Tmr Transhumberal Outcomes

8/6/2019 Tmr Transhumberal Outcomes

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OUTCOMES ON THREE TRANSHUMERAL LEVEL

FITTINGS FOLLOWING TARGETED

REINNERVATION NERVE TRANSFER SURGERY

Lipschutz,R.D. Miller, L.A., Stubblefield, K.A., Dumanian, G., Phillips, M.E. and

Kuiken, T.A.

Neural Engineering Center for Artificial Limbs, Rehabilitation Institute of ChicagoDept. of PM&R, Feinberg School of Medicine, Northwestern University

Dept. of Plastic Surgery, Northwestern Memorial Hospital


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Clinical Presentation

3 Individuals

Traumatic Transhumeral

Amputations

Motor Vehicle Accident

Railroad Accident Machinery Accident


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Customary Myoelectric Fitting

Following Transhumeral Amputation

1 - Elbow Extend

Triceps

2 - Hand Open

1 - Elbow Flex

Biceps

2 - Hand Close

Sequentially


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CHANGE TO

Myoelectric Fitting

1 - Elbow ExtendTriceps

2 - Hand Open

3 Wrist Pronation

1 - Elbow FlexBiceps

2 - Hand Close

3- Wrist Supination

Mode Selection via

Bump Switch


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Why the CHANGE??? Permit Simultaneous Control

Elbow Flexion / Extension - MYOELECTRICALLY

Hand or Wrist LINEAR TRANSDUCER

Prevent Future Confusion

Elbow Flexion (Musculocutaneous Nerve) Flex Elbow ONLY

Elbow Extension (*Prox. Radial Nerve) Extend Elbow ONLY


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Review of Surgical Intervention

Brachial Plexus


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Peripheral Nerve REVIEW Musculocutaneous Nerve Elbow Flexors

Radial Nerve Elbow Extensors, Wrist Extensors,Finger Extensors

Median Nerve Wrist Flexors, Finger Flexors,Forearm Pronators, Thumb Abductor

Ulnar Nerve Wrist Flexors, Palmar Intrinsics


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Surgical Review

Lateral Biceps

Lateral Branch ofMusculocutaneous Nerve

Medial Biceps

Medial Branch ofMusculocutaneous Nerve


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Surgical Review

Medial Biceps

Medial Branch ofMusculocutaneous Nerve

Reinnervatedwith

Median Nerve

Brachialis

Musculocutaneous Nerve Divided


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Nerve Transfers for

Transhumeral Amputee


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Experimental Myoelectric

Fitting Following TranshumeralAmputation

Elbow Extend Triceps

Hand Open Brachialis

Medial Biceps Hand Close

Lateral Biceps Elbow Flex

Simultaneously

Wrist Pronation Wrist Supination


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Components for Experimental

Externally Powered Prosthesis(Same as Pre-Op) LTI Linear Transducer

LTI Boston Digital Arm

Otto Bock Electronic

Wrist Rotator

Otto Bock Hand


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Location of Electrode Sites Triceps

Superior aspect of the

Postero-Medial Socket

Brachialis

Distal aspect of the

Lateral Socket (slightly

Posterior to Midline)

Posterior View Lateral View


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Location of Electrode Sites Lateral Biceps

Anterior Socket

Medial Biceps

Medial aspect of the

Socket (Just Anterior

to Midline)

Medial View


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CHALLENGES


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Location of Electrode Sites Proximity of Electrodes

Interference

Accuracy during donning

Electrodes

Originally

2-LTI

Packaged 2-Otto Bock (13E125=60)

Currently

4 LTI Remote


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As found in PREVIOUS

Four Channel EMG Testing

Co-contraction of

Elbow Extension

with

HandOpen


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Multiple Channel Viewing

Liberating Technologies Inc.


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ChallengesMovement of Soft Tissue


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Aggressive Modifications

andMore Proximal Electrode Placement


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Testing

and

Results


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Box and Blocks Test

Original Prosthesis Nerve Transfer Prosthesis(Used more than 8 months) (Used about 2 months)


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Box and Blocks Test

Original Prosthesis Nerve Transfer Prosthesis


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Results of Box and Blocks Test#ofBlocks Conventional

Prosthesis

Experimental

Prosthesis

Subject 1 (AVG) 7.3 22.7

% Difference +311%

Subject 3 (AVG) 5.3 15

% Difference +283%

*AVG = Average of 3 Trials


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Clothes Pin Test

Conventional Experimental

(Used more than 8 months) (Used about 2 months)


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Clothes Pin Test

Original Prosthesis Nerve Transfer Prosthesis


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Results of Clothes Pin TestTime in Seconds Conventional

Prosthesis (sec)

Experimental

Prosthesis (sec)

Subject 1 (AVG) 62.7 34

% Differences -45.7%

Subject 3 (AVG) 92.3 50.3

% Differences -45.5%

*AVG = Average of 3 Trials


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AMPS TestingSingle subject validated test of ADL function


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Results of AMPS Testing

Subject 1

Motor Score

Conventional = 0.51

Experimental = 1.05

Processing Score

Conventional = 0.35

Experimental = 1.10

Subject 3

Motor Score

Conventional = 0.90

Experimental = 1.56

Processing Score

Conventional = 1.09

Experimental = 1.43


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Outcomes from Targeted Reinnervation on

Transhumeral Amputee Subjects 1 & 3

Targeted muscle reinnervation created 2 new myoelectriccontrol sites

Multiple joints were simultaneously controlled withmyoelectric signals

2 with myoelectric control

1 with linear transducer

Control was more physiologically appropriate

Operation feels more natural Prosthesis is easier to use

Additional Tasks were performed

Faster and more accurate during testing


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What happened to Subject 2? Still has 2-site Myoelectric Prosthesis

Lack of success likely secondary to

undiagnosed brachial-plexopathy Additional testing continues**


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High Density Electrode Array

116 Electrodes


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No Detectable

HAND CLOSE

Signal

BUT

PATTERN

RECOGNITION

85-90%


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Thank You!

Documents

Tmr Transhumberal Outcomes