Review question The main purpose of this scoping review is to characterize loading information applied on the residuum of individuals with transfemoral amputation fitted with an osseointegrated fixation for bone-anchored prostheses. The objectives of this scoping review are: i) to map the scope of loading variables, and ii) to report the range of magnitude of loads that has been directly measured using a portable kinetic recording apparatus fitted at the distal end of the residuum during rehabilitation exercises, standardized and unscripted activities of daily living, and adverse events. The specific review questions are:i) What is the scope of variables used to describe loading data that has been directly measured using a portable kinetic recording apparatus mounted at the distal end of the residuum of individuals with transfemoral amputation fitted with an osseointegrated fixation?ii) What is the range of magnitude of the loads applied on the residuum of individuals with transfemoral amputation fitted with an osseointegrated fixation measured directly with a portable kinetic recording apparatus during rehabilitation exercises, standardized and unscripted activities of daily living, and adverse events?

This scoping review aims to answer two research questions (1) What is the clinical indicators’ intra-variability for both screw-type (Q1) and press-fit fixations (Q2)? (2) What is the clinical indicators’ inter-variability between screw-type and press-fit fixations (Q3)? The objectives of this scoping review are therefore, to characterize the rehabilitation programs performed by individuals with transfemoral amputation following the implantation of an osseointegrated fixation for bone-anchored prostheses; to describe partial weight bearing exercises in each rehabilitation program for screw-type and press-fit fixations; and to compare key rehabilitation parameters for each of these exercises within each program for screw-type and press-fit fixations (intra-variability) as between programs for screw-type and press-fit fixations (inter-variability). This scoping review will consider studies involving individuals with transfemoral amputation fitted with a bone-anchored prosthesis using either screw-type or press-fit osseointegrated fixation. This scoping review will examine the concepts of intra-variability and inter-variability in clinical indicators of the rehabilitation programs for screw-type and press-fit fixations fitted to bone-anchored prosthesis of individuals with transfemoral amputation. This scoping review will consider studies providing broad and specific clinical elements underlying the rehabilitation program aiming at promoting bone remodeling around osseointegrated fixation. Also, this scoping review will consider studies relying on measurements conducted in different settings. This scoping review will consider a broad range of study designs in order to capture the concepts outlined above. The search strategy will aim to find both unpublished and published studies

REVIEW QUESTION:The primary objective of this scoping review is to characterize rehabilitation programs for individuals with transfemoral amputation following the implantation of screw-type or press-fit osseointegrated fixations for bone-anchored prostheses.The secondary objective of this review is to describe partial weight bearing exercises including static and dynamic exercises as well as use of walking aids in each rehabilitation program for screw-type and press-fit fixations.The third objective of this review is to compare key rehabilitation parameters for various partial weight bearing exercises (e.g. type of training prosthesis, loading time and progression, monitoring of loading, loading direction, instructions given to patients and the use of loading regulators) within each program for screw-type and press-fit fixations (intra-variability) and between programs for screw-type and press-fit fixations (inter-variability).The specific review questions are.

To strive to improve the rehabilitation program of individuals with transfemoral amputation fitted with bone-anchored prosthesis based on data from direct measurements of the load applied on the residuum we first of all need to understand the load applied on the fixation. Therefore the load applied on the residuum was first directly measured during standardized activities of daily living such as straight line level walking, ascending and descending stairs and a ramp and walking around a circle. From measuring the load in standardized activities of daily living the load was also measured during different phases of the rehabilitation program such as during walking with walking aids and during load bearing exercises.[1-15] The rehabilitation program for individuals with a transfemoral amputation fitted with an OPRA implant relies on a combination of dynamic and static load bearing exercises.[16-20] This presentation will focus on the study of a set of experimental static load bearing exercises. [1] A group of eleven individuals with unilateral transfemoral amputation fitted with an OPRA implant participated in this study. The load on the implant during the static load bearing exercises was measured using a portable system including a commercial transducer embedded in a short pylon, a laptop and a customized software package. This apparatus was previously shown effective in a proof-of-concept study published by Prof. Frossard. [1-9] The analysis of the static load bearing exercises included an analysis of the reliability as well as the loading compliance. The analysis of the loading reliability showed a high reliability between the loading sessions indicating a correct repetition of the LBE by the participants. [1, 5] The analysis of the loading compliance showed a significant lack of axial compliance leading to a systematic underloading of the long axis of the implant during the proposed experimental static LBE.

This study aimed at presenting the intra-tester reliability of the static load bearing exercises (LBEs) performed by individuals with transfemoral amputation (TFA) fitted with an osseointegrated implant to stimulate the bone remodeling process. There is a need for a better understanding of the implementation of these exercises particularly the reliability. The intra-tester reliability is discussed with a particular emphasis on inter-load prescribed, inter-axis and inter-component reliabilities as well as the effect of body weight normalization. Eleven unilateral TFAs fitted with an OPRA implant performed five trials in four loading conditions. The forces and moments on the three axes of the implant were measured directly with an instrumented pylon including a six-channel transducer. Reliability of loading variables was assessed using intraclass correlation coefficients (ICCs) and percentage standard error of measurement values (SEMs). The ICCs of all variables were above 0.9 and the SEM values ranged between 0 and 87. This study showed a high between-participants' variance highlighting the lack of loading consistency typical of symptomatic population as well as a high reliability between the loading sessions indicating a plausible correct repetition of the LBE by the participants. However, these outcomes must be understood within the framework of the proposed experimental protocol.

Mots cles : Appareillage ; Osteo-integration ; Amputation ; Transfemoral ; Transhumeral ; Transradiale ; Pouce ; Reconstruction bionique Depuis son introduction dans le milieu des annees 1960, l’utilisation de protheses osteo-integrees en titane est devenue une technique de routine. Les implants intra-epidermiques ont fourni des solutions pour la fixation des epitheses dans les atteintes faciales et pour le transfert des vibrations acoustiques lors de l’utilisation d’aides auditives (BAHA). Les connaissances et l’experience acquises a partir de ces modeles se sont averes essentiels au developpement d’une solution similaire pour la fixation des exoprothese principalement sur les moignons femoral et de l’humerus problematiques. Les premiers patients amputes ont ete traites par Branemark et al. a Goteborg en 1990 (transfemoral et pouce, transradial en 1992, transhumeral en 1994). Des implants standardises et un protocole de rehabilitation detaillee (OPRA) ont ete developpes depuis 1999. Ce traitement n’est pas un substitut a une prothese exosquelettique par manchon bien toleree. Toutefois, il peut etre une alternative interessante pour les patients a moignons d’amputation courts, plaies chroniques ou autres troubles trophiques empechant l’utilisation reguliere d’un manchon. Dans cette population de patients des etudes ont montre des gains fonctionnels et de qualite de vie sur les resultats a moyen terme. La qualite de la fixation osseuse des implants dentaires et des protheses de hanche sans ciment semble se comporter de facon similaire dans le temps. Ces donnees permettent d’etre optimiste sur la survie a long terme de ces implants. Les complications infectieuses restent evidemment une preoccupation avec une incidence dans des limites raisonnables. Les infections superficielles peuvent etre traitees de facon conservatrice. Comme pour les implants dentaires, les infections profondes sont traitees selon les principes standards, le plus souvent sans extraction de l’implant. Faisant confiance a l’evolution de ces techniques, nous les avons integrees dans notre hopital. Notre premier ampute transhumeral a ete opere en mai 2010. Des patients amputes en transfemoral ont suivi depuis. Notre discussion portera sur les bases du programme de traitement, les explorations complementaires et les aspects techniques. Les recentes innovations techniques par implants peuvent optimiser l’effet d’autres evolutions dans le traitement des amputes, comme la re-innervation musculaire ciblee. La perspective de reconstruction de membres fonctionnels bioniques parait ainsi devenir plus realiste.

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.

The desire to solve problems caused by socket prostheses in transfemoral amputees and the acquired success of osseointegration in the dental application has led to the introduction of osseointegration in the orthopedic surgery. Since its first introduction in 1990 in Gothenburg Sweden the osseointegrated (OI) orthopedic fixation has proven several benefits[1]. The surgery consists of two surgical procedures followed by a lengthy rehabilitation program. The rehabilitation program after an OI implant includes a specific training period with a short training prosthesis. Since mechanical loading is considered to be one of the key factors that influence bone mass and the osseointegration of bone-anchored implants, the rehabilitation program will also need to include some form of load bearing exercises (LBE). To date there are two frequently used commercially available human implants. We can find proof in the literature that load bearing exercises are performed by patients with both types of OI implants. We refer to two articles, a first one written by Dr. Aschoff and all and published in 2010 in the Journal of Bone and Joint Surgery.[2] The second one presented by Hagberg et al in 2009 gives a very thorough description of the rehabilitation program of TFA fitted with an OPRA implant. The progression of the load however is determined individually according to the residual skeleton’s quality, pain level and body weight of the participant.[1] Patients are using a classical bathroom weighing scale to control the load on the implant during the course of their rehabilitation. The bathroom scale is an affordable and easy-to-use device but it has some important shortcomings. The scale provides instantaneous feedback to the patient only on the magnitude of the vertical component of the applied force. The forces and moments applied along and around the three axes of the implant are unknown. Although there are different ways to assess the load on the implant for instance through inverse dynamics in a motion analysis laboratory [3-6] this assessment is challenging. A recent proof- of-concept study by Frossard et al (2009) showed that the shortcomings of the weighing scale can be overcome by a portable kinetic system based on a commercial transducer[7].

Bossche, Luc Charles Vanden; Plasschaert, Frank; Vertriest, Sofie; Rimbaut, Steven; De Muynck, Martine; Vanderstraeten, Guy G Author Information

Individuals with lower limb amputation fitted with an OPRA osseointegrated fixation are facing an extensive rehabilitation program including static load bearing exercises (LBE). The application of a suitable amount of stress stimulates osseointegration and prepares the bone to tolerate the forces and moments that will be incurred during activities of daily living (ADL. At present, the monitoring is typically carried out using a normal bathroom weighing scale. This scale provides information only on the magnitude of the vertical component of the applied force. The moment around the long axis of the fixation when the femur is perpendicular to the ground is not assessed and neither are the components of force and moment generated on the other two axes.

Osseointegration has been introduced in the orthopaedic surgery in the 1990’s in Gothenburg (Sweden). To date, there are two frequently used commercially available human implants: the OPRA (Integrum, Sweden) and ILP (Orthodynamics, Germany) systems. The rehabilitation program with both systems include some form of static load bearing exercises. These latter involved following a load progression that is monitored by the bathroom scale, providing only the load applied on the vertical axis. The loading data could be analysed through different biomechanical variables. For instance, the load compliance, corresponding to the difference between the load recommended (LR) and the load actually applied on the implant, will be presented here.