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Kronsteiner B, Carrero-Rojas G, Reissig LF, Moghaddam AS, Schwendt KM, Gerges S, Maierhofer U, Aszmann OC, Pastor AM, Kiss A, Podesser BK, Birkfellner W, Moscato F, Blumer R, Weninger WJ. Characterization, number, and spatial organization of nerve fibers in the human cervical vagus nerve and its superior cardiac branch. Brain Stimul 2024; 17:510-524. [PMID: 38677543 DOI: 10.1016/j.brs.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/11/2024] [Accepted: 04/23/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Electrical stimulation of the vagus nerve (VN) is a therapy for epilepsy, obesity, depression, and heart diseases. However, whole nerve stimulation leads to side effects. We examined the neuroanatomy of the mid-cervical segment of the human VN and its superior cardiac branch to gain insight into the side effects of VN stimulation and aid in developing targeted stimulation strategies. METHODS Nerve specimens were harvested from eight human body donors, then subjected to immunofluorescence and semiautomated quantification to determine the signature, quantity, and spatial distribution of different axonal categories. RESULTS The right and left cervical VN (cVN) contained a total of 25,489 ± 2781 and 23,286 ± 3164 fibers, respectively. Two-thirds of the fibers were unmyelinated and one-third were myelinated. About three-quarters of the fibers in the right and left cVN were sensory (73.9 ± 7.5 % versus 72.4 ± 5.6 %), while 13.2 ± 1.8 % versus 13.3 ± 3.0 % were special visceromotor and parasympathetic, and 13 ± 5.9 % versus 14.3 ± 4.0 % were sympathetic. Special visceromotor and parasympathetic fibers formed clusters. The superior cardiac branches comprised parasympathetic, vagal sensory, and sympathetic fibers with the left cardiac branch containing more sympathetic fibers than the right (62.7 ± 5.4 % versus 19.8 ± 13.3 %), and 50 % of the left branch contained sensory and sympathetic fibers only. CONCLUSION The study indicates that selective stimulation of vagal sensory and motor fibers is possible. However, it also highlights the potential risk of activating sympathetic fibers in the superior cardiac branch, especially on the left side.
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Affiliation(s)
- Bettina Kronsteiner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Genova Carrero-Rojas
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Atieh Seyedian Moghaddam
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Karoline M Schwendt
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Sylvia Gerges
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Angel M Pastor
- Departamento de Fisiología, Facultad de Biología, Universidad de Sevilla, 41012, Sevilla, Spain
| | - Attila Kiss
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Center for Biomedical Research and Translational Surgery, Medical University of Vienna, Austria
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Center for Biomedical Research and Translational Surgery, Medical University of Vienna, Austria
| | - Wolfgang Birkfellner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Roland Blumer
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.
| | - Wolfgang J Weninger
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
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Tereshenko V, Dotzauer DC, Schmoll M, Harnoncourt L, Carrero Rojas G, Gfrerer L, Eberlin KR, Austen WG, Blumer R, Farina D, Aszmann OC. Peripheral neural interfaces: Skeletal muscles are hyper-reinnervated according to the axonal capacity of the surgically rewired nerves. Sci Adv 2024; 10:eadj3872. [PMID: 38416828 PMCID: PMC10901366 DOI: 10.1126/sciadv.adj3872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
Advances in robotics have outpaced the capabilities of man-machine interfaces to decipher and transfer neural information to and from prosthetic devices. We emulated clinical scenarios where high- (facial) or low-neural capacity (ulnar) donor nerves were surgically rewired to the sternomastoid muscle, which is controlled by a very small number of motor axons. Using retrograde tracing and electrophysiological assessments, we observed a nearly 15-fold functional hyper-reinnervation of the muscle after high-capacity nerve transfer, demonstrating its capability of generating a multifold of neuromuscular junctions. Moreover, the surgically redirected axons influenced the muscle's physiological characteristics, by altering the expression of myosin heavy-chain types in alignment with the donor nerve. These findings highlight the remarkable capacity of skeletal muscles to act as biological amplifiers of neural information from the spinal cord for governing bionic prostheses, with the potential of expressing high-dimensional neural function for high-information transfer interfaces.
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Affiliation(s)
- Vlad Tereshenko
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Dominik C Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Martin Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Leopold Harnoncourt
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Genova Carrero Rojas
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Dario Farina
- Department of Bioengineering, Imperial College London, South Kensington Campus London, SW7 2AZ London, UK
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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Gstoettner C, Laengle G, Harnoncourt L, Sassu P, Aszmann OC. Targeted muscle reinnervation in bionic upper limb reconstruction: current status and future directions. J Hand Surg Eur Vol 2024:17531934241227795. [PMID: 38366374 DOI: 10.1177/17531934241227795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man-machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Leopold Harnoncourt
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
| | - Paolo Sassu
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Orthoplastic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Vienna, Vienna, Austria
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Aszmann OC, Dellon AL. Discussion: Targeted Muscle Reinnervation at the Time of Amputation Decreases Recurrent Symptomatic Neuroma Formation. Plast Reconstr Surg 2024; 153:164-166. [PMID: 38127449 DOI: 10.1097/prs.0000000000010992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Oskar C Aszmann
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University
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Pejkova S, Aleksovski D, Hadjitrifon S, Tusheva S, Georgieva G, Srbov B, Aszmann OC. Paget-Schroetter syndrome: the importance of early detection and effective surgical intervention. Arch Clin Cases 2023; 10:200-204. [PMID: 38155995 PMCID: PMC10754040 DOI: 10.22551/2023.41.1004.10275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
Paget-Schroetter syndrome (PSS) is relatively rare condition of thoracic outlet syndrome characterized by thrombosis or blood clot formation in the subclavian vein. Due to the non-specific symptoms and low incidence rate, PSS is frequently missed by medical professionals, and as such it often leads to wrong diagnosis and untreated patients. We present the case of a 30-year-old CrossFit trainer who developed a thrombosis of the subclavian vein. Initially, the patient consulted an internist after experiencing swelling in the right shoulder region and discoloration of the right upper extremity. Angiography revealed occlusion of the subclavian vein and anticoagulant therapy was prescribed. For more than a year, the patient's symptoms remained unchanged, and the subclavian vein occlusion persisted. Venography suspected effort thrombosis of the subclavian vein. The patient underwent surgery for decompression of the subclavian vein. After six months, results from post-operative computed tomography angiography showed that venous flow was fully restored and no pathology of the venous vessel wall could be demonstrated. This report aims to increase awareness of PSS among medical professionals, leading to earlier diagnosis and adequate clinical-surgical management.
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Affiliation(s)
- Sofija Pejkova
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Darko Aleksovski
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Sara Hadjitrifon
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Sofija Tusheva
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Gordana Georgieva
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Blagoja Srbov
- University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Oskar C. Aszmann
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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Tereshenko V, Maierhofer U, Hruby LA, Klepetko J, Dotzauer DC, Politikou O, Laengle G, Luft M, Festin C, Blumer R, Bergmeister KD, Aszmann OC. Axonal mapping of motor and sensory components within the ulnar nerve and its branches. J Neurosurg 2023; 139:1396-1404. [PMID: 37029679 DOI: 10.3171/2023.2.jns23180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/08/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Intrinsic function is indispensable for dexterous hand movements. Distal ulnar nerve defects can result in intrinsic muscle dysfunction and sensory deficits. Although the ulnar nerve's fascicular anatomy has been extensively studied, quantitative and topographic data on motor axons traveling within this nerve remain elusive. METHODS The ulnar nerves of 14 heart-beating organ donors were evaluated. The motor branches to the flexor carpi ulnaris (FCU) and flexor digitorum profundus (FDP) muscles and the dorsal branch (DoBUN) as well as 3 segments of the ulnar nerve were harvested in 2-cm increments. Samples were subjected to double immunofluorescence staining using antibodies against choline acetyltransferase and neurofilament. RESULTS Samples revealed more than 25,000 axons in the ulnar nerve at the forearm level, with a motor axon proportion of only 5%. The superficial and DoBUN showed high axon numbers of more than 21,000 and 9300, respectively. The axonal mapping of more than 1300 motor axons revealed an increasing motor/sensory ratio from the proximal ulnar nerve (1:20) to the deep branch of the ulnar nerve (1:7). The motor branches (FDP and FCU) showed that sensory axons outnumber motor axons by a ratio of 10:1. CONCLUSIONS Knowledge of the detailed axonal architecture of the motor and sensory components of the human ulnar nerve is of the utmost importance for surgeons considering fascicular grafting or nerve transfer surgery. The low number of efferent axons in motor branches of the ulnar nerve and their distinct topographical distribution along the distal course of the nerve is indispensable information for modern nerve surgery.
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Affiliation(s)
- Vlad Tereshenko
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Udo Maierhofer
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Laura A Hruby
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
- Departments of2Orthopedics and Trauma Surgery and
| | - Johanna Klepetko
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Dominik C Dotzauer
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Olga Politikou
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Gregor Laengle
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Matthias Luft
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
- 3Department of Plastic, Aesthetic and Reconstructive Surgery, Karl Landsteiner University of Health Sciences, University Hospital St. Poelten, Krems, Austria; and
| | - Christopher Festin
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Roland Blumer
- 4Center for Anatomy and Cell Biology, Medical University of Vienna, Austria
| | - Konstantin D Bergmeister
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
- 3Department of Plastic, Aesthetic and Reconstructive Surgery, Karl Landsteiner University of Health Sciences, University Hospital St. Poelten, Krems, Austria; and
| | - Oskar C Aszmann
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
- 5Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Austria
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7
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Vetchy V, Aszmann OC, Laengle G, Platzgummer H. Intraneural Ganglion Cyst of the Tibial Nerve Originating from a Posterior Knee Joint Branch. Case Report on the Use of High-Resolution Volumetric Ultrasound and Magnetic Resonance Neurography. Ultraschall Med 2023; 44:547-549. [PMID: 36746197 DOI: 10.1055/a-2003-0999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Veronika Vetchy
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Gregor Laengle
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Hannes Platzgummer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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Pace A, Proksch L, Grioli G, Aszmann OC, Bicchi A, Catalano MG. An Experimental Setup to Test Obstacle-Dealing Capabilities of Prosthetic Feet. IEEE Int Conf Rehabil Robot 2023; 2023:1-6. [PMID: 37941253 DOI: 10.1109/icorr58425.2023.10304763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Small obstacles on the ground often lead to a fall when caught with commercial prosthetic feet. Despite some recently developed feet can actively control the ankle angle, for instance over slopes, their flat and rigid sole remains a cause of instability on uneven grounds. Soft robotic feet were recently proposed to tackle that issue; however, they lack consistent experimental validation. Therefore, this paper describes the experimental setup realized to test soft and rigid prosthetic feet with lower-limb prosthetic users. It includes a wooden walkway and differently shaped obstacles. It was preliminary validated with an able-bodied subject, the same subject walking on commercial prostheses through modified walking boots, and with a prosthetic user. They performed walking firstly on even ground, and secondly on even ground stepping on one of the obstacles. Results in terms of vertical ground reaction force and knee moments in both the sagittal and frontal planes show how the poor performance of commonly used prostheses is exacerbated in case of obstacles. The prosthetic user, indeed, noticeably relies on the sound leg to compensate for the stiff and unstable interaction of the prosthetic limb with the obstacle. Therefore, since the limitations of non-adaptive prosthetic feet in obstacle-dealing emerge from the experiments, as expected, this study justifies the use of the setup for investigating the performance of soft feet on uneven grounds and obstacle negotiation.
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Tereshenko V, Aszmann OC, Eberlin KR, Schweizer R, Austen WG, Dellon AL, Klein HJ. Beyond the tingling sensation: unveiling the neurobiological origin of the Hoffmann-Tinel sign. Plast Reconstr Surg 2023:00006534-990000000-02084. [PMID: 37585811 DOI: 10.1097/prs.0000000000010989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Vlad Tereshenko
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riccardo Schweizer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - William G Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A Lee Dellon
- Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Holger J Klein
- Department of Plastic Surgery and Hand Surgery, Kantonsspital Aarau, Aarau, Switzerland
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Tereshenko V, Maierhofer U, Dotzauer DC, Laengle G, Politikou O, Carrero Rojas G, Festin C, Luft M, Jaklin FJ, Hruby LA, Gohritz A, Farina D, Blumer R, Bergmeister KD, Aszmann OC. Axonal mapping of the motor cranial nerves. Front Neuroanat 2023; 17:1198042. [PMID: 37332322 PMCID: PMC10272770 DOI: 10.3389/fnana.2023.1198042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023] Open
Abstract
Basic behaviors, such as swallowing, speech, and emotional expressions are the result of a highly coordinated interplay between multiple muscles of the head. Control mechanisms of such highly tuned movements remain poorly understood. Here, we investigated the neural components responsible for motor control of the facial, masticatory, and tongue muscles in humans using specific molecular markers (ChAT, MBP, NF, TH). Our findings showed that a higher number of motor axonal population is responsible for facial expressions and tongue movements, compared to muscles in the upper extremity. Sensory axons appear to be responsible for neural feedback from cutaneous mechanoreceptors to control the movement of facial muscles and the tongue. The newly discovered sympathetic axonal population in the facial nerve is hypothesized to be responsible for involuntary control of the muscle tone. These findings shed light on the pivotal role of high efferent input and rich somatosensory feedback in neuromuscular control of finely adjusted cranial systems.
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Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik C. Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Genova Carrero Rojas
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Florian J. Jaklin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Laura A. Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gohritz
- Department of Plastic Surgery, University of Basel, Basel, Switzerland
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Konstantin D. Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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11
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Gohritz A, Laengle G, Boesendorfer A, Gesslbauer B, Gstoettner C, Politikou O, Sturma A, Aszmann OC. Nerve Transfers for Brachial Plexus Reconstruction in Patients over 60 Years. J Pers Med 2023; 13:jpm13040659. [PMID: 37109045 PMCID: PMC10142607 DOI: 10.3390/jpm13040659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Negative expectations regarding nerve reconstruction in the elderly prevail in the literature, but little is known about the effectiveness of nerve transfers in patients with brachial plexus injuries aged over 60 years. We present a series of five patients (1 female, 4 male) aged between 60 and 81 years (median 62.0 years) who underwent nerve reconstruction using multiple nerve transfers in brachial plexopathies. The etiology of brachial plexus injury was trauma (n = 2), or iatrogenic, secondary to spinal surgical laminectomy, tumor excision and radiation for breast cancer (n = 3). All but one patient underwent a one-stage reconstruction including neurolysis and extra-anatomical nerve transfer alone (n = 2) or combined with anatomical reconstruction by sural nerve grafts (n = 2). One patient underwent a two-stage reconstruction, which involved a first stage anatomical brachial plexus reconstruction followed by a second stage nerve transfer. Neurotizations were performed as double (n = 3), triple (n = 1) or quadruple (n = 1) nerve or fascicular transfers. Overall, at least one year postoperatively, successful results, characterized by a muscle strength of M3 or more, were restored in all cases, two patients even achieving M4 grading in the elbow flexion. This patient series challenges the widely held dogma that brachial plexus reconstruction in older patients will produce poor outcomes. Distal nerve transfers are advantageous as they shorten the reinnervation distance. Healthy, more elderly patients should be judiciously offered the whole spectrum of reconstructive methods and postoperative rehabilitation concepts to regain useful arm and hand function and thus preserve independence after a traumatic or nontraumatic brachial plexus injury.
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Affiliation(s)
- Andreas Gohritz
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, University Hospital, Petersgraben 4/Spitalstrasse 21, 4031 Basel, Switzerland
| | - Gregor Laengle
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Anna Boesendorfer
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Bernhard Gesslbauer
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
- Bachelor's Degree Program Physiotherapy, University of Applied Sciences FH Campus Wien, Favoritenstrasse 226, 1100 Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory of Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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12
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Bergmeister KD, Platzgummer H, Reichel-Vacariu G, Kretschmer T, Sturma A, Schaefer D, Mende K, Meissl G, Schlenz I, Aszmann OC, Rab M. [Perioperative Diagnostics of Peripheral Nerve Lesions and Compression Syndromes: Position Paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. HANDCHIR MIKROCHIR P 2023; 55:140-147. [PMID: 37023761 DOI: 10.1055/a-1984-8400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
The treatment of peripheral nerve pathologies requires a rapid and precise diagnosis. However, the correct identification of nerve pathologies is often difficult and valuable time is lost in the process. In this position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels (DAM), we describe the current evidence for various perioperative diagnostics for the detection of traumatic peripheral nerve lesions or compression syndromes. In detail, we evaluated the importance of clinical examinations, electrophysiology, nerve ultrasound and magnetic resonance neurography. Additionally, we surveyed our members for their diagnostic approach in this regard. The statements are based on a consensus workshop on the 42nd meeting of the DAM in Graz, Austria.
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Affiliation(s)
- Konstantin D Bergmeister
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Wien, Wien, Austria
- Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinikum St Pölten, St Polten, Austria
| | - Hannes Platzgummer
- Universitätsklinik für Radiologie und Nuklearmedizin, Klinische. Abteilung für Neuroradiologie und Muskuloskeletale Radiologie, Medizinische Universität Wien, Wien, Austria
| | - Gerda Reichel-Vacariu
- Institut für Physikalische Medizin und Orthopädische Rehabilitation, Orthopädisches Spital Speising GmbH, Wien, Austria
| | - Thomas Kretschmer
- Abteilung für Neurochirurgie und Neurorestauration, Klinikum Klagenfurt am Worthersee, Klagenfurt, Austria
| | - Agnes Sturma
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Wien, Wien, Austria
- Bachelorstudiengang Physiotherapie, Fachhochschule Campus Wien
| | - Dirk Schaefer
- Universitätsspital Basel, Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universität Basel, Schweiz
| | - Konrad Mende
- Universitätsspital Basel, Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universität Basel, Schweiz
| | - Günther Meissl
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Wien, Wien, Austria
| | - Ingrid Schlenz
- Abteilung für Plastische, Ästhetische und Wiederherstellungschirurgie, Klinik Ottakring, Wien, Austria
| | - Oskar C Aszmann
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Wien
| | - Matthias Rab
- Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Klinikum Klagenfurt am Wörthersee
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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Roche AD, Bailey ZK, Gonzalez M, Vu PP, Chestek CA, Gates DH, Kemp SWP, Cederna PS, Ortiz-Catalan M, Aszmann OC. Upper limb prostheses: bridging the sensory gap. J Hand Surg Eur Vol 2023; 48:182-190. [PMID: 36649123 PMCID: PMC9996795 DOI: 10.1177/17531934221131756] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Replacing human hand function with prostheses goes far beyond only recreating muscle movement with feedforward motor control. Natural sensory feedback is pivotal for fine dexterous control and finding both engineering and surgical solutions to replace this complex biological function is imperative to achieve prosthetic hand function that matches the human hand. This review outlines the nature of the problems underlying sensory restitution, the engineering methods that attempt to address this deficit and the surgical techniques that have been developed to integrate advanced neural interfaces with biological systems. Currently, there is no single solution to restore sensory feedback. Rather, encouraging animal models and early human studies have demonstrated that some elements of sensation can be restored to improve prosthetic control. However, these techniques are limited to highly specialized institutions and much further work is required to reproduce the results achieved, with the goal of increasing availability of advanced closed loop prostheses that allow sensory feedback to inform more precise feedforward control movements and increase functionality.
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Affiliation(s)
- Aidan D Roche
- College of Medicine, The Queen's Medical Research Institute, Edinburgh, UK.,Department of Plastic Surgery, NHS Lothian, Livingston, UK
| | - Zachary K Bailey
- Department of Bioengineering, Imperial College London, South Kensington Campus, UK
| | | | - Philip P Vu
- 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.,Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.,Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
| | - Deanna H Gates
- Robotics Institute, University of Michigan, Ann Arbor, MI, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI, USA
| | - Stephen W P Kemp
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Section of Plastic Surgery, 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
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden.,Department of Electrical Engineering, Chalmers University of Technology, Sweden.,Operational Area 3, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Oskar C Aszmann
- Department of Plastic & Reconstructive Surgery, Medical University of Vienna, Austria.,Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
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15
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Hruby LA, Sporer ME, Krusche-Mandl I, Tereshenko V, Platzgummer H, Hajdu S, Aszmann OC. Successful treatment of a painful neuroma using fascicular shifting in the ulnar nerve: Case report. J Reconstr Microsurg Open 2023. [DOI: 10.1055/a-2039-1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
The authors report the case of a forty-year old man with an inveterate ulnar nerve neuroma following a laceration injury of his left wrist twenty-three years ago. He presented with a typical ulnar claw-hand deformity and debilitating neuropathic pain in his hand (VAS 8.4). Pre-operative imaging revealed a neuroma of the ulnar nerve at the Guyon’s canal. Moreover, a complete atrophy of all intrinsic hand muscles innervated by the ulnar nerve was present. A Zancolli lasso procedure was performed to reduce the clawing effect. The neuroma was resected producing a nerve defect of five centimeters. Since the injury dated back more than two decades and any motor recovery was deemed impossible at that point, the motor fascicle of the ulnar nerve, i.e. the deep branch, was harvested and used as an autologous nerve graft to bridge the defect. The deep branch fascicle was dissected proximally, harvested and shifted into the defect to be coapted with the superficial branch fascicle in an end-to-end fashion. The presented procedure resulted in satisfying and sustained pain reduction (VAS 2.5) at two-year follow-up. Hence, the authors recommend considering fascicular shift procedure in peripheral sensory nerve reconstruction as a cost-effective alternative.
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Affiliation(s)
- Laura Antonia Hruby
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Wien, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Wien, Austria
| | - Matthias E. Sporer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Wien, Austria
| | - Irena Krusche-Mandl
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Wien, Austria
| | - Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Wien, Austria
| | - Hannes Platzgummer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Wien, Austria
| | - Stefan Hajdu
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Wien, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Wien, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Wien, Austria
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16
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Salminger S, Gstoettner C, Hirtler L, Blumer R, Fuchssteiner C, Laengle G, Mayer JA, Bergmeister KD, Weninger WJ, Aszmann OC. Distal Nerve Transfers in High Peroneal Nerve Lesions: An Anatomical Feasibility Study. J Pers Med 2023; 13:jpm13020344. [PMID: 36836578 PMCID: PMC9967983 DOI: 10.3390/jpm13020344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Abstract
The peroneal nerve is one of the most commonly injured nerves of the lower extremity. Nerve grafting has been shown to result in poor functional outcomes. The aim of this study was to evaluate and compare anatomical feasibility as well as axon count of the tibial nerve motor branches and the tibialis anterior motor branch for a direct nerve transfer to reconstruct ankle dorsiflexion. In an anatomical study on 26 human body donors (52 extremities) the muscular branches to the lateral (GCL) and the medial head (GCM) of the gastrocnemius muscle, the soleus muscle (S) as well as the tibialis anterior muscle (TA) were dissected, and each nerve's external diameter was measured. Nerve transfers from each of the three donor nerves (GCL, GCM, S) to the recipient nerve (TA) were performed and the distance between the achievable coaptation site and anatomic landmarks was measured. Additionally, nerve samples were taken from eight extremities, and antibody as well immunofluorescence staining were performed, primarily evaluating axon count. The average diameter of the nerve branches to the GCL was 1.49 ± 0.37, to GCM 1.5 ± 0.32, to S 1.94 ± 0.37 and to TA 1.97 ± 0.32 mm, respectively. The distance from the coaptation site to the TA muscle was 43.75 ± 12.1 using the branch to the GCL, 48.31 ± 11.32 for GCM, and 19.12 ± 11.68 mm for S, respectively. The axon count for TA was 1597.14 ± 325.94, while the donor nerves showed 297.5 ± 106.82 (GCL), 418.5 ± 62.44 (GCM), and 1101.86 ± 135.92 (S). Diameter and axon count were significantly higher for S compared to GCL as well as GCM, while regeneration distance was significantly lower. The soleus muscle branch exhibited the most appropriate axon count and nerve diameter in our study, while also reaching closest to the tibialis anterior muscle. These results indicate the soleus nerve transfer to be the favorable option for the reconstruction of ankle dorsiflexion, in comparison to the gastrocnemius muscle branches. This surgical approach can be used to achieve a biomechanically appropriate reconstruction, in contrast to tendon transfers which generally only achieve weak active dorsiflexion.
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Affiliation(s)
- Stefan Salminger
- AUVA Trauma Hospital Lorenz Böhler—European Hand Trauma Center, Donaueschingenstrasse 13, 1200 Vienna, Austria
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
| | - Clemens Gstoettner
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Lena Hirtler
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, 1090 Vienna, Austria
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Fuchssteiner
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, 1090 Vienna, Austria
| | - Gregor Laengle
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Johannes A. Mayer
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, Karl Landsteiner University of Health Sciences, University Hospital St. Poelten, 3100 Krems, Austria
| | - Konstantin D. Bergmeister
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, Karl Landsteiner University of Health Sciences, University Hospital St. Poelten, 3100 Krems, Austria
| | - Wolfgang J. Weninger
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, 1090 Vienna, Austria
| | - Oskar C. Aszmann
- Deparment of Plastic and Reconstructive Surgery, Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic and Reconstructive Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-69940; Fax: +43-1-40400-69880
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17
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Reissig LF, Carrero-Rojas G, Maierhofer U, Moghaddam AS, Hainfellner A, Gesslbauer B, Haider T, Streicher J, Aszmann OC, Pastor AM, Weninger WJ, Blumer R. Spinal cord from body donors is suitable for multicolor immunofluorescence. Histochem Cell Biol 2023; 159:23-45. [PMID: 36201037 PMCID: PMC9899749 DOI: 10.1007/s00418-022-02154-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 02/07/2023]
Abstract
Immunohistochemistry is a powerful tool for studying neuronal tissue from humans at the molecular level. Obtaining fresh neuronal tissue from human organ donors is difficult and sometimes impossible. In anatomical body donations, neuronal tissue is dedicated to research purposes and because of its easier availability, it may be an alternative source for research. In this study, we harvested spinal cord from a single organ donor 2 h (h) postmortem and spinal cord from body donors 24, 48, and 72 h postmortem and tested how long after death, valid multi-color immunofluorescence or horseradish peroxidase (HRP) immunohistochemistry is possible. We used general and specific neuronal markers and glial markers for immunolabeling experiments. Here we showed that it is possible to visualize molecularly different neuronal elements with high precision in the body donor spinal cord 24 h postmortem and the quality of the image data was comparable to those from the fresh organ donor spinal cord. High-contrast multicolor images of the 24-h spinal cords allowed accurate automated quantification of different neuronal elements in the same sample. Although there was antibody-specific signal reduction over postmortem intervals, the signal quality for most antibodies was acceptable at 48 h but no longer at 72 h postmortem. In conclusion, our study has defined a postmortem time window of more than 24 h during which valid immunohistochemical information can be obtained from the body donor spinal cord. Due to the easier availability, neuronal tissue from body donors is an alternative source for basic and clinical research.
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Affiliation(s)
- Lukas F. Reissig
- Division of Anatomy, MIC, Medical University Vienna, Vienna, Austria
| | | | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Bernhard Gesslbauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Haider
- Department of Orthopedic and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Streicher
- Department of Anatomy and Biomechanics, Division of Anatomy and Developmental Biology, Karl Landsteiner University of Health Science, Krems an der Donau, Austria
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Angel M. Pastor
- Departamento de Fisiología, Facultad de Biología, Universidad de Sevilla, Seville, Spain
| | | | - Roland Blumer
- Division of Anatomy, MIC, Medical University Vienna, Vienna, Austria
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18
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Sporer ME, Brugger PC, Aman M, Fuchssteiner CF, Festin C, Gstoettner C, Aszmann OC. Fascicular shifting in the reconstruction of brachial plexus injuries: an anatomical and clinical evaluation. J Neurosurg 2022:1-10. [PMID: 36681968 DOI: 10.3171/2022.11.jns221312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Until recently, autologous sensory nerve grafting has remained the gold-standard technique in peripheral nerve reconstruction. However, there are several disadvantages to these grafts, such as donor site morbidity, limited availability, and a qualitative mismatch. Building on this shortage, a new concept, the fascicular shift procedure, was proposed and successfully demonstrated nerve regeneration in a rat nerve injury model. This approach involves harvesting a fascicular group distal to a peripheral nerve injury and shifting it to bridge the defect. The present study aimed to evaluate the clinical applicability of this technique in brachial plexus reconstruction. METHODS The supra- and infraclavicular nerves of the brachial plexus were bilaterally explored in 18 formalin-fixed cadaveric specimens. Following dissection, their fascicular shifting potential was evaluated. The medial antebrachial cutaneous and sural nerves were investigated and used as references for the required cross-sectional area of potential nerve grafts. Furthermore, 29 brachial plexus injuries, which qualified for surgical repair, were subjected to retrospective analysis. The intraoperatively measured lengths of the harvested and ultimately transplanted nerve grafts served as a basis to assess graft requirements in brachial plexus lesions. RESULTS The transplanted nerve grafts measured a total length of 51.9 ± 28.1 cm in brachial plexus injuries. The individual inserted nerve grafts averaged 10.3 ± 5.1 cm. In the anatomical exploration, the ulnar and median nerves qualified for fascicular shifting. Their fascicular graft lengths measured 26.6 ± 2.5 cm and 24.8 ± 5.2 cm, respectively. The long thoracic, suprascapular, musculocutaneous, thoracodorsal, and axillary nerves were not suitable for fascicular shifting. The sensory graft length of the medial antebrachial cutaneous nerve measured 20.6 ± 3.4 cm. CONCLUSIONS In the surgical reconstruction of brachial plexus injuries, fascicular shifting of the ulnar and median nerves provides sufficient donor material. Even though potential donor length is limited in the radial nerve, it may still help to expand the surgical armamentarium in selected clinical scenarios. Overall, the fascicular shift procedure presents a novel alternative to allow modality-matched grafting in the reconstruction of large proximal nerve defects and was found to be an attractive option in brachial plexus reconstruction.
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Affiliation(s)
- Matthias E Sporer
- 1Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna
| | - Peter C Brugger
- 2Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Martin Aman
- 1Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna
- 3Department of Hand-, Plastic- and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; and
| | - Christoph F Fuchssteiner
- 2Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- 1Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna
| | - Clemens Gstoettner
- 1Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna
- 4Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- 1Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna
- 4Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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Tereshenko V, Dotzauer DC, Luft M, Ortmayr J, Maierhofer U, Schmoll M, Festin C, Carrero Rojas G, Klepetko J, Laengle G, Politikou O, Farina D, Blumer R, Bergmeister KD, Aszmann OC. Autonomic Nerve Fibers Aberrantly Reinnervate Denervated Facial Muscles and Alter Muscle Fiber Population. J Neurosci 2022; 42:8297-8307. [PMID: 36216502 PMCID: PMC9653283 DOI: 10.1523/jneurosci.0670-22.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022] Open
Abstract
The surgical redirection of efferent neural input to a denervated muscle via a nerve transfer can reestablish neuromuscular control after nerve injuries. The role of autonomic nerve fibers during the process of muscular reinnervation remains largely unknown. Here, we investigated the neurobiological mechanisms behind the spontaneous functional recovery of denervated facial muscles in male rodents. Recovered facial muscles demonstrated an abundance of cholinergic axonal endings establishing functional neuromuscular junctions. The parasympathetic source of the neuronal input was confirmed to be in the pterygopalatine ganglion. Furthermore, the autonomically reinnervated facial muscles underwent a muscle fiber change to a purely intermediate muscle fiber population myosin heavy chain type IIa. Finally, electrophysiological tests revealed that the postganglionic parasympathetic fibers travel to the facial muscles via the sensory infraorbital nerve. Our findings demonstrated expanded neuromuscular plasticity of denervated striated muscles enabling functional recovery via alien autonomic fibers. These findings may further explain the underlying mechanisms of sensory protection implemented to prevent atrophy of a denervated muscle.SIGNIFICANCE STATEMENT Nerve injuries represent significant morbidity and disability for patients. Rewiring motor nerve fibers to other target muscles has shown to be a successful approach in the restoration of motor function. This demonstrates the remarkable capacity of the CNS to adapt to the needs of the neuromuscular system. Yet, the capability of skeletal muscles being reinnervated by nonmotor axons remains largely unknown. Here, we show that under deprivation of original efferent input, the neuromuscular system can undergo functional and morphologic remodeling via autonomic nerve fibers. This may explain neurobiological mechanisms of the sensory protection phenomenon, which is because of parasympathetic reinnervation.
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Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Dominik C Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Joachim Ortmayr
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Johanna Klepetko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | | | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Centers for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic, Aesthetic, and Reconstructive Surgery, Karl Landsteiner University of Health Sciences, University Hospital, A-3500 Krems an der Donau, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria
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Salminger S, Gstoettner C, Sturma A, Mayer JA, Papst H, Aszmann OC. Actual prosthetic usage in relation to functional outcomes and wearing time in individuals with below-elbow amputation. Prosthet Orthot Int 2022; 46:408-413. [PMID: 35511449 DOI: 10.1097/pxr.0000000000000137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Wearing time of a prosthesis is regarded as an indicator for success of prosthetic rehabilitation. However, prostheses are frequently worn for esthetic purposes only. Although different supervised measurements to assess prosthetic dexterity are used, it is not clear how performance in such tests translates into actual use in everyday life. OBJECTIVES To evaluate the actual daily use of the prosthetic device in patients with below-elbow amputations by recording the number of grasping motions. STUDY DESIGN Observational study. METHODS Upper extremity function was evaluated using different objective and timed assessments in five unilateral patients with below-elbow amputations. In addition, patients reported daily wearing time, and the number of performed prosthetic movements over a period of at least three months was recorded. RESULTS The patients achieved a mean Southampton Hand Assessment Procedure score of 66.60 ± 18.64 points. The average blocks moved in the Box and Block Test were 20.80 ± 7.46, and the mean score in the Action Research Arm Test was 37.20 ± 5.45. The mean time for the Clothespin-Relocation Test was 26.90 ± 11.61 seconds. The patients reported a wearing time of an average of 12.80 ± 3.11 hours per day. The mean number of prosthetic motions performed each day was 257.23 ± 192.95 with a range from 23.07 to 489.13. CONCLUSIONS Neither high functionality nor long wearing times necessitated frequent use of a prosthesis in daily life. However, frequent daily motions did translate into good functional scores, indicating that regular device use in different real-life settings relates to functionality.
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Affiliation(s)
- Stefan Salminger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
- Department of Bioengineering, Imperial College London, London, UK
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Helmut Papst
- Otto Bock Healthcare Products GmbH, Vienna, Austria
| | - Oskar C Aszmann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
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21
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Tereshenko V, Blumer R, Klein HJ, Schweizer R, Aszmann OC, Bergmeister KD. Temporal and Zygomatic Branches of the Facial Nerve Contain Nonmyelinated Axons. Facial Plast Surg Aesthet Med 2022; 25:198-199. [PMID: 36166486 DOI: 10.1089/fpsam.2022.0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Holger J. Klein
- Clinic of Hand, Reconstructive, and Plastic Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Riccardo Schweizer
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konstantin D. Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Krems, Austria
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22
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Vujaklija I, Jung MK, Hasenoehrl T, Roche AD, Sturma A, Muceli S, Crevenna R, Aszmann OC, Farina D. Biomechanical Analysis of Body Movements of Myoelectric Prosthesis Users During Standardized Clinical Tests. IEEE Trans Biomed Eng 2022; 70:789-799. [PMID: 36037457 DOI: 10.1109/tbme.2022.3202250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective clinical evaluation of user's capabilities to handle their prosthesis is done using various tests which primarily focus on the task completion speed and do not explicitly account for the potential presence of compensatory motions. Given that the excessive body compensation is a common indicator of inadequate prosthesis control, tests which include subjective observations on the quality of performed motions have been introduced. However, these metrics are then influenced by the examiner's opinions, skills, and training making them harder to standardize across patient pools and compare across different prosthetic technologies. Here we aim to objectively quantify the severity of body compensations present in myoelectric prosthetic hand users and evaluate the extent to which traditional objective clinical scores are still able to capture them. METHODS We have instructed 9 below-elbow prosthesis users and 9 able-bodied participants to complete three established objective clinical tests: Box-and-Blocks-Test, Clothespin-Relocation-Test, and Southampton-Hand-Assessment-Procedure. During all tests, upper-body kinematics has been recorded. RESULTS While the analysis showed that there are some correlations between the achieved clinical scores and the individual body segment travel distances and average speeds, there were only weak correlations between the clinical scores and the observed ranges of motion. At the same time, the compensations were observed in all prosthesis users and, for the most part, they were substantial across the tests. CONCLUSION The sole reliance on the currently available objective clinical assessment methods seems inadequate as the compensatory movements are prominent in prosthesis users and yet not sufficiently accounted for.
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Frossard L, Conforto S, Aszmann OC. Editorial: Bionics limb prostheses: Advances in clinical and prosthetic care. Front Rehabilit Sci 2022; 3:950481. [PMID: 36189016 PMCID: PMC9397676 DOI: 10.3389/fresc.2022.950481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Laurent Frossard
- Griffith Centre of Biomedical and Rehabilitation Engineering, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Correspondence: Laurent Frossard
| | | | - Oskar C. Aszmann
- Bionic Laboratory of Extremity Reconstruction and Department of Plastic & Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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Gherardini M, Sturma A, Boesendorfer A, Ianniciello V, Mannini A, Aszmann OC, Cipriani C. Feasibility Study on Disentangling Muscle Movements in TMR Patients Through a Myokinetic Control Interface for the Control of Artificial Hands. IEEE Robot Autom Lett 2022. [DOI: 10.1109/lra.2022.3181748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Marta Gherardini
- Biorobotics Institute, Scuola Superiore Sant'Anna, Pontedera, PI, Italy
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi Onlus, Firenze, Italy
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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Gstoettner C, Festin C, Prahm C, Bergmeister KD, Salminger S, Sturma A, Hofer C, Russold MF, Howard CL, McDonnall D, Farina D, Aszmann OC. Feasibility of a Wireless Implantable Multi-electrode System for High-bandwidth Prosthetic Interfacing: Animal and Cadaver Study. Clin Orthop Relat Res 2022; 480:1191-1204. [PMID: 35202032 PMCID: PMC9263498 DOI: 10.1097/corr.0000000000002135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Currently used prosthetic solutions in upper extremity amputation have limited functionality, owing to low information transfer rates of neuromuscular interfacing. Although surgical innovations have expanded the functional potential of the residual limb, available interfaces are inefficacious in translating this potential into improved prosthetic control. There is currently no implantable solution for functional interfacing in extremity amputation which offers long-term stability, high information transfer rates, and is applicable for all levels of limb loss. In this study, we presented a novel neuromuscular implant, the the Myoelectric Implantable Recording Array (MIRA). To our knowledge, it is the first fully implantable system for prosthetic interfacing with a large channel count, comprising 32 intramuscular electrodes. QUESTIONS/PURPOSES The purpose of this study was to evaluate the MIRA in terms of biocompatibility, functionality, and feasibility of implantation to lay the foundations for clinical application. This was achieved through small- and large-animal studies as well as test surgeries in a human cadaver. METHODS We evaluated the biocompatibility of the system's intramuscular electromyography (EMG) leads in a rabbit model. Ten leads as well as 10 pieces of a biologically inert control material were implanted into the paravertebral muscles of four animals. After a 3-month implantation, tissue samples were taken and histopathological assessment performed. The probes were scored according to a protocol for the assessment of the foreign body response, with primary endpoints being inflammation score, tissue response score, and capsule thickness in µm. In a second study, chronic functionality of the full system was evaluated in large animals. The MIRA was implanted into the shoulder region of six dogs and three sheep, with intramuscular leads distributed across agonist and antagonist muscles of shoulder flexion. During the observation period, regular EMG measurements were performed. The implants were removed after 5 to 6 months except for one animal, which retained the implant for prolonged observation. Primary endpoints of the large-animal study were mechanical stability, telemetric capability, and EMG signal quality. A final study involved the development of test surgeries in a fresh human cadaver, with the goal to determine feasibility to implant relevant target muscles for prosthetic control at all levels of major upper limb amputation. RESULTS Evaluation of the foreign body reaction revealed favorable biocompatibility and a low-grade tissue response in the rabbit study. No differences regarding inflammation score (EMG 4.60 ± 0.97 [95% CI 4.00 to 5.20] versus control 4.20 ± 1.48 [95% CI 3.29 to 5.11]; p = 0.51), tissue response score (EMG 4.00 ± 0.82 [95% CI 3.49 to 4.51] versus control 4.00 ± 0.94 [95% CI 3.42 to 4.58]; p > 0.99), or thickness of capsule (EMG 19.00 ± 8.76 µm [95% CI 13.57 to 24.43] versus control 29.00 ± 23.31 µm [95% CI 14.55 to 43.45]; p = 0.29) were found compared with the inert control article (high-density polyethylene) after 3 months of intramuscular implantation. Throughout long-term implantation of the MIRA in large animals, telemetric communication remained unrestricted in all specimens. Further, the implants retained the ability to record and transmit intramuscular EMG data in all animals except for two sheep where the implants became dislocated shortly after implantation. Electrode impedances remained stable and below 5 kΩ. Regarding EMG signal quality, there was little crosstalk between muscles and overall average signal-to-noise ratio was 22.2 ± 6.2 dB. During the test surgeries, we found that it was possible to implant the MIRA at all major amputation levels of the upper limb in a human cadaver (the transradial, transhumeral, and glenohumeral levels). For each level, it was possible to place the central unit in a biomechanically stable environment to provide unhindered telemetry, while reaching the relevant target muscles for prosthetic control. At only the glenohumeral level, it was not possible to reach the teres major and latissimus dorsi muscles, which would require longer lead lengths. CONCLUSION As assessed in a combination of animal model and cadaver research, the MIRA shows promise for clinical research in patients with limb amputation, where it may be employed for all levels of major upper limb amputation to provide long-term stable intramuscular EMG transmission. CLINICAL RELEVANCE In our study, the MIRA provided high-bandwidth prosthetic interfacing through intramuscular electrode sites. Its high number of individual EMG channels may be combined with signal decoding algorithms for accessing spinal motor neuron activity after targeted muscle reinnervation, thus providing numerous degrees of freedom. Together with recent innovations in amputation surgery, the MIRA might enable improved control approaches for upper limb amputees, particularly for patients with above-elbow amputation where the mismatch between available control signals and necessary degrees of freedom for prosthetic control is highest.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Cosima Prahm
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- BG Trauma Clinic, Eberhard Karls University, Department for Plastic and Reconstructive Surgery, Tübingen, Germany
| | - Konstantin D. Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Bioengineering, Imperial College London, London, UK
| | - Christian Hofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Otto Bock Healthcare Products GmbH, Vienna, Austria
| | | | | | | | - Dario Farina
- Department of Bioengineering, Imperial College London, London, UK
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
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Sturma A, Stamm T, Hruby LA, Bischof B, Salminger S, Gstoettner C, Prahm C, Pittermann A, Wakolbinger R, Hofer C, Farina D, Aszmann OC. Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation. J Hand Ther 2022; 35:58-66. [PMID: 33250398 DOI: 10.1016/j.jht.2020.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a Delphi study based on a scoping literature review. INTRODUCTION Targeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists. PURPOSE OF THE STUDY We aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training. METHODS European clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round. RESULTS Experts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one. DISCUSSION Within this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists' practice. CONCLUSION Graded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction. LEVEL OF EVIDENCE Low.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Bioengineering, Imperial College London, London, United Kingdom; Health Assisting Engineering, University of Applied Sciences FH Campus Wien, Vienna, Austria
| | - Tanja Stamm
- Institute for Outcomes Research Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria.
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Cosima Prahm
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department for Plastic and Reconstructive Surgery, BG Trauma Clinic, Eberhard-Karls University, Tuebingen, Germany
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Robert Wakolbinger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | | | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
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Tereshenko V, Maierhofer U, Dotzauer DC, Laengle G, Schmoll M, Festin C, Luft M, Carrero Rojas G, Politikou O, Hruby LA, Klein HJ, Eisenhardt SU, Farina D, Blumer R, Bergmeister KD, Aszmann OC. Newly identified axon types of the facial nerve unveil supplemental neural pathways in the innervation of the face. J Adv Res 2022; 44:135-147. [PMID: 36725185 PMCID: PMC9936413 DOI: 10.1016/j.jare.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/02/2022] [Accepted: 04/16/2022] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Neuromuscular control of the facial expressions is provided exclusively via the facial nerve. Facial muscles are amongst the most finely tuned effectors in the human motor system, which coordinate facial expressions. In lower vertebrates, the extracranial facial nerve is a mixed nerve, while in mammals it is believed to be a pure motor nerve. However, this established notion does not agree with several clinical signs in health and disease. OBJECTIVES To elucidate the facial nerve contribution to the facial muscles by investigating axonal composition of the human facial nerve. To reveal new innervation pathways of other axon types of the motor facial nerve. METHODS Different axon types were distinguished using specific molecular markers (NF, ChAT, CGRP and TH). To elucidate the functional role of axon types of the facial nerve, we used selective elimination of other neuronal support from the trigeminal nerve. We used retrograde neuronal tracing, three-dimensional imaging of the facial muscles, and high-fidelity neurophysiological tests in animal model. RESULTS The human facial nerve revealed a mixed population of only 85% motor axons. Rodent samples revealed a fiber composition of motor, afferents and, surprisingly, sympathetic axons. We confirmed the axon types by tracing the originating neurons in the CNS. The sympathetic fibers of the facial nerve terminated in facial muscles suggesting autonomic innervation. The afferent fibers originated in the facial skin, confirming the afferent signal conduction via the facial nerve. CONCLUSION These findings reveal new innervation pathways via the facial nerve, support the sympathetic etiology of hemifacial spasm and elucidate clinical phenomena in facial nerve regeneration.
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Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Dominik C. Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Martin Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Genova Carrero Rojas
- Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Street 13, 1090 Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Laura A. Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Holger J. Klein
- Clinic of Hand, Reconstructive, and Plastic Surgery, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Steffen U. Eisenhardt
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Dario Farina
- Department of Bioengineering, Imperial College London, South Kensington Campus London, SW7 2AZ London, UK
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Street 13, 1090 Vienna, Austria
| | - Konstantin D. Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Dr.-Karl-Dorrek-Strasse 30, 3500 Krems an der Donau, Austria
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria,Corresponding author at: Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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28
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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29
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Boesendorfer A, Sturma A, Gstoettner C, Pittermann A, Laengle G, Aszmann OC. Case Report: Bionic Reconstruction in an Adult With Obstetric Brachial Plexus Injury. Front Rehabilit Sci 2022; 2:804376. [PMID: 36188841 PMCID: PMC9397750 DOI: 10.3389/fresc.2021.804376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/09/2021] [Indexed: 11/21/2022]
Abstract
Introduction: Many adults who had a severe Narakas IV obstetric brachial plexus injury (OBPI) suffer from extensive impairments in daily living due to limited hand-arm function. The dramatic loss of axonal support at this very early age of development often render the entire extremity a biologic wasteland and reconstructive methods and therapies often fail to recover any functional hand use. In this scenario bionic reconstruction, including an elective amputation and a subsequent prosthetic fitting, may enable functional improvement in adults suffering from the consequences of such severe brachial plexus injuries. We here describe our experience in treating such patients and lay out the surgical rational and rehabilitation protocol exemplified in one patient. Case Presentation/Methods: A 27-year-old adult with a unilateral OBPI contacted our center. He presented with globally diminished function of the affected upper extremity with minimal hand activity, resulting in an inability to perform various tasks of daily living. No biological reconstructive efforts were available to restore meaningful hand function. An interdisciplinary evaluation, including a psychosocial assessment, was used to assess eligibility for bionic reconstruction. Before the amputation and after the prosthetic fitting functional assessments and self-reported questionnaires were performed. Results: One month after the amputation and de-rotation osteotomy of the humerus the patient was fitted with a myoelectric prosthesis. At the 1.5 year-follow-up assessment, the patient presented with a distinct improvement of function: the ARAT improved from 12 to 20 points, SHAP score improved from 8 to 29, and the DASH value improved from 50 to 11.7. The average wearing times of the prosthesis were 5 to 6 h per day (on 4–5 days a week). Discussion: The options for adults suffering from the consequences of severe OBPIs to improve function are limited. In selected patients in whom the neurological deficit is so severe that biologic hand function is unsatisfactory, an elective amputation and subsequent restoration of the hand with mechatronic means may be an option. The follow-up results indicate that this concept can indeed lead to solid hand function and independence in daily activities after amputation, subsequent prosthetic fitting, and rehabilitation.
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Affiliation(s)
- Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Neurorehabilitation Engineering Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Clinical Psychology, General Hospital of Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C. Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Oskar C. Aszmann
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30
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Sturma A, Hruby LA, Boesendorfer A, Gstoettner C, Farina D, Aszmann OC. Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers. J Vis Exp 2021. [PMID: 34779428 DOI: 10.3791/62896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna; Bioengineering Department, Imperial College London
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna; Department of Orthopaedics and Trauma Surgery, Medical University of Vienna
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna
| | - Dario Farina
- Bioengineering Department, Imperial College London
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna; Department of Plastic and Reconstructive Surgery, Medical University of Vienna;
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31
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Luft M, Klepetko J, Muceli S, Ibáñez J, Tereshenko V, Festin C, Laengle G, Politikou O, Maierhofer U, Farina D, Aszmann OC, Bergmeister KD. Proof of concept for multiple nerve transfers to a single target muscle. eLife 2021; 10:71312. [PMID: 34596042 PMCID: PMC8530510 DOI: 10.7554/elife.71312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Surgical nerve transfers are used to efficiently treat peripheral nerve injuries, neuromas, phantom limb pain, or improve bionic prosthetic control. Commonly, one donor nerve is transferred to one target muscle. However, the transfer of multiple nerves onto a single target muscle may increase the number of muscle signals for myoelectric prosthetic control and facilitate the treatment of multiple neuromas. Currently, no experimental models are available. This study describes a novel experimental model to investigate the neurophysiological effects of peripheral double nerve transfers to a common target muscle. In 62 male Sprague-Dawley rats, the ulnar nerve of the antebrachium alone (n=30) or together with the anterior interosseus nerve (n=32) was transferred to reinnervate the long head of the biceps brachii. Before neurotization, the motor branch to the biceps’ long head was transected at the motor entry point. Twelve weeks after surgery, muscle response to neurotomy, behavioral testing, retrograde labeling, and structural analyses were performed to assess reinnervation. These analyses indicated that all nerves successfully reinnervated the target muscle. No aberrant reinnervation was observed by the originally innervating nerve. Our observations suggest a minimal burden for the animal with no signs of functional deficit in daily activities or auto-mutilation in both procedures. Furthermore, standard neurophysiological analyses for nerve and muscle regeneration were applicable. This newly developed nerve transfer model allows for the reliable and standardized investigation of neural and functional changes following the transfer of multiple donor nerves to one target muscle.
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Affiliation(s)
- Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Johanna Klepetko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Silvia Muceli
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Jaime Ibáñez
- Department of Bioengineering, Imperial College London, London, United Kingdom.,Department of Clinical and Movement Neuroscience, University College London, London, London, United Kingdom.,BSICoS Group, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom.,Department of Clinical and Movement Neuroscience, University College London, London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konstantin Davide Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and ReconstructiveSurgery, University Hospital St. Poelten, St. Poelten, Austria
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32
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Sporer ME, Aman M, Bergmeister KD, Depisch D, Scheuba KM, Unger E, Podesser BK, Aszmann OC. Experimental nerve transfer model in the neonatal rat. Neural Regen Res 2021; 17:1088-1095. [PMID: 34558537 PMCID: PMC8552847 DOI: 10.4103/1673-5374.324851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Clinically, peripheral nerve reconstructions in neonates are most frequently applied in brachial plexus birth injuries. Most surgical concepts, however, have investigated nerve reconstructions in adult animal models. The immature neuromuscular system reacts differently to the effects of nerve lesion and surgery and is poorly investigated due to the lack of reliable experimental models. Here, we describe an experimental forelimb model in the neonatal rat, to study these effects on both the peripheral and central nervous systems. Within 24 hours after birth, three groups were prepared: In the nerve transfer group, a lesion of the musculocutaneous nerve was reconstructed by selectively transferring the ulnar nerve. In the negative control group, the musculocutaneous nerve was divided and not reconstructed and in the positive control group, a sham surgery was performed. The animal´s ability to adapt to nerve lesions and progressive improvement over time were depict by the Bertelli test, which observes the development of grooming. Twelve weeks postoperatively, animals were fully matured and the nerve transfer successfully reinnervated their target muscles, which was indicated by muscle force, muscle weight, and cross sectional area evaluation. On the contrary, no spontaneous regeneration was found in the negative control group. In the positive control group, reference values were established. Retrograde labeling indicated that the motoneuron pool of the ulnar nerve was reduced following nerve transfer. Due to this post-axotomy motoneuron death, a diminished amount of motoneurons reinnervated the biceps muscle in the nerve transfer group, when compared to the native motoneuron pool of the musculocutaneous nerve. These findings indicate that the immature neuromuscular system behaves profoundly different than similar lesions in adult rats and explains reduced muscle force. Ultimately, pathophysiologic adaptations are inevitable. The maturing neuromuscular system, however, utilizes neonatal capacity of regeneration and seizes a variety of compensation mechanism to restore a functional extremity. The above described neonatal rat model demonstrates a constant anatomy, suitable for nerve transfers and allows all standard neuromuscular analyses. Hence, detailed investigations on the pathophysiological changes and subsequent effects of trauma on the various levels within the neuromuscular system as well as neural reorganization of the neonatal rat may be elucidated. This study was approved by the Ethics Committee of the Medical University of Vienna and the Austrian Ministry for Research and Science (BMWF-66.009/0187-WF/V/3b/2015) on March 20, 2015.
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Affiliation(s)
- Matthias E Sporer
- Christian Doppler Laboratory for the Restoration of Extremity Function; 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
| | - Martin Aman
- Christian Doppler Laboratory for the Restoration of Extremity Function, Department of Surgery; Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Konstantin D Bergmeister
- Christian Doppler Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna; Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital of St. Poelten, Karl Landsteiner University of Health Sciences, St. Poelten, Austria
| | - Dieter Depisch
- Christian Doppler Laboratory for the Restoration of Extremity Function; Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Katharina M Scheuba
- Christian Doppler Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ewald Unger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Christian Doppler Laboratory for the Restoration of Extremity Function; Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery; Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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Hochgeschurz S, Bergmeister KD, Brånemark R, Aman M, Rocchi A, Restitutti F, Gumpenberger M, Sporer ME, Gstoettner C, Kramer AM, Lang S, Podesser BK, Aszmann OC. Author Correction: Avian extremity reconstruction via osseointegrated leg-prosthesis for intuitive embodiment. Sci Rep 2021; 11:19231. [PMID: 34552182 PMCID: PMC8458493 DOI: 10.1038/s41598-021-99053-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sarah Hochgeschurz
- Service for Birds and Reptiles, Department for Companion Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria.
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Rickard Brånemark
- Department of Orthopaedics, Gothenburg University, Gothenburg, Sweden.,Biomechatronics Group, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Attillio Rocchi
- Department of Anaesthesiology and Perioperative Intensive-Care Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Flavia Restitutti
- Department of Anaesthesiology and Perioperative Intensive-Care Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Michaela Gumpenberger
- Diagnostic Imaging, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | - Matthias E Sporer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for 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.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Susanna Lang
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Abstract
Targeted muscle reinnervation (TMR) is a surgical procedure, whereby nerves without muscle targets after extremity amputation are transferred to residual stump muscles. Thereby, the control of prosthesis is improved by increasing the number of independent muscle signals. The authors describe indications for TMR to improve prosthetic control and present standard nerve transfer matrices suitable for transhumeral and glenohumeral amputees. In addition, the perioperative procedure is described, including preoperative testing, surgical approach, and postoperative rehabilitation. Based on recent neurophysiological insights and technological advances, they present an outlook into the future of prosthetic control combining TMR and implantable electromyographic technology.
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Affiliation(s)
- Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
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35
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Hochgeschurz S, Bergmeister KD, Brånemark R, Aman M, Rocchi A, Restitutti F, Gumpenberger M, Sporer ME, Gstoettner C, Kramer AM, Lang S, Podesser BK, Aszmann OC. Avian extremity reconstruction via osseointegrated leg-prosthesis for intuitive embodiment. Sci Rep 2021; 11:12360. [PMID: 34117270 PMCID: PMC8195993 DOI: 10.1038/s41598-021-90048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 04/13/2021] [Indexed: 11/09/2022] Open
Abstract
For large avians such as vultures, limb loss leads to loss of ambulation and eventually death from malnutrition. Prosthetic devices may replace the limb, however, conventional prosthetic sockets are not feasible in feathered limbs and the extreme stress and strain of unreflected daily use in animals. Osseointegration is a novel technique, where external prosthetic parts are connected directly to a bone anchor to provide a solid skeletal-attachment. This concept provides a high degree of embodiment since osseoperception will provide direct intuitive feedback allowing natural use of the limb in gait and feeding. Here we demonstrate for the first time an osseointegrated bionic reconstruction of a limb in a vulture after a tarsometatarsal amputation with a longterm follow-up.
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Affiliation(s)
- Sarah Hochgeschurz
- Service for Birds and Reptiles, Department for Companion Animals and Horses, University of Veterinary Medicine Vienna, Vienna, Austria.
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Rickard Brånemark
- Department of Orthopaedics, Gothenburg University, Gothenburg, Sweden.,Biomechatronics Group, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Attillio Rocchi
- Department of Anaesthesiology and Perioperative Intensive-Care Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Flavia Restitutti
- Department of Anaesthesiology and Perioperative Intensive-Care Medicine, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Michaela Gumpenberger
- Diagnostic Imaging, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | - Matthias E Sporer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for 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.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Susanna Lang
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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36
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Sturma A, Hruby LA, Boesendorfer A, Pittermann A, Salminger S, Gstoettner C, Politikou O, Vujaklija I, Farina D, Aszmann OC. Prosthetic Embodiment and Body Image Changes in Patients Undergoing Bionic Reconstruction Following Brachial Plexus Injury. Front Neurorobot 2021; 15:645261. [PMID: 33994986 PMCID: PMC8119996 DOI: 10.3389/fnbot.2021.645261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/01/2021] [Indexed: 01/10/2023] Open
Abstract
Brachial plexus injuries with multiple-root involvement lead to severe and long-lasting impairments in the functionality and appearance of the affected upper extremity. In cases, where biologic reconstruction of hand and arm function is not possible, bionic reconstruction may be considered as a viable clinical option. Bionic reconstruction, through a careful combination of surgical augmentation, amputation, and prosthetic substitution of the functionless hand, has been shown to achieve substantial improvements in function and quality of life. However, it is known that long-term distortions in the body image are present in patients with severe nerve injury as well as in prosthetic users regardless of the level of function. To date, the body image of patients who voluntarily opted for elective amputation and prosthetic reconstruction has not been investigated. Moreover, the degree of embodiment of the prosthesis in these patients is unknown. We have conducted a longitudinal study evaluating changes of body image using the patient-reported Body Image Questionnaire 20 (BIQ-20) and a structured questionnaire about prosthetic embodiment. Six patients have been included. At follow up 2.5–5 years after intervention, a majority of patients reported better BIQ-20 scores including a less negative body evaluation (5 out of 6 patients) and higher vital body dynamics (4 out of 6 patients). Moreover, patients described a strong to moderate prosthesis embodiment. Interestingly, whether patients reported performing bimanual tasks together with the prosthetic hand or not, did not influence their perception of the prosthesis as a body part. In general, this group of patients undergoing prosthetic substitution after brachial plexus injury shows noticeable inter-individual differences. This indicates that the replacement of human anatomy with technology is not a straight-forward process perceived in the same way by everyone opting for it.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Neurorehabilitation Engineering Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Boesendorfer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Clinical Psychology, General Hospital of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ivan Vujaklija
- Bionic and Rehabilitation Engineering Research Group, Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland
| | - Dario Farina
- Neurorehabilitation Engineering Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Tereshenko V, Dotzauer DC, Maierhofer U, Festin C, Luft M, Laengle G, Politikou O, Klein HJ, Blumer R, Aszmann OC, Bergmeister KD. Selective Denervation of the Facial Dermato-Muscular Complex in the Rat: Experimental Model and Anatomical Basis. Front Neuroanat 2021; 15:650761. [PMID: 33828465 PMCID: PMC8019738 DOI: 10.3389/fnana.2021.650761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
The facial dermato-muscular system consists of highly specialized muscles tightly adhering to the overlaying skin and thus form a complex morphological conglomerate. This is the anatomical and functional basis for versatile facial expressions, which are essential for human social interaction. The neural innervation of the facial skin and muscles occurs via branches of the trigeminal and facial nerves. These are also the most commonly pathologically affected cranial nerves, often requiring surgical treatment. Hence, experimental models for researching these nerves and their pathologies are highly relevant to study pathophysiology and nerve regeneration. Experimental models for the distinctive investigation of the complex afferent and efferent interplay within facial structures are scarce. In this study, we established a robust surgical model for distinctive exploration of facial structures after complete elimination of afferent or efferent innervation in the rat. Animals were allocated into two groups according to the surgical procedure. In the first group, the facial nerve and in the second all distal cutaneous branches of the trigeminal nerve were transected unilaterally. All animals survived and no higher burden was caused by the procedures. Whisker pad movements were documented with video recordings 4 weeks after surgery and showed successful denervation. Whole-mount immunofluorescent staining of facial muscles was performed to visualize the innervation pattern of the neuromuscular junctions. Comprehensive quantitative analysis revealed large differences in afferent axon counts in the cutaneous branches of the trigeminal nerve. Axon number was the highest in the infraorbital nerve (28,625 ± 2,519), followed by the supraorbital nerve (2,131 ± 413), the mental nerve (3,062 ± 341), and the cutaneous branch of the mylohyoid nerve (343 ± 78). Overall, this surgical model is robust and reliable for distinctive surgical deafferentation or deefferentation of the face. It may be used for investigating cortical plasticity, the neurobiological mechanisms behind various clinically relevant conditions like facial paralysis or trigeminal neuralgia as well as local anesthesia in the face and oral cavity.
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Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Dominik C Dotzauer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Holger J Klein
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Roland Blumer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Krems, Austria.,Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Krems, Austria
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Abstract
Hintergrund Nach Verlust einer Gliedmaße ist es die Aufgabe des Chirurgen, einen möglichst schmerzfreien und belastbaren Stumpf zu formen. Hierbei kommt insbesondere an der oberen Extremität ein funktioneller Aspekt hinzu, da zur Steuerung myoelektrischer Prothesen entsprechende Muskelsignale notwendig sind. Der Umgang mit peripheren Nerven im Stumpfbereich nimmt sowohl hinsichtlich der Schmerztherapie als auch der funktionellen Mensch-Maschinen-Anbindung eine zentrale Rolle ein. Ziel der Arbeit Die Darstellung aktueller chirurgischer Verfahren zum Umgang mit peripheren Nerven nach Extremitätenamputation. Material und Methoden Es erfolgt eine Literaturrecherche bzgl. chirurgischer Prophylaxe und Therapie von Neurom- und Phantomschmerzen, sowie zu Techniken zur Verbesserung der funktionellen Schnittstelle zwischen Stumpf und Prothese. Anhand relevanter Arbeiten sowie der Erfahrungen der Autoren werden entsprechende Empfehlungen formuliert. Ergebnisse und Diskussion Es gibt eine große Anzahl an verschiedenen Operationstechniken, insbesondere im Umgang mit schmerzhaften Neuromen. Von den klassischen Verfahren findet besonders häufig die intramuskuläre Verlagerung der endständiger Nerven Anwendung. Neuere Techniken wie Targeted Muscle Reinnervation (TMR) und Regenerative Peripheral Nerve Interface (RPNI) zielen erstmals darauf ab, dem Nerven auch nach Amputation funktionelle Endorgane zu liefern. Neben der verbesserten Steuerung myoelektrischer Prothesen zeigen diese Verfahren auch exzellente Ergebnisse in Bezug auf Neurom- und Phantomschmerzen.
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Affiliation(s)
- Clemens Gstoettner
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Gregor Laengle
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Stefan Salminger
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.,Klinische Abteilung für Plastische und Rekonstruktive Chirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Christopher Festin
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Hannes Platzgummer
- Univ. Klinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Oskar C Aszmann
- Klinisches Labor für Bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich. .,Klinische Abteilung für Plastische und Rekonstruktive Chirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Wien, Wien, Österreich.
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Gstoettner C, Salminger S, Sturma A, Moser V, Hausner T, Brånemark R, Aszmann OC. Successful salvage via re-osseointegration of a loosened implant in a patient with transtibial amputation. Prosthet Orthot Int 2021; 45:76-80. [PMID: 33834747 DOI: 10.1177/0309364620953985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CASE DESCRIPTION Osseointegration is a relatively new technique for prosthetic limb attachment that offers various improvements for patients with amputation and facilitates joint preservation. We present a case of implant loosening during rehabilitation in a patient with transtibial amputation that was successfully managed through a combination of measures, aiming to promote re-osseointegration of the implant. OBJECTIVES Not much is known about structured management of adverse events after osseointegration. Septic or aseptic loosening is currently regarded as implant failure, prompting removal and possible re-implantation at a later stage. The objective of this case report was to evaluate the feasibility of salvaging a loosened implant. STUDY DESIGN Case report. TREATMENT A novel treatment approach was employed to enable renewed osseointegration of the implant. First, the bone-implant interface was disrupted and renewed through axial rotation and distal repositioning of the implant. Afterwards, extracorporal shockwave therapy and antibiotic treatment were administered. Prosthetic rehabilitation was then started anew. Regular follow-up x-rays and clinical evaluations were conducted, including standardized outcome tests. OUTCOMES These combined measures led to a successful re-osseointegration of the implant. In a 21-month follow-up, the patient regained a stable and secure gait pattern, using his prosthesis every day for 15 hours and scoring above average on standardized outcome measures. CONCLUSION This represents the first report of implant salvage after failed primary osseointegration. As the associated risks of this novel treatment are very low, investigations are warranted to evaluate this approach on a larger scale.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Department of Bioengineering, Imperial College London, London, UK
| | - Veith Moser
- AUVA Trauma Hospital Lorenz Böhler-European Hand Trauma Center, Vienna, Austria
| | - Thomas Hausner
- AUVA Trauma Hospital Lorenz Böhler-European Hand Trauma Center, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Rickard Brånemark
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Biomechatronics Group, Center for Extreme Bionics, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Salminger S, Stino H, Pichler LH, Gstoettner C, Sturma A, Mayer JA, Szivak M, Aszmann OC. Current rates of prosthetic usage in upper-limb amputees - have innovations had an impact on device acceptance? Disabil Rehabil 2020; 44:3708-3713. [PMID: 33377803 DOI: 10.1080/09638288.2020.1866684] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE There is a large body of evidence demonstrating high rates of prosthesis abandonment in the upper extremity. However, these surveys were conducted years ago, thus the influence of recent refinements in prosthetic technology on acceptance is unknown. This study aims to gather current data on prosthetic usage, to assess the effects of these advancements. MATERIALS AND METHODS A questionnaire was sent to 68 traumatic upper limb amputees treated within the Austrian Trauma Insurance Agency between the years 1996 and 2016. Responses were grouped by the year of amputation to assess the effect of time. RESULTS The rejection rate at all levels of amputation was 44%. There was no significant difference in acceptance between responders amputated before or after 2006 (p = 0.939). Among users, 92.86% (n = 13) used a myoelectric, while only one amputee (7.14%, n = 1) used a body-powered device. Most responders complained about the comfort (60.87%, n = 14) as well as the weight of the device (52.17%, n = 12). CONCLUSIONS The advancements of the last decade in the arena of upper limb prosthetics have not yet achieved a significant change in prosthetic abandonment within this study cohort. Although academic solutions have been presented to tackle patient's complaints, clinical reality still shows high rejection rates of cost-intensive prosthetic devices.Implications for rehabilitationAbandonment rates in prosthetic rehabilitation after upper limb amputation have shown to be 50% and higher.The advancements of the last decade in the arena of upper limb prosthetics have not yet achieved a significant change in prosthetic abandonment.Well-structured and patient-tailored prosthetic training as well as ensuring the amputee's active participation in the decision making process will most likely improve prosthetic acceptance.
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Affiliation(s)
- Stefan Salminger
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria.,Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Heiko Stino
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | | | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria.,Department of Bioengineering, Imperial College London, London, UK
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
| | - Michael Szivak
- Department of Medical Documentation and Statistics, Austrian Trauma Insurance Agency (AUVA), Vienna, Austria
| | - Oskar C Aszmann
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria.,Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Vienna, Austria
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Tereshenko V, Pashkunova-Martic I, Manzano-Szalai K, Friske J, Bergmeister KD, Festin C, Aman M, Hruby LA, Klepetko J, Theiner S, Klose MHM, Keppler B, Helbich TH, Aszmann OC. MR Imaging of Peripheral Nerves Using Targeted Application of Contrast Agents: An Experimental Proof-of-Concept Study. Front Med (Lausanne) 2020; 7:613138. [PMID: 33363189 PMCID: PMC7759654 DOI: 10.3389/fmed.2020.613138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Current imaging modalities for peripheral nerves display the nerve's structure but not its function. Based on a nerve's capacity for axonal transport, it may be visualized by targeted application of a contrast agent and assessing the distribution through radiological imaging, thus revealing a nerve's continuity. This concept has not been explored, however, may potentially guide the treatment of peripheral nerve injuries. In this experimental proof-of-concept study, we tested imaging through MRI after administering gadolinium-based contrast agents which were then retrogradely transported. Methods: We synthesized MRI contrast agents consisting of paramagnetic agents and various axonal transport facilitators (HSA-DTPA-Gd, chitosan-DTPA-Gd or PLA/HSA-DTPA-Gd). First, we measured their relaxivity values in vitro to assess their radiological suitability. Subsequently, the sciatic nerve of 24 rats was cut and labeled with one of the contrast agents to achieve retrograde distribution along the nerve. One week after surgery, the spinal cords and sciatic nerves were harvested to visualize the distribution of the respective contrast agent using 7T MRI. In vivo MRI measurements were performed using 9.4 T MRI on the 1st, 3rd, and the 7th day after surgery. Following radiological imaging, the concentration of gadolinium in the harvested samples was analyzed using inductively coupled mass spectrometry (ICP-MS). Results: All contrast agents demonstrated high relaxivity values, varying between 12.1 and 116.0 mM-1s-1. HSA-DTPA-Gd and PLA/HSA-DTPA-Gd application resulted in signal enhancement in the vertebral canal and in the sciatic nerve in ex vivo MRI. In vivo measurements revealed significant signal enhancement in the sciatic nerve on the 3rd and 7th day after HSA-DTPA-Gd and chitosan-DTPA-Gd (p < 0.05) application. Chemical evaluation showed high gadolinium concentration in the sciatic nerve for HSA-DTPA-Gd (5.218 ± 0.860 ng/mg) and chitosan-DTPA-Gd (4.291 ± 1.290 ng/mg). Discussion: In this study a novel imaging approach for the evaluation of a peripheral nerve's integrity was implemented. The findings provide radiological and chemical evidence of successful contrast agent uptake along the sciatic nerve and its distribution within the spinal canal in rats. This novel concept may assist in the diagnostic process of peripheral nerve injuries in the future.
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Affiliation(s)
- Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Irena Pashkunova-Martic
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna & General Hospital, Vienna, Austria.,Institute of Inorganic Chemistry, University of Vienna, Vienna, Austria
| | - Krisztina Manzano-Szalai
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Centre for Microbiology and Environmental Systems Science, University of Vienna, Vienna, Austria
| | - Joachim Friske
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna & General Hospital, Vienna, Austria
| | - Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Johanna Klepetko
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Sarah Theiner
- Institute of Inorganic Chemistry, University of Vienna, Vienna, Austria
| | | | - Bernhard Keppler
- Institute of Inorganic Chemistry, University of Vienna, Vienna, Austria
| | - Thomas H Helbich
- Department of Biomedical Imaging and Image-guided Therapy, Division of Molecular and Structural Preclinical Imaging, Medical University of Vienna & General Hospital, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Division of Plastic and Reconstructive Surgery, 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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Bergmeister KD, Aman M, Kramer A, Schenck TL, Riedl O, Daeschler SC, Aszmann OC, Bergmeister H, Golriz M, Mehrabi A, Hundeshagen G, Enkhbaatar P, Kinsky MP, Podesser BK. Simulating Surgical Skills in Animals: Systematic Review, Costs & Acceptance Analyses. Front Vet Sci 2020; 7:570852. [PMID: 33195561 PMCID: PMC7554573 DOI: 10.3389/fvets.2020.570852] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Modern surgery demands high-quality and reproducibility. Due to new working directives, resident duty hours have been restricted and evidence exists that pure on-the-job training provides insufficient exposure. We hypothesize that supplemental simulations in animal models provide a realistic training to augment clinical experiences. This study reviews surgical training models, their costs and survey results illustrating academic acceptance. Methods: Animal models were identified by literature research. Costs were analyzed from multiple German and Austrian training programs. A survey on their acceptance was conducted among faculty and medical students. Results: 915 articles were analyzed, thereof 91 studies described in-vivo animal training models, predominantly for laparoscopy (30%) and microsurgery (24%). Cost-analysis revealed single-training costs between 307€ and 5,861€ depending on model and discipline. Survey results illustrated that 69% of the participants had no experience, but 66% would attend training under experienced supervision. Perceived public acceptance was rated intermediate by medical staff and students (4.26; 1–low, 10 high). Conclusion: Training in animals is well-established and was rated worth attending in a majority of a representative cohort to acquire key surgical skills, in light of reduced clinical exposure. Animal models may therefore supplement the training of tomorrow's surgeons to overcome limited hands-on experience until virtual simulations can provide such educational tools.
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Affiliation(s)
- Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Krems, Austria
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Anne Kramer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Krems, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Thilo L Schenck
- Hand Surgery, Plastic Surgery and Aesthetic Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Otto Riedl
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Simeon C Daeschler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Helga Bergmeister
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States
| | - Michael P Kinsky
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
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Vincitorio F, Staffa G, Aszmann OC, Fontana M, Brånemark R, Randi P, Macchiavelli T, Cutti AG. Targeted Muscle Reinnervation and Osseointegration for Pain Relief and Prosthetic Arm Control in a Woman with Bilateral Proximal Upper Limb Amputation. World Neurosurg 2020; 143:365-373. [PMID: 32791219 DOI: 10.1016/j.wneu.2020.08.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bilateral proximal upper limb loss is a dramatic life-changing event. Replacement of the lost function with prosthetic arms, including multiple mechatronic joints, has remained a challenge from the control, comfort, and pain management perspectives. Targeted muscle reinnervation (TMR) is a peripheral nerve surgical procedure proposed to improve the intuitive control of the prosthetic arm and for neuroma and phantom pain management. Moreover, osseointegrated percutaneous implants (OPIs) allow for direct skeletal attachment of the prosthetic arm, ensuring freedom of movement to the patient's residual articulations. CASE DESCRIPTION We have reported the first combined application of TMR and an OPI to treat a 24-year-old woman with a bilateral amputation at the shoulder level on the right side and at the very proximal transhumeral level on the left side. TMR was performed bilaterally in a single day, accounting for the peculiar patient's anatomy, as preparatory stage to placement of the OPI, and considering the future availability of implantable electromyographic sensors. The 2 OPI surgeries on the left side were completed after 8.5 months, and prosthetic treatment was completed 17 months after TMR. CONCLUSIONS The use of TMR resolved the phantom pain bilaterally and the right-side neuroma pain. It had also substantially reduced the left side neuroma pain. The actual prosthetic control result was intuitive, although partially different from expectations. At 2 years after TMR, the patient reported improvement in essential activities of daily living, with a remarkable preference for the OPI prosthesis. Only 1 suspected case of superficial infection was noted, which had resolved. Overall, this combined treatment required a highly competent multidisciplinary team and exceptional commitment by the patient and her family.
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Affiliation(s)
- Francesca Vincitorio
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Guido Staffa
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Oskar C Aszmann
- Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria; Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Maurizio Fontana
- Complex Operative Unit of the Peripheral Nervous System, Ospedale degli Infermi, Faenza, Italy
| | - Rickard Brånemark
- Center for Extreme Bionics, Biomechatronics Group, MIT Media Lab, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Pericle Randi
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy
| | - Thomas Macchiavelli
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy
| | - Andrea G Cutti
- INAIL Prosthetic Center, Italian Workers' Compensation Authority, Vigorso di Budrio, Italy.
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Salminger S, Gstoettner C, Mayer JA, Aszmann OC. Die Rolle der rekonstruktiven Chirurgie bei neuropathischen Schmerzen. Therapeutische Umschau 2020; 77:281-286. [DOI: 10.1024/0040-5930/a001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Neuropathische Schmerzen können auch in Folge iatrogener Nervenläsionen auftreten. Iatrogene oder traumatische Nervenläsionen führen häufig zu erheblichen funktionellen Beeinträchtigungen und können chronische neuropathische Schmerzen nach sich ziehen. Nur wer sich regelmässig mit der Problematik peripherer Nervenläsionen auseinandersetzt, kann auf einen ausreichend grossen diagnostischen und chirurgischen Erfahrungsschatz zurückgreifen, um rasch und effizient die richtige Diagnose und gegebenenfalls Indikation zur optimalen rekonstruktiven Therapie zu stellen. Zeit ist meist der Hauptfaktor, welcher über den Erfolg der Schadensbehebung oder zumindest -begrenzung entscheidet. Chirurgen anderer Fachdisziplinen, die nicht routinemässig, sondern rein komplikationsbedingt plötzlich mit dieser spezifischen Problemstellung konfrontiert sind, benötigen daher einen klaren Überblick über die adäquate Abklärung und Rekonstruktionsmöglichkeiten, um ihren Patienten zeitgerecht die richtige Diagnostik und Therapie zukommen zu lassen. In dieser Übersichtsarbeit sollen einerseits jene Operationen aufgelistet werden, bei denen besonders häufig iatrogene Nervenläsionen dokumentiert wurden. Des Weiteren möchten wir gemäss unseren Erfahrungen aus dem Spezialgebiet der peripheren Nervenchirurgie über die richtige und effiziente Diagnostik sowie die rekonstruktiven Möglichkeiten informieren. Mit funktionierender interdisziplinärer Zusammenarbeit und einem entsprechenden diagnostischen und therapeutischen Vorgehen lassen sich die Ergebnisse nach iatrogenen Nervenverletzungen verbessern und somit auch eventuelle juristische Konsequenzen verhindern.
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Affiliation(s)
- Stefan Salminger
- Klinische Abteilung für Plastische und Rekonstruktive Chirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Wien
- Klinisches Labor für bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien
| | - Clemens Gstoettner
- Klinisches Labor für bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien
| | - Johannes A. Mayer
- Klinisches Labor für bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien
| | - Oskar C. Aszmann
- Klinische Abteilung für Plastische und Rekonstruktive Chirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Wien
- Klinisches Labor für bionische Extremitätenrekonstruktion, Universitätsklinik für Chirurgie, Medizinische Universität Wien
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Gstoettner C, Mayer JA, Rassam S, Hruby LA, Salminger S, Sturma A, Aman M, Harhaus L, Platzgummer H, Aszmann OC. Neuralgic amyotrophy: a paradigm shift in diagnosis and treatment. J Neurol Neurosurg Psychiatry 2020; 91:879-888. [PMID: 32487526 DOI: 10.1136/jnnp-2020-323164] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 01/22/2023]
Abstract
Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome, is characterised by sudden pain attacks, followed by patchy muscle paresis in the upper extremity. Recent reports have shown that incidence is much higher than previously assumed and that the majority of patients never achieve full recovery. Traditionally, the diagnosis was mainly based on clinical observations and treatment options were confined to application of corticosteroids and symptomatic management, without proven positive effects on long-term outcomes. These views, however, have been challenged in the last years. Improved imaging methods in MRI and high-resolution ultrasound have led to the identification of structural peripheral nerve pathologies in NA, most notably hourglass-like constrictions. These pathognomonic findings have paved the way for more accurate diagnosis through high-resolution imaging. Furthermore, surgery has shown to improve clinical outcomes in such cases, indicating the viability of peripheral nerve surgery as a valuable treatment option in NA. In this review, we present an update on the current knowledge on this disease, including pathophysiology and clinical presentation, moving on to diagnostic and treatment paradigms with a focus on recent radiological findings and surgical reports. Finally, we present a surgical treatment algorithm to support clinical decision making, with the aim to encourage translation into day-to-day practice.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department for Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen at the Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Stephanie Rassam
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of General, Visceral, Endocrine and Transplantation Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Bioengineering, Imperial College London, London, UK
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center-Hand and Plastic Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center-Hand and Plastic Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Hannes Platzgummer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria .,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Mayer JA, Hruby LA, Salminger S, Bodner G, Aszmann OC. Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk. J Neurosurg Spine 2020; 31:133-138. [PMID: 30952116 DOI: 10.3171/2018.12.spine18498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 12/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle. METHODS Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented. RESULTS All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients. CONCLUSIONS Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.
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Affiliation(s)
- Johannes A Mayer
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
| | - Laura A Hruby
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna
| | - Stefan Salminger
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna.,2Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
| | | | - Oskar C Aszmann
- 1Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna.,2Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and
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Dellon AL, Aszmann OC. In musculus, veritas? Nerve "in muscle" versus targeted muscle reinnervation versus regenerative peripheral nerve interface: Historical review. Microsurgery 2020; 40:516-522. [PMID: 32181914 DOI: 10.1002/micr.30575] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/21/2020] [Indexed: 11/08/2022]
Affiliation(s)
| | - Oskar C Aszmann
- Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
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48
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hruby LA, Gstoettner C, Sturma A, Salminger S, Mayer JA, Aszmann OC. Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series. J Clin Med 2019; 9:jcm9010023. [PMID: 31861941 PMCID: PMC7019829 DOI: 10.3390/jcm9010023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
Global brachial plexopathies including multiple nerve root avulsions may result in complete upper limb paralysis despite surgical treatment. Bionic reconstruction, which includes the elective amputation of the functionless hand and its replacement with a mechatronic device, has been described for the transradial level. Here, we present for the first time that patients with global brachial plexus avulsion injuries and lack of biological shoulder and elbow function benefit from above-elbow amputation and prosthetic rehabilitation. Between 2012 and 2017, forty-five patients with global brachial plexus injuries approached our centre, of which nineteen (42.2%) were treated with bionic reconstruction. While fourteen patients were amputated at the transradial level, the entire upper limb was replaced with a prosthetic arm in a total of five patients. Global upper extremity function before and after bionic arm substitution was assessed using two objective hand function tests, the action research arm test (ARAT), and the Southampton hand assessment procedure (SHAP). Other outcome measures included the DASH questionnaire, VAS to assess deafferentation pain and the SF-36 health survey to evaluate changes in quality of life. Using a hybrid prosthetic arm mean ARAT scores improved from 0.6 ± 1.3 to 11.0 ± 6.7 (p = 0.042) and mean SHAP scores increased from 4.0 ± 3.7 to 13.8 ± 9.2 (p = 0.058). After prosthetic arm replacement mean DASH scores improved from 52.5 ± 9.4 to 31.2 ± 9.8 (p = 0.003). Deafferentation pain decreased from mean VAS 8.5 ± 1.0 to 6.7 ± 2.1 (p = 0.055), while the physical and mental component summary scale as part of the SF-36 health survey improved from 32.9 ± 6.4 to 40.4 ± 9.4 (p = 0.058) and 43.6 ± 8.9 to 57.3 ± 5.5 (p = 0.021), respectively. Bionic reconstruction can restore simple but robust arm and hand function in longstanding brachial plexus patients with lack of treatment alternatives.
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Affiliation(s)
- Laura A Hruby
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, Challenges, and Pitfalls after Targeted Muscle Reinnervation in High-Level Amputees: Is It Worth the Effort? Plast Reconstr Surg 2019; 144:1037e-1043e. [PMID: 31764652 DOI: 10.1097/prs.0000000000006277] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the distal targets have been lost in proximal upper limb amputees, the neural signals for intuitive hand and arm function are still available and thus can be incorporated into more useful prosthetic function using targeted muscle reinnervation technique. In this article, the authors present their outcomes and range of indications in addition to experiences and pitfalls after 30 targeted muscle reinnervation cases at above-elbow and shoulder disarticulation level of amputation. METHODS Thirty patients with above-elbow or shoulder disarticulation amputations were enrolled between 2012 and 2017. Indications for targeted muscle reinnervation surgery differed between improvement of prosthetic function (n = 19) and/or pain (n = 11). Functional outcome was evaluated with the Action Research Arm Test, the Southampton Hand Assessment Procedure, and the Clothespin-Relocation Test. Functional evaluation was performed at least at 6 months after final prosthetic fitting. RESULTS All nerve transfers were successful and provided independent myoelectric signals. The 10 patients available for final functional evaluation showed Action Research Arm Test scores of 20.4 ± 1.9 and Southampton Hand Assessment Procedure scores of 40.5 ± 8.1. The Clothespin-Relocation Test showed a mean time of 34.3 ± 14.4 seconds. CONCLUSIONS Targeted muscle reinnervation has improved prosthetic control and revolutionized neuroma treatment in upper limb amputees. Still, the rate of abandonment even after targeted muscle reinnervation surgery has been shown high, and several advances within the biotechnological interface will be needed to improve prosthetic function and acceptance in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Stefan Salminger
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
| | - Agnes Sturma
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
| | - Aidan D Roche
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
| | - Johannes A Mayer
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
| | - Clemens Gstoettner
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
| | - Oskar C Aszmann
- From the Division of Plastic and Reconstructive Surgery and the Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Medical University of Vienna; and the Department of Plastic Surgery, Southmead Hospital, North Bristol NHS Trust
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