OSSEOINTEGRATION FOR AMPUTEES SCGH SERVICE and REHABILITATION

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1 OSSEOINTEGRATION FOR AMPUTEES SCGH SERVICE and REHABILITATION Beck Hefferon Snr Physiotherapist Amputee Rehabilitation Sir Charles Gairdner Hospital, WA

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

3 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.

4 Implant systems OPRA - Sweden OGAP-OPL - Australia

5 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

6 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.

7 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

8 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

9 Orthopaedics SCGH OI PATHWAY Initial Assessment Patient screening and education Amputee Rehab Surgical Planning- Ortho OMs, XR, Bone density test Full wound Healing Creation of stoma and permanent attachment stem for prosthetic limb Orthopaedics and Infectious Diseases monitoring Orthopaedics F/up, OMs and XR, monitor foe infection Orthopaedics F/up, OMs and XR, monitor foe infection S1 ~3mths healing Interim Rehab S2 4-6 wks Healing REHAB 1-3-6mths REHAB mths REHAB mths Pre op Physio strengthening, baseline OMs Psych, Prosthetic OT screening No prosthetic mobility, Physio to trunk/hip stability/mobility Gentle AROM, torso stability ex Repeat OMs. Prosthetic Prescription Short prosthesis loading NO rotation! to long prosthesis once 80% bodyweight tolerated ~ 4mths 2ECs. Transition to 1 EC as tolerated Repeat OMs with both 1 and 2 ECs Prosthetic reviews as required Advance mobility skills- slopes, stairs Repeat OMs

10 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

11 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

12 Timeline 0-6 weeks > 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

13 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.

14 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

15 Follow up 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 SCGH Ortho Team SCGH Pain Team SCGH Amputee MDT Patient SCGH ID Team Prosthetics

16 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

17 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

18 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

19 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

20 SCGH SERVICE Osseointegration for Amputees at SCGH Surgical Plan Rehabilitation Plan Collaboration between Orthopaedics (surgical) and Amputee MDT Rehab Service Selection Criteria Patient Education Long-term Follow up Supported by OPH YAR, SCGH Pain Services and SCGH Infectious Diseases Suitable LL amputees Contraindications Patient Referral Action Plan for Complications 2 year Rehab programme

21 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