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Quinn KN, Tian Y, Budde R, Irazoqui PP, Tuffaha S, Thakor NV. Neuromuscular implants: Interfacing with skeletal muscle for improved clinical translation of prosthetic limbs. Muscle Nerve 2024; 69:134-147. [PMID: 38126120 DOI: 10.1002/mus.28029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 11/27/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
After an amputation, advanced prosthetic limbs can be used to interface with the nervous system and restore motor function. Despite numerous breakthroughs in the field, many of the recent research advancements have not been widely integrated into clinical practice. This review highlights recent innovations in neuromuscular implants-specifically those that interface with skeletal muscle-which could improve the clinical translation of prosthetic technologies. Skeletal muscle provides a physiologic gateway to harness and amplify signals from the nervous system. Recent surgical advancements in muscle reinnervation surgeries leverage the "bio-amplification" capabilities of muscle, enabling more intuitive control over a greater number of degrees of freedom in prosthetic limbs than previously achieved. We anticipate that state-of-the-art implantable neuromuscular interfaces that integrate well with skeletal muscle and novel surgical interventions will provide a long-term solution for controlling advanced prostheses. Flexible electrodes are expected to play a crucial role in reducing foreign body responses and improving the longevity of the interface. Additionally, innovations in device miniaturization and ongoing exploration of shape memory polymers could simplify surgical procedures for implanting such interfaces. Once implanted, wireless strategies for powering and transferring data from the interface can eliminate bulky external wires, reduce infection risk, and enhance day-to-day usability. By outlining the current limitations of neuromuscular interfaces along with potential future directions, this review aims to guide continued research efforts and future collaborations between engineers and specialists in the field of neuromuscular and musculoskeletal medicine.
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Affiliation(s)
- Kiara N Quinn
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yucheng Tian
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ryan Budde
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Pedro P Irazoqui
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sami Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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Tian Y, Vaskov AK, Adidharma W, Cederna PS, Kemp SW. Merging Humans and Neuroprosthetics through Regenerative Peripheral Nerve Interfaces. Semin Plast Surg 2024; 38:10-18. [PMID: 38495064 PMCID: PMC10942838 DOI: 10.1055/s-0044-1779028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Limb amputations can be devastating and significantly affect an individual's independence, leading to functional and psychosocial challenges in nearly 2 million people in the United States alone. Over the past decade, robotic devices driven by neural signals such as neuroprostheses have shown great potential to restore the lost function of limbs, allowing amputees to regain movement and sensation. However, current neuroprosthetic interfaces have challenges in both signal quality and long-term stability. To overcome these limitations and work toward creating bionic limbs, the Neuromuscular Laboratory at University of Michigan Plastic Surgery has developed the Regenerative Peripheral Nerve Interface (RPNI). This surgical construct embeds a transected peripheral nerve into a free muscle graft, effectively amplifying small peripheral nerve signals to provide enhanced control signals for a neuroprosthetic limb. Furthermore, the RPNI has the potential to provide sensory feedback to the user and facilitate neuroprosthesis embodiment. This review focuses on the animal studies and clinical trials of the RPNI to recapitulate the promising trajectory toward neurobionics where the boundary between an artificial device and the human body becomes indistinct. This paper also sheds light on the prospects of the improvement and dissemination of the RPNI technology.
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Affiliation(s)
- Yucheng Tian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Alex K. Vaskov
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stephen W.P. Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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González-Prieto J, Cristóbal L, Arenillas M, Giannetti R, Muñoz Frías JD, Alonso Rivas E, Sanz Barbero E, Gutiérrez-Pecharromán A, Díaz Montero F, Maldonado AA. Regenerative Peripheral Nerve Interfaces (RPNIs) in Animal Models and Their Applications: A Systematic Review. Int J Mol Sci 2024; 25:1141. [PMID: 38256216 PMCID: PMC10816042 DOI: 10.3390/ijms25021141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
Regenerative Peripheral Nerve Interfaces (RPNIs) encompass neurotized muscle grafts employed for the purpose of amplifying peripheral nerve electrical signaling. The aim of this investigation was to undertake an analysis of the extant literature concerning animal models utilized in the context of RPNIs. A systematic review of the literature of RPNI techniques in animal models was performed in line with the PRISMA statement using the MEDLINE/PubMed and Embase databases from January 1970 to September 2023. Within the compilation of one hundred and four articles employing the RPNI technique, a subset of thirty-five were conducted using animal models across six distinct institutions. The majority (91%) of these studies were performed on murine models, while the remaining (9%) were conducted employing macaque models. The most frequently employed anatomical components in the construction of the RPNIs were the common peroneal nerve and the extensor digitorum longus (EDL) muscle. Through various histological techniques, robust neoangiogenesis and axonal regeneration were evidenced. Functionally, the RPNIs demonstrated the capability to discern, record, and amplify action potentials, a competence that exhibited commendable long-term stability. Different RPNI animal models have been replicated across different studies. Histological, neurophysiological, and functional analyses are summarized to be used in future studies.
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Affiliation(s)
- Jorge González-Prieto
- Peripheral Nerve Unit, Department of Plastic Surgery, University Hospital of Getafe, 28905 Madrid, Spain; (J.G.-P.); (L.C.)
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Lara Cristóbal
- Peripheral Nerve Unit, Department of Plastic Surgery, University Hospital of Getafe, 28905 Madrid, Spain; (J.G.-P.); (L.C.)
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Mario Arenillas
- Animal Medicine and Surgery Department, Complutense University of Madrid, 28040 Madrid, Spain;
| | - Romano Giannetti
- Institute for Research in Technology, ICAI School of Engineering, Comillas Pontifical University, 28015 Madrid, Spain; (R.G.); (J.D.M.F.)
| | - José Daniel Muñoz Frías
- Institute for Research in Technology, ICAI School of Engineering, Comillas Pontifical University, 28015 Madrid, Spain; (R.G.); (J.D.M.F.)
| | - Eduardo Alonso Rivas
- Institute for Research in Technology, ICAI School of Engineering, Comillas Pontifical University, 28015 Madrid, Spain; (R.G.); (J.D.M.F.)
| | - Elisa Sanz Barbero
- Peripheral Nerve Unit, Neurophysiology Department, University Hospital of Getafe, 28905 Madrid, Spain;
| | - Ana Gutiérrez-Pecharromán
- Peripheral Nerve Unit, Pathological Anatomy Department, University Hospital of Getafe, 28905 Madrid, Spain;
| | - Francisco Díaz Montero
- Department of Design, BAU College of Arts & Design of Barcelona, 28036 Barcelona, Spain;
| | - Andrés A. Maldonado
- Peripheral Nerve Unit, Department of Plastic Surgery, University Hospital of Getafe, 28905 Madrid, Spain; (J.G.-P.); (L.C.)
- Department of Medicine, Faculty of Biomedical Science and Health, Universidad Europea de Madrid, 28670 Madrid, Spain
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Hanwright PJ, Suresh V, Shores JT, Souza JM, Tuffaha SH. Current Concepts in Lower Extremity Amputation: A Primer for Plastic Surgeons. Plast Reconstr Surg 2023; 152:724e-736e. [PMID: 37768220 DOI: 10.1097/prs.0000000000010664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the goals of lower extremity reconstruction and identify clinical scenarios favoring amputation. 2. Understand lower extremity amputation physiology and biomechanics. 3. Review soft-tissue considerations to achieve durable coverage. 4. Appreciate the evolving management of transected nerves. 5. Highlight emerging applications of osseointegration and strategies to improve myoelectric prosthetic control. SUMMARY Plastic surgeons are well versed in lower extremity reconstruction for traumatic, oncologic, and ischemic causes. Limb amputation is an increasingly sophisticated component of the reconstructive algorithm and is indicated when the residual limb is predicted to be more functional than a salvaged limb. Although plastic surgeons have traditionally focused on limb salvage, they play an increasingly vital role in optimizing outcomes from amputation. This warrants a review of core concepts and an update on emerging reconstructive techniques in amputee care.
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Affiliation(s)
- Philip J Hanwright
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Visakha Suresh
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jaimie T Shores
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
| | - Jason M Souza
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center
| | - Sami H Tuffaha
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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Leach GA, Dean RA, Kumar NG, Tsai C, Chiarappa FE, Cederna PS, Kung TA, Reid CM. Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5127. [PMID: 37465283 PMCID: PMC10351954 DOI: 10.1097/gox.0000000000005127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 07/20/2023]
Abstract
Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.
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Affiliation(s)
- Garrison A. Leach
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Riley A. Dean
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Nishant Ganesh Kumar
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Catherine Tsai
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Frank E. Chiarappa
- Department of Orthopedic Surgery, University of California San Diego, La Jolla, Calif
| | - Paul S. Cederna
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Theodore A. Kung
- Section of Plastic and Reconstructive Surgery and the Department of Biomedical Engineering, University of Michigan, Ann Arbor, Mich
| | - Chris M. Reid
- From the Department of General Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
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Farina D, Vujaklija I, Brånemark R, Bull AMJ, Dietl H, Graimann B, Hargrove LJ, Hoffmann KP, Huang HH, Ingvarsson T, Janusson HB, Kristjánsson K, Kuiken T, Micera S, Stieglitz T, Sturma A, Tyler D, Weir RFF, Aszmann OC. Toward higher-performance bionic limbs for wider clinical use. Nat Biomed Eng 2023; 7:473-485. [PMID: 34059810 DOI: 10.1038/s41551-021-00732-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/01/2021] [Indexed: 12/19/2022]
Abstract
Most prosthetic limbs can autonomously move with dexterity, yet they are not perceived by the user as belonging to their own body. Robotic limbs can convey information about the environment with higher precision than biological limbs, but their actual performance is substantially limited by current technologies for the interfacing of the robotic devices with the body and for transferring motor and sensory information bidirectionally between the prosthesis and the user. In this Perspective, we argue that direct skeletal attachment of bionic devices via osseointegration, the amplification of neural signals by targeted muscle innervation, improved prosthesis control via implanted muscle sensors and advanced algorithms, and the provision of sensory feedback by means of electrodes implanted in peripheral nerves, should all be leveraged towards the creation of a new generation of high-performance bionic limbs. These technologies have been clinically tested in humans, and alongside mechanical redesigns and adequate rehabilitation training should facilitate the wider clinical use of bionic limbs.
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Affiliation(s)
- Dario Farina
- Department of Bioengineering, Imperial College London, London, UK.
| | - Ivan Vujaklija
- Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland
| | - Rickard Brånemark
- Center for Extreme Bionics, Biomechatronics Group, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK
| | - Hans Dietl
- Ottobock Products SE & Co. KGaA, Vienna, Austria
| | | | - Levi J Hargrove
- Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine & Rehabilitation, Northwestern University, Chicago, IL, USA
- Department of Biomedical Engineering, Northwestern University, Chicago, IL, USA
| | - Klaus-Peter Hoffmann
- Department of Medical Engineering & Neuroprosthetics, Fraunhofer-Institut für Biomedizinische Technik, Sulzbach, Germany
| | - He Helen Huang
- NCSU/UNC Joint Department of Biomedical Engineering, North Carolina State University, Raleigh, NC, USA
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thorvaldur Ingvarsson
- Department of Research and Development, Össur Iceland, Reykjavík, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Hilmar Bragi Janusson
- School of Engineering and Natural Sciences, University of Iceland, Reykjavík, Iceland
| | | | - Todd Kuiken
- Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine & Rehabilitation, Northwestern University, Chicago, IL, USA
- Department of Biomedical Engineering, Northwestern University, Chicago, IL, USA
| | - Silvestro Micera
- The Biorobotics Institute and Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pontedera, Italy
- Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pontedera, Italy
- Bertarelli Foundation Chair in Translational NeuroEngineering, Center for Neuroprosthetics and Institute of Bioengineering, School of Engineering, Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | - Thomas Stieglitz
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering-IMTEK, BrainLinks-BrainTools Center and Bernstein Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Agnes Sturma
- Department of Bioengineering, Imperial College London, London, UK
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| | - Dustin Tyler
- Case School of Engineering, Case Western Reserve University, Cleveland, OH, USA
- Louis Stokes Veterans Affairs Medical Centre, Cleveland, OH, USA
| | - Richard F Ff Weir
- Biomechatronics Development Laboratory, Bioengineering Department, University of Colorado Denver and VA Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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Yu AX, Wang Z, Yi XZ. Regenerative peripheral nerve interface prevents neuroma formation after peripheral nerve transection. Neural Regen Res 2023; 18:814-818. [DOI: 10.4103/1673-5374.353498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lee C, Vaskov AK, Gonzalez MA, Vu PP, Davis AJ, Cederna PS, Chestek CA, Gates DH. Use of regenerative peripheral nerve interfaces and intramuscular electrodes to improve prosthetic grasp selection: a case study. J Neural Eng 2022; 19:10.1088/1741-2552/ac9e1c. [PMID: 36317254 PMCID: PMC9942093 DOI: 10.1088/1741-2552/ac9e1c] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Objective.Advanced myoelectric hands enable users to select from multiple functional grasps. Current methods for controlling these hands are unintuitive and require frequent recalibration. This case study assessed the performance of tasks involving grasp selection, object interaction, and dynamic postural changes using intramuscular electrodes with regenerative peripheral nerve interfaces (RPNIs) and residual muscles.Approach.One female with unilateral transradial amputation participated in a series of experiments to compare the performance of grasp selection controllers with RPNIs and intramuscular control signals with controllers using surface electrodes. These experiments included a virtual grasp-matching task with and without a concurrent cognitive task and physical tasks with a prosthesis including standardized functional assessments and a functional assessment where the individual made a cup of coffee ('Coffee Task') that required grasp transitions.Main results.In the virtual environment, the participant was able to select between four functional grasps with higher accuracy using the RPNI controller (92.5%) compared to surface controllers (81.9%). With the concurrent cognitive task, performance of the virtual task was more consistent with RPNI controllers (reduced accuracy by 1.1%) compared to with surface controllers (4.8%). When RPNI signals were excluded from the controller with intramuscular electromyography (i.e. residual muscles only), grasp selection accuracy decreased by up to 24%. The participant completed the Coffee Task with 11.7% longer completion time with the surface controller than with the RPNI controller. She also completed the Coffee Task with 11 fewer transition errors out of a maximum of 25 total errors when using the RPNI controller compared to surface controller.Significance.The use of RPNI signals in concert with residual muscles and intramuscular electrodes can improve grasp selection accuracy in both virtual and physical environments. This approach yielded consistent performance without recalibration needs while reducing cognitive load associated with pattern recognition for myoelectric control (clinical trial registration number NCT03260400).
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Affiliation(s)
- Christina Lee
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Alex K. Vaskov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Philip P. Vu
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Alicia J. Davis
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Paul S. Cederna
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H. Gates
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
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Vaskov AK, Vu PP, North N, Davis AJ, Kung TA, Gates DH, Cederna PS, Chestek CA. Surgically Implanted Electrodes Enable Real-Time Finger and Grasp Pattern Recognition for Prosthetic Hands. IEEE T ROBOT 2022; 38:2841-2857. [PMID: 37193351 PMCID: PMC10168021 DOI: 10.1109/tro.2022.3170720] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Currently available prosthetic hands are capable of actuating anywhere from five to 30 degrees of freedom (DOF). However, grasp control of these devices remains unintuitive and cumbersome. To address this issue, we propose directly extracting finger commands from the neuromuscular system. Two persons with transradial amputations had bipolar electrodes implanted into regenerative peripheral nerve interfaces (RPNIs) and residual innervated muscles. The implanted electrodes recorded local electromyography with large signal amplitudes. In a series of single-day experiments, participants used a high speed movement classifier to control a virtual prosthetic hand in real-time. Both participants transitioned between 10 pseudo-randomly cued individual finger and wrist postures with an average success rate of 94.7% and trial latency of 255 ms. When the set was reduced to five grasp postures, metrics improved to 100% success and 135 ms trial latency. Performance remained stable across untrained static arm positions while supporting the weight of the prosthesis. Participants also used the high speed classifier to switch between robotic prosthetic grips and complete a functional performance assessment. These results demonstrate that pattern recognition systems can use intramuscular electrodes and RPNIs for fast and accurate prosthetic grasp control.
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Affiliation(s)
- Alex K Vaskov
- Robotics Institute, University of Michigan, Ann Arbor, MI 48109 USA
| | - Philip P Vu
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Naia North
- Mechanical Engineering department at University of Michigan, Ann Arbor, MI 48109 USA
| | - Alicia J Davis
- Department of Physical Medicine and Rehabilitation at the University of Michigan, Ann Arbor, MI 48109 USA
| | - Theodore A Kung
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Deanna H Gates
- School of Kinesiology, University of Michigan, Ann Arbor, MI 48109 USA
| | - Paul S Cederna
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI 48109 USA
| | - Cynthia A Chestek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109 USA
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Wang Z, Zhang D, Yi XZ, Zhao Y, Yu A. Effects of regenerative peripheral nerve interface on dorsal root ganglia neurons following peripheral axotomy. Front Neurosci 2022; 16:914344. [PMID: 36161173 PMCID: PMC9489947 DOI: 10.3389/fnins.2022.914344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/15/2022] [Indexed: 12/05/2022] Open
Abstract
Background Long-term delayed reconstruction of injured peripheral nerves always results in poor recovery. One important reason is retrograde cell death among injured sensory neurons of dorsal root ganglia (DRG). A regenerative peripheral nerve interface (RPNI) was capable of generating new synaptogenesis between the proximal nerve stump and free muscle graft. Meanwhile, sensory receptors within the skeletal muscle can also be readily reinnervated by donor sensory axons, which allows the target muscles to become sources of sensory information for function reconstruction. To date, the effect of RPNI on injured sensory neurons is still unclear. Here, we aim to investigate the potential neuroprotective role of RPNI on sensory DRG neurons after sciatic axotomy in adult rats. Materials and methods The sciatic nerves of sixty rats were transected. The rats were randomly divided into three groups following this nerve injury: no treatment (control group, n = 20), nerve stump implantation inside a fully innervated muscle (NSM group, n = 20), or nerve stump implantation inside a free muscle graft (RPNI group, n = 20). At 8 weeks post-axotomy, ipsilateral L4 and L5 DRGs were harvested in each group. Toluidine blue staining was employed to quantify the neuronal densities in DRGs. The neuronal apoptosis index was quantified with TUNEL assay. Western blotting was applied to measure the expressions of Bax, Bcl-2, and neurotrophins (NTs) in ipsilateral DRGs. Results There were significantly higher densities of neurons in ipsilateral DRGs of RPNI group than NSM and control groups at 8 weeks post-axotomy (p < 0.01). Meanwhile, neuronal apoptosis index and the expressions of pro-apoptotic Bax within the ipsilateral DRGs were significantly lower in the RPNI group than those in the control and NSM groups (p < 0.05), while the opposite result was observed in the expression of pro-survival Bcl-2. Furthermore, the expressions of NGF, NT-3, BDNF, and GDNF were also upregulated in the ipsilateral DRGs in the RPNI group (p < 0.01). Conclusion The present results demonstrate that RPNI could prevent neuronal loss after peripheral axotomy. And the neuroprotection effect has a relationship with the upregulation of NTs in DRGs, such as NGF, NT-3, BDNF, and GDNF. These findings provide an effective therapy for neuroprotection in the delayed repair of the peripheral nerve injury.
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Suresh V, Schaefer EJ, Calotta NA, Giladi AM, Tuffaha SH. Use of Vascularized, Denervated Muscle Targets for Prevention and Treatment of Upper-Extremity Neuromas. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:92-96. [PMID: 36704382 PMCID: PMC9870797 DOI: 10.1016/j.jhsg.2022.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/01/2022] [Indexed: 01/29/2023] Open
Abstract
Purpose Neuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options. In this study, we followed the short-term pain outcomes of patients who underwent VDMT surgery for neuroma prevention or treatment. Methods We performed a retrospective chart review of 9 patients (2 pediatric and 7 adult) who underwent VDMTs either for symptomatic upper-extremity neuromas or as a prophylactic measure to prevent primary neuroma formation. In-person and/or telephone interviews were conducted to assess their postoperative clinical outcomes, including the visual analog pain scale simple pain score. Results Of the 9 patients included in this study, 7 underwent VDMT surgery as a prophylactic measure against neuroma formation, and 2 presented with symptomatic neuromas that were treated with VDMTs. The average follow-up was 5.6 ± 4.1 months (range, 0.5-13.2 months). The average postoperative pain score of the 7 adult patients was 1.1 (range, 0-8). Conclusions This study demonstrated favorable short-term outcomes in a small cohort of patients treated with VDMTs in the upper extremity. Larger, prospective, and comparative studies with validated patient-reported and objective outcome measures and longer-term follow-ups are needed to further evaluate the benefits of VDMTs in upper-extremity neuroma management and prevention. Type of study/level of evidence Therapeutic III.
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Affiliation(s)
- Visakha Suresh
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eliana J. Schaefer
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD,Department of Orthopedics, Georgetown University School of Medicine, Washington, DC
| | - Nicholas A. Calotta
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aviram M. Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD,Corresponding author: Sami H. Tuffaha, MD, and Aviram M.Giladi, MD, MS, The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, JPB #200, Baltimore, MD 21218.
| | - Sami H. Tuffaha
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD,The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD,Corresponding author: Sami H. Tuffaha, MD, and Aviram M.Giladi, MD, MS, The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, JPB #200, Baltimore, MD 21218.
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12
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Gonzalez MA, Vu PP, Vaskov AK, Cederna PS, Chestek CA, Gates DH. Characterizing sensory thresholds and intensity sensitivity of Regenerative Peripheral Nerve Interfaces: A Case Study . IEEE Int Conf Rehabil Robot 2022; 2022:1-6. [PMID: 36176116 DOI: 10.1109/icorr55369.2022.9896481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current prosthetic limbs offer little to no sensory feedback. Developments in peripheral nerve interfaces provide opportunities to restore some level of tactile feedback that is referred to the prosthetic limb. One such method is a Regenerative Peripheral Nerve Interface (RPNI), composed of a muscle graft wrapped around a free nerve ending. Here, we characterize perception and discomfort thresholds, as well as sensitivity to stimulation through two-alternative forced choice discrimination tasks. One person with transradial amputation who had one RPNI constructed from the median nerve and two constructed from the ulnar nerve participated. Average perception thresholds across all RPNIs were between 950 and 1120 nC with variance of less than 350 nC over a 36-month period. Discomfort thresholds were from 3880 nC to 9770 nC across all RPNIs. The just noticeable difference for the Median RPNI was 520 nC, larger than either the Ulnar-1 or Ulnar-2 RPNIs (210 nC, 470 nC, respectively). We also calculated Weber fractions to compare sensitivity between different RPNIs and relate our results to previous studies. Weber fractions for each of the Median, Ulnar-1, and Ulnar-2 RPNIs were 0.134, 0.088, 0.087, respectively. This work is the first to quantify the functional stimulation range and sensitivity of RPNIs in a human participant. Future work will focus on characterizing RPNI sensation in additional individuals to determine if these findings are generalizable to the amputee population.
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13
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Mablekos-Alexiou A, Kontogiannopoulos S, Bertos GA, Papadopoulos E. A biomechatronics-based EPP topology for upper-limb prosthesis control: Modeling & benchtop prototype. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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14
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Pasluosta C, Kiele P, Čvančara P, Micera S, Aszmann OC, Stieglitz T. Bidirectional bionic limbs: a perspective bridging technology and physiology. J Neural Eng 2022; 19. [PMID: 35132954 DOI: 10.1088/1741-2552/ac4bff] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
Abstract
Precise control of bionic limbs relies on robust decoding of motor commands from nerves or muscles signals and sensory feedback from artificial limbs to the nervous system by interfacing the afferent nerve pathways. Implantable devices for bidirectional communication with bionic limbs have been developed in parallel with research on physiological alterations caused by an amputation. In this perspective article, we question whether increasing our effort on bridging these technologies with a deeper understanding of amputation pathophysiology and human motor control may help to overcome pressing stalls in the next generation of bionic limbs.
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Affiliation(s)
- C Pasluosta
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - P Kiele
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | - P Čvančara
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany.,BrainLinks-BrainTools, University of Freiburg, Freiburg, Germany
| | - S Micera
- School of Engineering, École Polytechnique Fédérale de Lausanne, Bertarelli Foundation Chair in Translational Neuroengineering, Centre for Neuroprosthetics and Institute of Bioengineering, Lausanne, Switzerland.,The BioRobotics Institute and Department of Excellence in Robotics and Artificial Intelligence, Scuola Superiore Sant'Anna, Pisa, Italy
| | - O C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna; Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - T Stieglitz
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany.,Bernstein Center Freiburg, University of Freiburg, Freiburg, Germany.,BrainLinks-BrainTools, University of Freiburg, Freiburg, Germany
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15
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Regenerative Peripheral Nerve Interfaces for Advanced Prosthetic Control and Mitigation of Postamputation Pain. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Segil JL, Lukyanenko P, Lambrecht J, Weir RFF, Tyler D. Comparison of Myoelectric Control Schemes for Simultaneous Hand and Wrist Movement using Chronically Implanted Electromyography: A Case Series . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:6224-6230. [PMID: 34892537 PMCID: PMC10964936 DOI: 10.1109/embc46164.2021.9630845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE A current biomedical engineering challenge is the development of a system that allows fluid control of multi-functional prosthetic devices through a human-machine interface. Here we probe this challenge by studying two subjects with trans-radial limb loss as they control a virtual hand and wrist system using 6 or 8 chronically implanted intramuscular electromyographic (iEMG) signals. The subjects successfully controlled a 4, 5, and 6 Degrees of Freedom (DoF's) virtual hand and wrist systems to perform a target matching task. APPROACH Two control systems were evaluated where one tied EMG features directly to movement directions (Direct Control) and the other method determines user intent in the context of prior training data (Linear Interpolation). MAIN RESULTS Subjects successfully matched most targets with both controllers but differences were seen as the complexity of the virtual limb system increased. The Direct Control method encountered difficulty due to crosstalk at higher DoF's. The Linear Interpolation method reduced crosstalk effects and outperformed Direct Control at higher DoF's. This work also studied the use of the Postural Control Algorithm to control the hand postures simultaneously with wrist degrees of freedom. SIGNIFICANCE This work presents preliminary evidence that the PC algorithm can be used in conjunction with wrist control, that Direct Control with iEMG signals allows stable 4-DoF control, and that EMG pre-processing using the Linear Interpolation method can improve performance at 5 and 6-DoF's.
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17
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Kubiak CA, Adidharma W, Kung TA, Kemp SWP, Cederna PS, Vemuri C. "Decreasing Postamputation Pain with the Regenerative Peripheral Nerve Interface (RPNI)". Ann Vasc Surg 2021; 79:421-426. [PMID: 34656720 DOI: 10.1016/j.avsg.2021.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/06/2021] [Accepted: 08/14/2021] [Indexed: 11/01/2022]
Abstract
Over 185,000 limb amputations are performed in the United States annually, many of which are due to the sequelae of peripheral vascular disease. Symptomatic neuromas remain a significant source of postamputation morbidity and contribute to both phantom limb (PLP) and residual limb pain (RLP). While many interventions have been proposed for the treatment of symptomatic neuromas, conventional methods lead to a high incidence of neuroma recurrence. Furthermore, these existing methods do not facilitate an ability to properly interface with myoelectric prosthetic devices. The Regenerative Peripheral Nerve Interface (RPNI) was developed to overcome these limitations. The RPNI consists of an autologous free muscle graft secured around the end of a transected nerve. The muscle graft provides regenerating axons with end organs to reinnervate, thereby preventing neuroma formation. We have shown that this simple, reproducible, and safe surgical technique successfully treats and prevents neuroma formation in major limb amputations. In this paper, we describe RPNI surgery in the setting of major limb amputation and highlight the promising results of RPNIs in our animal and clinical studies.
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Affiliation(s)
- Carrie A Kubiak
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Widya Adidharma
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI.
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Chandu Vemuri
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
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18
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Ganesh Kumar N, Kung TA, Cederna PS. Regenerative Peripheral Nerve Interfaces for Advanced Control of Upper Extremity Prosthetic Devices. Hand Clin 2021; 37:425-433. [PMID: 34253315 DOI: 10.1016/j.hcl.2021.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The quest to find the ideal prosthetic device interface that enables intuitive control has motivated several recent innovations. Although current prosthetic device control strategies have advanced the field of neuroprosthetic control, they are limited in their ability to generate reliable, stable, and specific signals to replicate the complex movements of the upper extremity. The regenerative peripheral nerve interface (RPNI) is a promising solution to enhance prosthetic device control. This article describes the development of RPNIs and summarizes its successful use in the control of advanced prosthetic devices in patients with upper extremity amputations.
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Affiliation(s)
- Nishant Ganesh Kumar
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA
| | - Paul S Cederna
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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19
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Hand Bionic Score: a clinical follow-up study of severe hand injuries and development of a recommendation score to supply bionic prosthesis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background
Severe hand injuries significantly limit function and esthetics of the affected hand due to massive trauma in skeletal and soft tissues. Surgical reconstruction is often unsatisfactory, so bionic prostheses are a consideration. However, assessment of functional outcomes and quality of life after surgical reconstruction to guide clinical decisions immediately after injury and in the course of treatment remain difficult.
Methods
We conducted a prospective follow-up analysis of patients with severe hand injuries during 2016–2018. We retrospectively evaluated initial trauma severity and examined current functional status, quality of life, general function, and satisfaction in everyday situations of the hand. We also developed a novel Hand Bionic Score to guide clinical recommendation for selective amputation and bionic prosthesis supply.
Results
We examined 30 patients with a mean age of 53.8 years and mean initial severity of hand injury (iHISS) of 138.4. Measures indicated moderate quality of life limitations, moderate to severe limitation of overall hand function, and slight to moderate limitation of actual hand strength and function. Mean time to follow-up examination was 3.67 years. Using the measured outcomes, we developed a Hand Bionic Score that showed good ability to differentiate patients based on outcome markers. Appropriate cutoff scores for all measured outcome markers were used to determine Hand Bionic Score classifications to guide clinical recommendation for elective amputation and bionic prosthetic supply: < 10 points, bionic hand supply not recommended; 10–14, bionic supply should be considered; or > 14, bionic supply is recommended.
Conclusions
While iHISS can guide early clinical decisions following severe hand injury, our novel Hand Bionic Score provides orientation for clinical decision-making regarding elective amputation and bionic prosthesis supply later during the course of treatment. The score not only considers hand function but also psychological outcomes and quality of life, which are important considerations for patients with severe hand injuries. However, future randomized multicenter studies are needed to validate Hand Bionic Score before further clinical application.
Level of evidence: Level III, risk/prognostic study.
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20
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Hu Y, Ursu DC, Sohasky RA, Sando IC, Ambani SLW, French ZP, Mays EA, Nedic A, Moon JD, Kung TA, Cederna PS, Kemp SWP, Urbanchek MG. Regenerative peripheral nerve interface free muscle graft mass and function. Muscle Nerve 2020; 63:421-429. [PMID: 33290586 DOI: 10.1002/mus.27138] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 11/26/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Regenerative peripheral nerve interfaces (RPNIs) transduce neural signals to provide high-fidelity control of neuroprosthetic devices. Traditionally, rat RPNIs are constructed with ~150 mg of free skeletal muscle grafts. It is unknown whether larger free muscle grafts allow RPNIs to transduce greater signal. METHODS RPNIs were constructed by securing skeletal muscle grafts of various masses (150, 300, 600, or 1200 mg) to the divided peroneal nerve. In the control group, the peroneal nerve was transected without repair. Endpoint assessments were conducted 3 mo postoperatively. RESULTS Compound muscle action potentials (CMAPs), maximum tetanic isometric force, and specific muscle force were significantly higher for both the 150 and 300 mg RPNI groups compared to the 600 and 1200 mg RPNIs. Larger RPNI muscle groups contained central areas lacking regenerated muscle fibers. CONCLUSIONS Electrical signaling and tissue viability are optimal in smaller as opposed to larger RPNI constructs in a rat model.
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Affiliation(s)
- Yaxi Hu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Groningen, Groningen, The Netherlands
| | - Daniel C Ursu
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Racquel A Sohasky
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ian C Sando
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shoshana L W Ambani
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary P French
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth A Mays
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrej Nedic
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jana D Moon
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore A Kung
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul S Cederna
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen W P Kemp
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Melanie G Urbanchek
- Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, USA
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21
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Vaskov AK, Vu PP, North N, Davis AJ, Kung TA, Gates DH, Cederna PS, Chestek CA. Surgically Implanted Electrodes Enable Real-Time Finger and Grasp Pattern Recognition for Prosthetic Hands. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020:2020.10.28.20217273. [PMID: 33173910 PMCID: PMC7654906 DOI: 10.1101/2020.10.28.20217273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Currently available prosthetic hands are capable of actuating anywhere from five to 30 degrees of freedom (DOF). However, grasp control of these devices remains unintuitive and cumbersome. To address this issue, we propose directly extracting finger commands from the neuromuscular system via electrodes implanted in residual innervated muscles and regenerative peripheral nerve interfaces (RPNIs). Two persons with transradial amputations had RPNIs created by suturing autologous free muscle grafts to their transected median, ulnar, and dorsal radial sensory nerves. Bipolar electrodes were surgically implanted into their ulnar and median RPNIs and into their residual innervated muscles. The implanted electrodes recorded local electromyography (EMG) with Signal-to-Noise Ratios ranging from 23 to 350 measured across various movements. In a series of single-day experiments, participants used a high speed pattern recognition system to control a virtual prosthetic hand in real-time. Both participants were able to transition between 10 pseudo-randomly cued individual finger and wrist postures in the virtual environment with an average online accuracy of 86.5% and latency of 255 ms. When the set was reduced to five grasp postures, average metrics improved to 97.9% online accuracy and 135 ms latency. Virtual task performance remained stable across untrained static arm positions while supporting the weight of the prosthesis. Participants also used the high speed classifier to switch between robotic prosthetic grips and complete a functional performance assessment. These results demonstrate that pattern recognition systems can use the high-quality EMG afforded by intramuscular electrodes and RPNIs to provide users with fast and accurate grasp control. SUMMARY Surgically implanted electrodes recorded finger-specific electromyography enabling reliable finger and grasp control of an upper limb prosthesis.
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22
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TMRpni: Combining Two Peripheral Nerve Management Techniques. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3132. [PMID: 33173670 PMCID: PMC7647640 DOI: 10.1097/gox.0000000000003132] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Abstract
Amputee patients suffer high rates of chronic neuropathic pain, residual limb dysfunction, and disability. Recently, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are 2 techniques that have been advocated for such patients, given their ability to maximize intuitive prosthetic function while also minimizing neuropathic pain, such as residual and phantom limb pain. However, there remains room to further improve outcomes for our residual limb patients and patients suffering from symptomatic end neuromas. "TMRpni" is a nerve management technique that leverages beneficial elements described for both TMR and RPNI. TMRpni involves coaptation of a sensory or mixed sensory/motor nerve to a nearby motor nerve branch (ie, a nerve transfer), as performed in traditional TMR surgeries. Additionally, the typically mismatched nerve coaptation is wrapped with an autologous free muscle graft that is akin to an RPNI. The authors herein describe the "TMRpni" technique and illustrate a case where this technique was employed.
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23
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Bates TJ, Fergason JR, Pierrie SN. Technological Advances in Prosthesis Design and Rehabilitation Following Upper Extremity Limb Loss. Curr Rev Musculoskelet Med 2020; 13:485-493. [PMID: 32488625 PMCID: PMC7340716 DOI: 10.1007/s12178-020-09656-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The complexity of the human extremity, particularly the upper extremity and the hand, allows us to interact with the world. Prosthetists have struggled to recreate the intuitive motor control, light touch sensation, and proprioception of the innate limb in a manner that reflects the complexity of its native form and function. Nevertheless, recent advances in prosthesis technology, surgical innovations, and enhanced rehabilitation appear promising for patients with limb loss who hope to return to their pre-injury level of function. The purpose of this review is to illustrate recent technological advances that are moving us one step closer to the goal of multi-functional, self-identifiable, durable, and intuitive prostheses. RECENT FINDINGS Surgical advances such as targeted muscle reinnervation, regenerative peripheral nerve interfaces, agonist-antagonist myoneural interfaces, and targeted sensory reinnervation; development of technology designed to restore sensation, such as implanted sensors and haptic devices; and evolution of osseointegrated (bone-anchored) prostheses show great promise. Augmented and virtual reality platforms have the potential to enhance prosthesis design, pre-prosthetic training, incorporation, and use. Emerging technologies move surgeons, rehabilitation physicians, therapists, and prosthetists closer to the goal of creating highly functional prostheses with elevated sensory and motor control. Collaboration between medical teams, scientists, and industry stakeholders will be required to keep pace with patients who require durable, high-functioning prostheses.
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Affiliation(s)
- Taylor J Bates
- Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA-Ft Sam Houston, TX, 78234, USA
| | - John R Fergason
- Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, JBSA-Ft Sam Houston, TX, USA
| | - Sarah N Pierrie
- Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA-Ft Sam Houston, TX, 78234, USA.
- Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, JBSA-Ft Sam Houston, TX, USA.
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24
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Riccelli V, Pontell M, Gabrick K, Drolet BC. Outcomes Following Mangling Upper Extremity Trauma. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2792. [PMID: 32766027 PMCID: PMC7339232 DOI: 10.1097/gox.0000000000002792] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 11/25/2022]
Abstract
Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6-128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.
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26
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Santosa KB, Oliver JD, Cederna PS, Kung TA. Regenerative Peripheral Nerve Interfaces for Prevention and Management of Neuromas. Clin Plast Surg 2020; 47:311-321. [DOI: 10.1016/j.cps.2020.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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27
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Yildiz KA, Shin AY, Kaufman KR. Interfaces with the peripheral nervous system for the control of a neuroprosthetic limb: a review. J Neuroeng Rehabil 2020; 17:43. [PMID: 32151268 PMCID: PMC7063740 DOI: 10.1186/s12984-020-00667-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/17/2020] [Indexed: 12/22/2022] Open
Abstract
The field of prosthetics has been evolving and advancing over the past decade, as patients with missing extremities are expecting to control their prostheses in as normal a way as possible. Scientists have attempted to satisfy this expectation by designing a connection between the nervous system of the patient and the prosthetic limb, creating the field of neuroprosthetics. In this paper, we broadly review the techniques used to bridge the patient's peripheral nervous system to a prosthetic limb. First, we describe the electrical methods including myoelectric systems, surgical innovations and the role of nerve electrodes. We then describe non-electrical methods used alone or in combination with electrical methods. Design concerns from an engineering point of view are explored, and novel improvements to obtain a more stable interface are described. Finally, a critique of the methods with respect to their long-term impacts is provided. In this review, nerve electrodes are found to be one of the most promising interfaces in the future for intuitive user control. Clinical trials with larger patient populations, and for longer periods of time for certain interfaces, will help to evaluate the clinical application of nerve electrodes.
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Affiliation(s)
- Kadir A Yildiz
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kenton R Kaufman
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
- Motion Analysis Laboratory, W. Hall Wendel, Jr., Musculoskeletal Research, 200 First Street SW, Rochester, MN, 55905, USA.
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28
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Zheng XS, Griffith AY, Chang E, Looker MJ, Fisher LE, Clapsaddle B, Cui XT. Evaluation of a conducting elastomeric composite material for intramuscular electrode application. Acta Biomater 2020; 103:81-91. [PMID: 31863910 DOI: 10.1016/j.actbio.2019.12.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/25/2019] [Accepted: 12/10/2019] [Indexed: 01/14/2023]
Abstract
Electrical stimulation of the muscle has been proven efficacious in preventing atrophy and/or reanimating paralyzed muscles. Intramuscular electrodes made from metals have significantly higher Young's Moduli than the muscle tissues, which has the potential to cause chronic inflammation and decrease device performance. Here, we present an intramuscular electrode made from an elastomeric conducting polymer composite consisting of PEDOT-PEG copolymer, silicone and carbon nanotubes (CNT) with fluorosilicone insulation. The electrode wire has a Young's modulus of 804 (±99) kPa, which better mimics the muscle tissue modulus than conventional stainless steel (SS) electrodes. Additionally, the non-metallic composition enables metal-artifact free CT and MR imaging. These soft wire (SW) electrodes present comparable electrical impedance to SS electrodes of similar geometric surface area, activate muscle at a lower threshold, and maintain stable electrical properties in vivo up to 4 weeks. Histologically, the SW electrodes elicited significantly less fibrotic encapsulation and less IBA-1 positive macrophage accumulation than the SS electrodes at one and three months. Further phenotyping the macrophages with the iNOS (pro-inflammatory) and ARG-1 (pro-healing) markers revealed significantly less presence of pro-inflammatory macrophage around SW implants at one month. By three months, there was a significant increase in pro-healing macrophages (ARG-1) around the SW implants but not around the SS implants. Furthermore, a larger number of AchR clusters closer to SW implants were found at both time points compared to SS implants. These results suggest that a softer implant encourages a more intimate and healthier electrode-tissue interface. STATEMENT OF SIGNIFICANCE: Intramuscular electrodes made from metals have significantly higher Young's Moduli than the muscle tissues, which has the potential to cause chronic inflammation and decrease device performance. Here, we present an intramuscular electrode made from an elastomeric conducting polymer composite consisting of PEDOT-PEG copolymer, silicone and carbon nanotubes with fluorosilicone insulation. This elastomeric composite results in an electrode wire with a Young's modulus mimicking that of the muscle tissue, which elicits significantly less foreign body response compared to stainless steel wires. The lack of metal in this composite also enables metal-artifact free MRI and CT imaging.
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Affiliation(s)
- X Sally Zheng
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Azante Y Griffith
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Emily Chang
- TDA Research Inc., Wheat Ridge, CO 80033, United States
| | | | - Lee E Fisher
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - X Tracy Cui
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States; Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
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29
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Wolf EJ, Cruz TH, Emondi AA, Langhals NB, Naufel S, Peng GCY, Schulz BW, Wolfson M. Advanced technologies for intuitive control and sensation of prosthetics. Biomed Eng Lett 2020; 10:119-128. [PMID: 32175133 PMCID: PMC7046895 DOI: 10.1007/s13534-019-00127-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/31/2019] [Indexed: 02/06/2023] Open
Abstract
The Department of Defense, Department of Veterans Affairs and National Institutes of Health have invested significantly in advancing prosthetic technologies over the past 25 years, with the overall intent to improve the function, participation and quality of life of Service Members, Veterans, and all United States Citizens living with limb loss. These investments have contributed to substantial advancements in the control and sensory perception of prosthetic devices over the past decade. While control of motorized prosthetic devices through the use of electromyography has been widely available since the 1980s, this technology is not intuitive. Additionally, these systems do not provide stimulation for sensory perception. Recent research has made significant advancement not only in the intuitive use of electromyography for control but also in the ability to provide relevant meaningful perceptions through various stimulation approaches. While much of this previous work has traditionally focused on those with upper extremity amputation, new developments include advanced bidirectional neuroprostheses that are applicable to both the upper and lower limb amputation. The goal of this review is to examine the state-of-the-science in the areas of intuitive control and sensation of prosthetic devices and to discuss areas of exploration for the future. Current research and development efforts in external systems, implanted systems, surgical approaches, and regenerative approaches will be explored.
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Affiliation(s)
- Erik J. Wolf
- Clinical and Rehabilitative Medicine Research Program, US Army Medical Research and Development Command, Fort Detrick, MD 21702 USA
| | - Theresa H. Cruz
- National Institute of Child Health and Human Development, National Institute of Health, Bethesda, MD 20817 USA
| | - Alfred A. Emondi
- Defense Advanced Research Projects Agency, Arlington, VA 22203 USA
| | - Nicholas B. Langhals
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD 20892 USA
| | | | - Grace C. Y. Peng
- National Institute of Biomedical Imaging and Bioengineering, National Institute of Health, Bethesda, MD 20817 USA
| | - Brian W. Schulz
- VA Office of Research and Development, Washington, DC 20002 USA
| | - Michael Wolfson
- National Institute of Biomedical Imaging and Bioengineering, National Institute of Health, Bethesda, MD 20817 USA
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30
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Aman M, Bergmeister KD, Festin C, Sporer ME, Russold MF, Gstoettner C, Podesser BK, Gail A, Farina D, Cederna P, Aszmann OC. Experimental Testing of Bionic Peripheral Nerve and Muscle Interfaces: Animal Model Considerations. Front Neurosci 2020; 13:1442. [PMID: 32116485 PMCID: PMC7025572 DOI: 10.3389/fnins.2019.01442] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/23/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction: Man-machine interfacing remains the main challenge for accurate and reliable control of bionic prostheses. Implantable electrodes in nerves and muscles may overcome some of the limitations by significantly increasing the interface's reliability and bandwidth. Before human application, experimental preclinical testing is essential to assess chronic in-vivo biocompatibility and functionality. Here, we analyze available animal models, their costs and ethical challenges in special regards to simulating a potentially life-long application in a short period of time and in non-biped animals. Methods: We performed a literature analysis following the PRISMA guidelines including all animal models used to record neural or muscular activity via implantable electrodes, evaluating animal models, group size, duration, origin of publication as well as type of interface. Furthermore, behavioral, ethical, and economic considerations of these models were analyzed. Additionally, we discuss experience and surgical approaches with rat, sheep, and primate models and an approach for international standardized testing. Results: Overall, 343 studies matched the search terms, dominantly originating from the US (55%) and Europe (34%), using mainly small animal models (rat: 40%). Electrode placement was dominantly neural (77%) compared to muscular (23%). Large animal models had a mean duration of 135 ± 87.2 days, with a mean of 5.3 ± 3.4 animals per trial. Small animal models had a mean duration of 85 ± 11.2 days, with a mean of 12.4 ± 1.7 animals. Discussion: Only 37% animal models were by definition chronic tests (>3 months) and thus potentially provide information on long-term performance. Costs for large animals were up to 45 times higher than small animals. However, costs are relatively small compared to complication costs in human long-term applications. Overall, we believe a combination of small animals for preliminary primary electrode testing and large animals to investigate long-term biocompatibility, impedance, and tissue regeneration parameters provides sufficient data to ensure long-term human applications.
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Affiliation(s)
- Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias E Sporer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Alexander Gail
- Cognitive Neuroscience Lab, German Primate Center, Göttingen, Germany
| | - Dario Farina
- Department of Bioengineering, Imperial College, London, United Kingdom
| | - Paul Cederna
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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