OSSEOINTEGRATION FOR AMPUTEES SCGH SERVICE and REHABILITATION

Beck Hefferon

Snr Physiotherapist Amputee Rehabilitation

Sir Charles Gairdner Hospital, WA

What is it? Benefits and Risks Different Systems Who it is for SCGH Service

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.

Implant systems OPRA - Sweden OGAP-OPL - Australia

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

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.

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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