C. A. R. E. Centre for Advanced Reconstruction of Extremities

Transcription

1 C. A. R. E. Centre for Advanced Reconstruction of Extremities TREATMENT WITH BONE-ANCHORED PROSTHESES FOR INDIVIDUALS WITH LOWER LIMB AMPUTATION Sahlgrenska University Hospital/ Mölndal Hospital

2 BACKGROUND Treatment with a direct bone-anchored prosthesis means that the prosthesis is attached without a socket. The method is based on the principle of osseointegration and has been used for the treatment of amputation since Osseointegration means the formation of a direct interface between an implant and bone, and provides a solid anchorage. The direct connection of the prosthesis to the leg is made possible by inserting a titanium screw into the skeleton that will integrate with the living bone. ADVANTAGES Many people with leg amputation experience difficulties using socketsuspended prosthesis. The socket can cause problems with heat, sweating, abrasions, pressure, dermatitis and impaired comfort. The main difference between a conventional socket-suspended prosthesis and a bone-anchored prosthesis is the absence of a socket, which means the prosthesis always fits and always stays in place, safe and stable. Other advantages are better walking ability, improved osseoperception (sensory feedback) and improved sitting comfort. When the residual limb is short it is even more difficult to get a good fit and fastening of a socket. In these cases osseointegration is especially suitable. Overall, bone-anchored prostheses increase quality of life! 1

3 FOR WHOM Above-knee amputation or below-knee amputation Adequate skeleton condition in the residual limb Problems to be experienced with the conventional socket This treatment is not suitable: For children During pregnancy If amputation is due to vascular disease or diabetes For patients with high body weight (about 100kg) For smokers 2

4 OPERATIONS The treatment consists of two operations with a six-month interval. At the first operation (S1), a specially designed titanium screw (a fixture) is screwed into the thigh bone. Hospitalisation is usually about seven days. When the residual limb has healed, it is in many cases possible to use your socket-suspended prosthesis again (after 6 8 weeks). The existing prosthetic socket may need to be adjusted or replaced. This is done at your home clinic. At the second operation (S2), an extension (an abutment) is added to the fixture. The abutment protrudes through the skin. In order to optimise the skin s healing, you need to remain still in bed with your residual limb raised. Dressings are changed at 3 4 day intervals. Hospitalisation is usually days. Surgery is carried out on muscles and soft tissue during this operation, which means that you may not do any strength exercises or stretching over the following six weeks. 3

5 SKIN PENETRATION AREA The place where the abutment screw protrudes through the skin is called the skin penetration area. It is important that the skin penetration area is cleaned every day; you should learn to do this yourself. REHABILITATION To achieve good attachment (osseointegration) between the implant and the bone, the amount of loading and activity must gradually increase before you can use the bone-anchored prosthesis unrestricted. Troublesome pain is a sign that the bone needs more time to gain strength. Short training prosthesis When the skin penetration area has healed (approx. 6 weeks after operation S2) training can begin using a short training prosthesis. This takes place during visits to the Dept. for Prosthetics and Orthotics at the Sahlgrenska University Hospital. You will receive instructions for exercises that you should carry out every day at home for the upcoming weeks. The training consists of you standing and putting weight on the short prosthesis on an ordinary weighing scale. 4

6 During the first week you should only load it with a little weight, and as each week passes you add a little more. The bone is stimulated to grow and become stronger by gradually increasing the load. You will also be given an exercise programme for strength and range of motion. In most cases, training with the short prosthesis goes on for about six weeks. If your quality of bone is poor, you should expect a longer period of short prosthesis training. The short prosthesis is a training tool and is not for walking on, which means that you will not have a prosthesis for walking during this period. Long prosthesis At about 12 weeks after operation S2, training will begin with the first long prosthesis. Prosthetic fitting and training instruction will take place at the Dept. for Prosthetics and Orthotics/ Sahlgrenska University Hospital. During the first few weeks you may use the prosthesis only for a few hours a day, indoors. After this, you can gradually use the prosthesis more. For the first three months, you must use crutches when you are walking with the prosthesis. A decision about starting to walk using only one crutch or without any support, will be taken at the outpatient visit six months after operation S2. a b a) Patient using the short prosthesis, b) protection, short prosthesis and soft tissue support 5

7 Activities An OI prosthesis means that everyday activities can be performed with no risk of the prosthesis falling off or chafing. However, you may not walk unsupported or start to cycle before you are given permission. Later on, we recommend that you use a walking stick or walking poles during longer walks. You may not run, jump or lift really heavy weights when you are using the prosthesis. Bathing in your own bath or in clean seawater is permitted when the skin penetration area has healed properly. Bathing in a swimming pool can be done if Vaseline is placed around the skin penetration area; a liner/silicone cover can be used as a bathing cap. Avoid using pools with poor quality of water and when the skin penetration area is irritated or infected. Always clean the skin penetration area after bathing. Place a damp towel around the abutment when using a sauna. In conditions of severe cold, ensure the cold does not reach the abutment. THE PROSTHESIS The prosthesis generally has the same attachment device as an ordinary prosthesis. At the top of the prosthesis there is an attachment device between the abutment screw and the prosthesis. The attachment device has an integral safety mechanism in order to prevent bone injury during heavy loading, such as during a fall. The cosmetic cover of the prosthesis fits to the lower part of the residual limb. 6

8 Soft tissue support When you receive the short prosthesis, you will also receive a soft tissue support which is used to stabilise the skin around the penetration area. Future problems with the skin penetration area can be prevented by stopping it from gaping while you are active. The soft tissue support is made at the Department for Prosthetics and Orthotics at Sahlgrenska University Hospital. 7

9 COMPLICATIONS As with all types of surgical treatment, there is a risk of complications that may change the treatment or lead to a less satisfactory result. Superficial infections in or around the skin penetration area are not unusual and antibiotics are sometimes necessary. More serious complications, such as the fixture becoming loose, a deep infection or one of the abutment sections or the bone breaking may occur. These are all serious. Most complications can be treated, but usually require a visit to Sahlgrenska University Hospital. Checks to abutment screw and possible replacement of abutment and/or abutment screw Regular checks of the abutment s attachment in the fixture are important to guarantee long-term durability. This is carried out at every follow-up appointment using a torque wrench. In some cases this can be done locally or by the patient. Dark (grey-black) secretion from the skin penetration area may be a sign of wear and tear and needs to be checked. If the abutment is bent or broken, it is necessary to replace it. This can happen as a result of serious wear or a fall. Replacing the abutment and/or abutment screw requires a visit to and operation at Sahlgrenska University Hospital. Transfemoral (left) and transtibial (right) amputee using the osseointegrated prosthesis. 8

10 TREATMENT PROCEDURE An overview of the treatment process. Individual variations may occur. Operation Seans days hospitalisation Socket prosthesis can be used again after 6 8 weeks End bearing in the socket should be avoided! Operation Seans months after Seans days hospitalisation 6 weeks after surgery Seans 2 Follow-up with medical team Rehabilitation starts using short training prosthesis Instructions for daily training at home over the next 6 8 weeks Possible 1 2 extra visits to Dept. for Prosthetics and Orthotics for new training instructions 12 weeks after Seans 2 Fllow-up with medical team Rehabilitation starts using long prosthesis Instructions on how much the prosthesis may be used and gradual increase of activities Possible 1 3 extra visits to Dept. for Prosthetics and Orthotics for prosthesis adjustment and new instructions 6 months after Seans 2 X-ray Follow-up with medical team Possibibly start walking without crutches Extra visits to Dept. for Prosthetics and Orthotics for cosmetic finalisation and possible replacement of prosthesis components 1 year after Seans 2 X-ray Follow-up with medical team Visit to "walking school" at Dept. for Prosthetics and Orthotics 2 years after Seans 2 X-ray Follow-up with medical team Visit to "walking school" at Dept. for Prosthetics and Orthotics Continued follow-ups 3, 5, 7, 10, 15, 20 and 25 years after Seans 2, including X-ray examination 9

11 TEAM ASSESSMENT Before a decision can be taken on whether the treatment is suitable for you, you will be invited to our outpatient clinic at Sahlgrenska University Hospital/ Mölndal for a team assessment. At the team assessment you will meet the whole team and be provided with information about the treatment and we will also try to arrange a meeting with an already treated patient. What is needed for team assessment? In order to investigate whether treatment with a bone-anchored prosthesis is suitable, you need to complete a questionnaire. For further information, please contact us at careinfo@vgregion.se All applications and financial matters relating to foreign nationals are administered by Sahlgrenska International Care (SIC). For a cost estimation, please contact Sahlgrenska I.C. at info@sahlgrenskaic.com Photos from our ward 233 C.A.R.E. 10

12 Coordinator C.A.R.E. Vivika Muller Centre for Advanced Reconstruction of Extremities (C.A.R.E.) Sahlgrenska University Hospital/ Mölndal sjukhus Göteborgsvägen Mölndal, Sweden Phone: Coordinates visits to C.A.R.E. (doctors, X-ray, etc.). Contact in case of complications. Sahlgrenska International Care Coordinator Anna Carlsson Phone: +46 (0) All applications and financial matters relating to foreign nationals Prosthetist and Orthotist Joakim Engström Dept. for Prosthetics and Orthotics/ Sahlgrenska University Hospital Falkenbergsgatan 3 Phone: Joakim.engstrom@vgregion.se Questions about the prosthesis. Physiotherapist Kerstin Hagberg Dept. for Prosthetics and Orthotics/ Sahlgrenska University Hospital Falkenbergsgatan 3 SE Göteborg Phone: kerstin.hagberg@vgregion.se Surgeons Joakim Strömberg, Senior Consultant Örjan Berlin, Associated Professor, Senior Consultant 11

13 C.A.R.E. Reception and ward 233 Elevator T1, 5th floor X-ray is located at the main enterance behind the escalator 12