pistoning.
Development of “normal” muscle tone + muscular strength ->
greater control and less effort -> reduced energy consumption
 ROM is not restricted by the interfering edges of a prosthesis
regardless of whether you are sitting, standing or walking
 Lighter components and improved perception of weight
 Greater proprioception with the ground than with
conventional prosthesis
 Reduced phantom pain
 No need to continually replace sockets -> cost-saving
 Can sit on the toilet!
Negatives
 Cost
 Permanent stoma: risk of infection
 Swimming: public pools
 Mechanical failure following a fall ->
fracture or loosening, fear of falls
 ?? High impact activities
 Weight loading through the femur -> hip
joint integrity, bone mineral density
 ?? Lifespan
Who will Osseointegration benefit?
 Problems with socket
 Pain / Rubbing
 Skin breakdown / surgical intervention
 Stump size fluctuations
 Falling off!!
 Getting stuck on!
 Weight of componentry
 Restriction / Limitations on clothes
 Impact on ADL’s and QOL from limited prosthesis use
 Prosthetic user with nothing to lose / everything to gain
 Money  very expensive surgery
Stages of Osseointegration
 Decision & Planning
 Surgery
 Stage 1
 Stage 2
 Loading
 Prosthetic training
Decision-making Process
 Information online + online enquiry form
 http://www.osseointegrationaustralia.com.au/
 Questionnaire




Pain
Current activity levels
Prosthetic comfort / fit
Goals
 Osseointegration Clinic:
 Meet & Greet, Q&A with peers and patients who
have had osseointegration
Decision-making Process
 Multidisciplinary Concurrent Assessment





Surgeon
NUM
Prosthetist
Rehabilitation Speciailist
Physiotherapist
Team need to approve
surgery candidate must
be appropriate
 Clinical Psychology Assessment
 No advice given as to whether to have the surgery or
not – impartial facts given
Decision-making Process
Assessment Includes:
 Time and cause of amputation
 “k” classification and exercise tolerance
 General health
 Psychological wellbeing / motivation
 Family and support network
 BMI
 Core and pelvic strength
 Pelvic dysfunction
 Hip ROM
 Hip strength
Planning Process
 Orthopaedic Planning
 CT measurements
 BMD measurements
 Custom made implant
 Prosthetic Planning
 Not to wear prosthesis for 6/52 preop to rest the stump
and allow any skin abrasions to heal
Surgical Process
 Two Stages
 Stage 1 Insertion of
Endo-Prosthesis
 Stage 2  Attachment of
Exo-Prosthesis
Stage 1
Stage 2
Integral Leg Prosthesis (ILP)
System
This video has been removed from the presentation due to
size. It can be viewed at:
 http://www.osseointegrationaustralia.com.au/ (original
hosts)
 www.austpar.com/portals/acute_care/osseointegration.
php (YouTube hosted)
The Prosthesis
 The Integral Leg Prosthesis:
Stage 1
Endo – Prosthesis
6/52
Later
Stage 2
Exo- Prosthesis
 PatentedSpongiosa-Metal® II surface. Osseointegration occurs
within this three-dimensional grid structure, providing secure
fixation of the prosthesis.
The Prosthesis
 A dual adapter connects the endo and exo Prosthesis.
 The silicone cover is used to protect the stoma. The
cone sleeve and the rotation disc serve as connection
for the knee-lower leg prosthesis system.
 All other components (height adjusters, spinners) can
be quickly and easily connected to the Endo-prosthesis
using the knee connection adapter – tightened with an
allen key.
After Stage 1








Bed rest
Analgesia
Ice
Oedema management taught
self lymphatic drainage
Mobilise with crutches for 6/52
Monitor for hip contractures
Hip strengthening exercises
TA + pelvic control exercises
After Stage 2








Bed rest
Analgesia
Stoma management / hygiene
Minimum Day 5 Post-op commence
loading
Maximal axial loading of 20 kg for
30 mins x 2 / day
Progress 5-10 kg per day
Once at 50 kg or 80 – 90% body weight
commence dynamic loading through
prosthesis
PWB for 3/12 post stage 2
Rehab process
 Gait re-training
 Prosthetic adjustments
 Knee-specific training
 Stomal care
 AVOID falls, rotational
forces, infection
Rehab Process
 Gradual vertical loading
Rehab Process
 Core & limb strengthening
Rehab Process
 Generally, when at 80-90% WB, Prosthetist fits prosthesis
Rehab Process
 Prosthetic adjustments
Rehab Process
 Gait Retraining
Rehab Process
 Knee-specific training
Rehab Process
 Stoma care
 AVOID falls, rotational forces, infection
Case Study 1: J
 32 y.o. male
 Bilateral AKA – Car Accident – 2003
 Wore socket prosthesis intermittently over past 9 years
 Discarded previous prostheses due to discomfort
 Prostheses: Genium
 Previous mobility  Prosthesis with crutches / walking sticks or
wheelchair
 Goals :
to walk with 1 x walking stick / unaided
To take their dog for a walk
Case Study 1: J- Socket Prosthesis
This video was removed due to its size. It can be
downloaded from:
 www.austpar.com/portals/acute_care/videos/CaseStudy
1_J-SocketProsthesis.mp4
Case Study 1: J- Day 1 ILP
 This video shows J walking, day 1 with ILP.
 The video was removed due to size, and can be found at
www.austpar.com/portals/acute_care/videos/CaseStudy
1_J-Day1-ILP.mp4
Case Study 1: J
Challenges
 Bilateral Amputee
 Previous brain injury
 not responded well to physios in the past
 Back / Hip / Leg / Bone pain
 Self funded + international patient
 Height adjustment of prosthesis
 Shoes
Case Study 1: J - Discharge
 Two videos demonstrating J’s gait at discharge.
 The videos were removed from the presentation due to
size, but can be found at:
 www.austpar.com/portals/acute_care/videos/CaseStudy1_
J-Discharge1.mp4
 www.austpar.com/portals/acute_care/videos/CaseStudy1_
J-Discharge2.mp4
Case Study 2: A
 39 y.o Feale
 Hit by car 2 years ago
 Left AKA
 Phantom pain+++ related to bowel function and preventing functional
prosthetic use
 Prosthesis: C-Leg
 Post MVA mobility  Canadian Crutches
 Post traumatic stress & not returned to work
 Goals :
use a prosthesis without pain
to participate more in kids’ lives
Case Study 2: A – D1 ILP
 These videos shows A walking, day 1 with ILP.
 The video was removed due to size, and can be found
at:
 www.austpar.com/portals/acute_care/videos/CaseStudy2_
A-Day1-ILP1.mp4
 www.austpar.com/portals/acute_care/videos/CaseStudy2_
A-Day1-ILP2.mp4
 www.austpar.com/portals/acute_care/videos/CaseStudy2_
A-Day1-ILP3.mp4
Case Study 2: A
Challenges
 Piriformis and gluts tenderness
 Phantom pain
 Fatigue
 Stomal infection after discharge home -> AB’s
Case Study 3: D
 29 y.o Male
 MBA 5 years ago: trail bike on private property
 Right AKA
 Wore socket prosthesis for ~ 3 months
 Discarded previous prosthesis due to discomfort
 Prosthesis: C-Leg
 Post MBA mobility  Axillary Crutches
 Goals :
walk without walking aids
to walk holding kids’ hands
Case Study 3: D- Day 1 ILP
 This video shows D’s gait on Day 1 with ILP.
 The video was removed due to size, but can be found
at:
 www.austpar.com/portals/acute_care/videos/CaseStudy3_
D-Day1-ILP.mp4
Case Study 3: D
Challenges
 Alignment
 Tight hip flexors
 Poor hip extensors
 Poor Core Strength
 Minimal weight bearing through prosthesis
  confidence with prosthesis
 Varying gait patterns
 Self funded / Money
Case Study 3: D - Discharge
 This video shows D’s gait pattern at discharge.
 The video was removed from the presentation due to
size, but can be found at:
 www.austpar.com/portals/acute_care/videos/CaseStudy3_
D-Discharge.mp4
Case Study 4: M
 25 y.o. female
 R AKA
 Congenital Amputation at 18 months


Malformation of Right Hip joint
Malformation of thumb  index finger transplanted to thumb at ? 8 y.o.
 Highly functioning socket prosthetic user
 Unaided prior to operation
 Prosthesis: 3R60
 Goals :
Return to normal life
To climb a mountain
Complete 5 or 10 km fun run (walking)
Wear high heels
Ride a road bike
Case Study 4: M – X-Ray
Case Study 4: M-Socket Prosthesis
 This video shows M’s gait pattern with a socket
prosthesis.
 The video was removed due to size, but can be found
at:
 www.austpar.com/portals/acute_care/videos/CaseStudy4_
M-SocketProsthesis.mp4
Case Study 4: M- Day 1 ILP
 This video shows M’s gait pattern day 1 with ILP.
 The video was removed due to size, but can be found
at:
 www.austpar.com/portals/acute_care/videos/CaseStudy4_
M-Day1-ILP.mp4
Case Study 4: M
Challenges
 Congenital under development
 Lack of Hip Joint / ROM / Strength
 Expectations
 Psychological Issues
 Componentry
 Hip Pain
 Limitations of stoma: swimming
 Limitations on assistance
Case Study 4: M – Week 3
 This video show M’s gait pattern at week 3.
 The video was removed from the presentation due to
size, but can be found at:
 www.austpar.com/portals/acute_care/videos/CaseStudy4_
M-Week3-ILP.mp4
Case Study 4: M - Discharge
 This video show M’s gait pattern at discharge.
 The video was removed from the presentation due to
size, but can be found at:
 www.austpar.com/portals/acute_care/videos/CaseStudy4_
M-Discharge.mp4
Acknowledgements
 Dr Al Muderis and the Team at Macquarie University Hospital:





Sarah Benson, Physiotherapist
Jennifer, NUM
Dr Simon Chan, Rehab Consultant
Stefan Laux, Prosthetist, APC
Chris Bastien, Clinical Psychologist
 Team at Norwest Private Hospital:
 Natalie Tymoc-Campbell, Physiotherapist
 www.almuderis.com.au/osseointegration
 http://www.osseointegrationaustralia.com.au