Towards an accurate biomechanical model of the ankle

When compared with similar joint arthroplasties, the prognosis of Total Ankle Replacement (TAR) is not satisfactory although it shows promising results post surgery. To date, most models do not provide the full anatomical functionality and biomechanical range of motion of the healthy ankle joint. This has sparked additional research and evaluation of clinical outcomes in order to enhance ankle prosthesis design. However, the limited biomechanical data that exist in literature are based upon two-dimensional, discrete and outdated techniques1 and may be inaccurate. Since accurate force estimations are crucial to prosthesis design, a paper based on a new biomechanical modeling approach, providing three dimensional forces acting on the ankle joint and the surrounding tissues was published recently, but the identified forces were suspected of being under-estimated, while muscles were . The present paper reports an attempt to improve the accuracy of the analysis by means of novel methods for kinematic processing of gait data, provided in release 4.1 of the AnyBody Modeling System (AnyBody Technology, Aalborg, Denmark) Results from the new method are shown and remaining issues are discussed.

One step closer into the design of fall protective device for individuals fitted with a bone-anchored prosthesis

The consequences of falls are often dreadful for individuals with lower limb amputation using bone-anchored prosthesis.[1-5] Typically, the impact on the fixation is responsible for bending the intercutaneous piece that could lead to a complete breakage over time. .[3, 5-8] The surgical replacement of this piece is possible but complex and expensive. Clearly, there is a need for solid data enabling an evidence-based design of protective devices limiting impact forces and torsion applied during a fall. The impact on the fixation during an actual fall is obviously difficult to record during a scientific experiment.[6, 8-13] Consequently, Schwartze and colleagues opted for one of the next best options science has to offer: simulation with an able-bodied participant. They recorded body movements and knee impacts on the floor while mimicking several plausible falling scenarios. Then, they calculated the forces and moments that would be applied at four levels along the femur corresponding to amputation heights.[6, 8-11, 14-25] The overall forces applied during the falls were similar regardless of the amputation height indicating that the impact forces were simply translated along the femur. As expected, they showed that overall moments generally increased with amputation height due to changes in lever arm. This work demonstrates that devices preventing only against force overload do not require considering amputation height while those protecting against bending moments should. Another significant contribution is to provide, for the time, the magnitude of the impact load during different falls. This loading range is crucial to the overall design and, more precisely, the triggering threshold of protective devices. Unfortunately, the analysis of only a single able-bodied participant replicating falls limits greatly the generalisation of the findings. Nonetheless, this case study is an important milestone contributing to a better understanding of load impact during a fall. This new knowledge will improve the treatment, the safe ambulation and, ultimately, the quality of life of individuals fitted with bone-anchored prosthesis.

Evolution in design of integral leg prosthesis leads to improved outcomes

Developments of surgical attachments for bone-anchored prostheses are slowly but surely winning over the initial disbelief in the orthopedic community. Clearly, this option is becoming accessible to a wide range of individuals with limb loss. Seminal studies have demonstrated that the pioneering procedure relying on screw-type fixation engenders major clinical benefits and acceptable safety. The surgical procedure for press-fit implants, such as the Integral-Leg-Prosthesis (ILP) has been described Dr Aschoff and his team. Some clinical benefits of press-fit implants have been also established. Here, his team is once again taking a leading role by sharing the progression over 15 years of the rate of deep infections for 69 individuals with transfemoral amputation fitted with three successive refined versions of the ILP. By definition, a double-blind randomized clinical trial to test the effect of different fixation’s design is difficult. Alternatively, Juhnke and colleagues are reporting the outcomes of action-research study for a cohort of participants. The first and foremost important outcome of this study is the confirmation that the current design of the IPL and rehabilitation program are altogether leading to an acceptable rate of deep infection and other adverse events (e.g., structural failure of implant, periprosthetic factures). This study is also providing a strong insight onto the effect of major phases in redesign of an implant on the risk of infection. This is an important reminder that the development of a successful osseointegrated implant is unlikely to be immediate but the results of a learning curve made of empirical and sequential changes led by a reflective clinical practice. Clearly, this study provided better understanding of the safety of the ILP surgical and rehabilitation procedure while establishing standards and benchmark data for future studies focusing on design and infection of press-fit implants. Complementary observations of relationship between infection and cofounders such as loading of the prosthesis and prosthetic components used would be beneficial.Further definitive evidences of the clinical benefits with the latest design would be valuable, although an increase in health related quality of life and functional outcomes are likely to be confirmed. Altogether, the authors are providing compelling evidence that bone-anchored attachments particularly those relying on press-fit implants are an established alternative to socket prostheses.

The silent and apparent neurological injury in transcatheter aortic valve implantation study (SANITY) : concept, design and rationale

Background The incidence of clinically apparent stroke in transcatheter aortic valve implantation (TAVI) exceeds that of any other procedure performed by interventional cardiologists and, in the index admission, occurs more than twice as frequently with TAVI than with surgical aortic valve replacement (SAVR). However, this represents only a small component of the vast burden of neurological injury that occurs during TAVI, with recent evidence suggesting that many strokes are clinically silent or only subtly apparent. Additionally, insult may manifest as slight neurocognitive dysfunction rather than overt neurological deficits. Characterisation of the incidence and underlying aetiology of these neurological events may lead to identification of currently unrecognised neuroprotective strategies. Methods The Silent and Apparent Neurological Injury in TAVI (SANITY) Study is a prospective, multicentre, observational study comparing the incidence of neurological injury after TAVI versus SAVR. It introduces an intensive, standardised, formal neurologic and neurocognitive disease assessment for all aortic valve recipients, regardless of intervention (SAVR, TAVI), valve-type (bioprosthetic, Edwards SAPIEN-XT) or access route (sternotomy, transfemoral, transapical or transaortic). Comprehensive monitoring of neurological insult will also be recorded to more fully define and compare the neurological burden of the procedures and identify targets for harm minimisation strategies. Discussion The SANITY study undertakes the most rigorous assessment of neurological injury reported in the literature to date. It attempts to accurately characterise the insult and sustained injury associated with both TAVI and SAVR in an attempt to advance understanding of this complication and associations thus allowing for improved patient selection and procedural modification.

Description of body posture during Static load bearing exercises for individuals with transfemoral amputation fitted with bone-anchored prosthesis

The rehabilitation programs of bone-anchorage prostheses relying either on the OPRA (Integrum, Sweden) or the ILP (Orthodynamics, Germany) fixation involve some forms of static load bearing exercises (LBE). So far, most of biomechanical studies of these static LBEs focused on the direct measurements of the actual forces and moments applied on the OPRA fixation of individuals with transfemoral amputation (TFA). To date, the proof-of-concept of an apparatus to conduct these kinetic measurements has been presented, along with some preliminary data. The understanding of the kinetic data is essential to improve rehabilitation programs as well as the design of upcoming loading frames. However, kinetic information alone is difficult to interpret without concomitant kinematic data. The purpose of this preliminary study was to introduce a qualitative analysis describing the different body postures during LBE for a group of TFAs.

Bone-anchored prosthesis: Update in international developments

This symposium will provide hand-on update on the current development of the load sensors measuring the inner prosthetic loading that can strongly contribute the ever increasing demand for evidence-based clinical practice. Surgical implantations of osseointegrated fixations for bone-anchored prosthesis are developing at an unprecedented pace worldwide (e.g., Australia, UK, Sweden, US). This option is becoming accessible to a wide range of individuals with limb loss. With these new developments come new potential challenges and opportunities for all the stakeholders involved in the prosthetic care of these patients. Clearly, there is a need for those stakeholders, particularly those attending the ISPO, to be informed of the current and upcoming international developments in bone-anchored prostheses. The objectives of this symposium will be: • To present an overview of the current growth of the procedures worldwide (e.g., identification of key players, centers of activities, growth trend) with a strong focus on the introduction of the framework to evaluate the availability of the procedure at national level (e.g., number of patients treated, range of the levels of implantation, number of commercial fixations accessible), • To provide first-hand updates on the latest cutting-edge scientific and clinical developments of fixations and rehabilitations programs (e.g., Innovative design of implant, cost-effectiveness, long-terms rehabilitation outcomes for screw-type fixation, current developments in US, comparative analysis for press-fit type of implant, potential moves toward single-stage surgeries).

Rehabilitation of individuals with bone-anchored prosthesis: State-of-the-art and challenges

Individuals with limb amputation fitted with conventional socket-suspended prostheses often experience socket-related discomfort leading to a significant decrease in quality of life. Bone-anchored prostheses are increasingly acknowledged as viable alternative method of attachment of artificial limb. In this case, the prosthesis is attached directly to the residual skeleton through a percutaneous fixation. To date, a few osseointegration fixations are commercially available. Several devices are at different stages of development particularly in Europe and the US.[1-15] Clearly, surgical procedures are currently blooming worldwide. Indeed, Australia and Queensland in particular have one of the fastest growing populations. Previous studies involving either screw-type implants or press-fit fixations for bone-anchorage have focused on fragmented biomechanics aspects as well as the clinical benefits and safety of the procedure. However, very few publications have synthetized this information and provided an overview of the current developments in bone-anchored prostheses worldwide, let alone in Australia. The purposes of the presentation will be: 1. To provide an overview of the state-of-art developments in bone-anchored prostheses with as strong emphasis on the design of fixations, treatment, benefits, risks as well as future opportunities and challenges, 2. To present the current international developments of procedures for bone-anchored prostheses in terms of numbers of centers, number of cases and typical case-mix, 3. To highlight the current role Australia is playing as a leader worldwide in terms of growing population, broadest range of case-mix, choices of fixations, development of reimbursement schemes, unique clinical outcome registry for evidence-based practice, cutting-edge research, consumer demand and general public interest.