Bionic limb replacement: an evolving concept in lower extremity reconstruction

Abstract

Limb loss is disabling and carries significant functional and psychological repercussions to both the individual and society. The numbers of amputees are forecasted to double by 2050 from vascular disease and diabetes alone. Europe has 4.66 million amputees (431,000 amputations per year) and the United States 2 million amputees (185,000 amputations per year). Microvascular expertise is now more commonplace, increasing the likelihood of limb salvage and replantation. Further reconstructive input can take advantage of nerve and tendon grafting/transfers, free tissue transfer, and complex bone reconstruction. When this strategy does not satisfy individual needs, such as that seen with unstable soft tissues, amputation may be requested or offered. In part, the decision for salvage, replantation, or amputation in the future is likely to be guided by the sophistication of limb substitutes. This review will introduce the growing domain of bionics and where research in this area may deliver a sought clinical need.

Keywords

Lower limb / lower extremity / amputation / transplantation / prosthesis / neural interface / bionic limb

References

[1] McCarthy ML,Edwin D,Castillo RC.LEAP study groupPsychological distress associated with severe lower-limb injury.J Bone Joint Surg Am2003;85:1689-97

[2] Robbins CB,Sothmann MS,Oldridge NB.A review of the long-term health outcomes associated with war-related amputation.Mil Med2009;174:588-92

[3] Gailey R,Castles J,Roeder M.Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use.J Rehabil Res Dev2008;45:15-29

[4] Ephraim PL,MacKenzie EJ,Pezzin LE.Phantom pain, residual limb pain, and back pain in amputees: results of a national survey.Arch Phys Med Rehabil2005;86:1910-9

[5] Bourke HE,Robinson KP,Ward DA.Is revision surgery following lower-limb amputation a worthwhile procedure?.Injury2011;42:660-6

[6] Higgins TF,Beals TC.Lower Extremity Assessment Project (LEAP)--the best available evidence on limb-threatening lower extremity trauma.Orthop Clin North Am2010;41:233-9

[7] Livingston DH,Kim D,Malangoni MA.Extent of disability following traumatic extremity amputation.J Trauma1994;37:495-9

[8] Huang CT,Moore NB.Amputation: energy cost of ambulation.Arch Phys Med Rehabil1979;60:18-24

[9] Court-Brown CM,Clement ND,McQueen MM.The epidemiology of open fractures in adults. A 15-year review.Injury2012;43:891-7

[10] Court-Brown CM.The epidemiology of tibial fractures.J Bone Joint Surg Br1995;77:417-21

[11] MacKenzie EJ,Kellam JF.Characterization of patients with high-energy lower extremity trauma.J Orthop Trauma2000;14:455-66

[12] Aaron RK,Ciombor DM.Horizons in prosthesis development for the restoration of limb function.J Am Acad Orthop Surg2006;14:S198-204

[13] MacKenzie EJ,Kellam JF.LEAP Study GroupFactors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.J Trauma2002;52:641-9

[14] Bosse MJ,Kellam JF.An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.N Engl J Med2002;347:1924-31

[15] Hierner R,Frederix PR.Lower leg replantation--decision-making, treatment, and long-term results.Microsurgery2007;27:398-410

[16] Khouri RK.Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases.J Trauma1989;29:1086-94

[17] Culliford AT 4th,Blank A,Kasabian A.The fate of lower extremities with failed free flaps: a single institution’s experience over 25 years.Ann Plast Surg2007;59:18-21; discussion 21-2

[18] Nho SJ,Rozbruch SR.Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame.J Orthop Trauma2006;20:419-24

[19] Aronson J.Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method.J Bone Joint Surg Am1997;79:1243-58

[20] Papakostidis C,Giannoudis PV.Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis.Bone Joint J2013;95-B:1673-80

[21] Heller L,Levin LS.Pedicled osteocutaneous fibula flap for reconstruction in the lower extremity.Plast Reconstr Surg2002;109:2037-42

[22] Dorafshar AH,DeWolfe M,Gottlieb LJ.Split lateral iliac crest chimera flap: utility of the ascending branch of the lateral femoral circumflex vessels.Plast Reconstr Surg2010;125:574-81

[23] Jeng SF,Wei FC,Chen SH.Concomitant ipsilateral pedicled fibular transfer and free muscle flap for compound tibial defect reconstruction.Ann Plast Surg2001;47:47-52

[24] Engel H,Wei FC.Role of microsurgery in lower extremity reconstruction.Plast Reconstr Surg2011;127 Suppl 1:228S-38S

[25] Masquelet AC,Begue T.[Reconstruction of the long bones by the induced membrane and spongy autograft].Ann Chir Plast Esthet2000;45:346-53

[26] Bakri K,Mardini S.Combined massive allograft and intramedullary vascularized fibula transfer: the capanna technique for lower-limb reconstruction.Semin Plast Surg2008;22:234-41 PMCID:PMC2884882

[27] Ziegler-Graham K,Ephraim PL,Brookmeyer R.Estimating the prevalence of limb loss in the United States: 2005 to 2050.Arch Phys Med Rehabil2008;89:422-9

[28] Thaunat O,Dubois V,Petruzzo P.Immunopathology of rejection: do the rules of solid organ apply to vascularized composite allotransplantation?.Curr Opin Organ Transplant2015;20:596-601

[29] Bermú Dez L, Santamaría A, Romero T, Calderó DF. Experimental model of facial transplant.Plast Reconstr Surg2002;110:1374-5

[30] Gorantla VS,Jones JW,Maldonado C.Immunosuppressive agents in transplantation: Mechanisms of action and current anti-rejection strategies.Microsurgery2000;20:420-9

[31] Cavadas PC,Carballeira A.Bilateral transfemoral lower extremity transplantation: result at 1 year.Am J Transplant2013;13:1343-9

[32] Schirò GR,Piccioli A.Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system.BMC Musculoskelet Disord2015;16:372 PMCID:PMC4722671

[33] Battiston B,Pontini I.Lower limb replantations: indications and a new scoring system.Microsurgery2002;22:187-92

[34] Koehler-McNicholas SR,Gard SA.The biomechanical response of persons with transfemoral amputation to variations in prosthetic knee alignment during level walking.J Rehabil Res Dev2016;53:1089-106 PMCID:PMC5559886

[35] Souza JM,Harrington CJ,Forsberg JA.Osseointegration of extremity prostheses: a primer for the plastic surgeon.Plast Reconstr Surg2020;146:1394-403

[36] Pezzin LE,Mackenzie EJ,Rossbach P.Use and satisfaction with prosthetic limb devices and related services.Arch Phys Med Rehabil2004;85:723-9

[37] Hagberg K,Gunterberg B.Osseointegrated trans-femoral amputation prostheses: prospective results of general and condition-specific quality of life in 18 patients at 2-year follow-up.Prosthet Orthot Int2008;32:29-41

[38] Hagberg K,Brånemark R.Outcome of percutaneous osseointegrated prostheses for patients with unilateral transfemoral amputation at two-year follow-up.Arch Phys Med Rehabil2014;95:2120-7

[39] Hagberg K,Kulbacka-Ortiz K,Malchau H.A 15-year follow-up of transfemoral amputees with bone-anchored transcutaneous prostheses.Bone Joint J2020;102-B:55-63

[40] Kilgore KL,Keith MW.Durability of implanted electrodes and leads in an upper-limb neuroprosthesis.J Rehabil Res Dev2003;40:457-68

[41] Solomonow M.External control of the neuromuscular system.IEEE Trans Biomed Eng1984;31:752-63

[42] Winslow BD,Huber Z.Mobile, game-based training for myoelectric prosthesis control.Front Bioeng Biotechnol2018;6:94 PMCID:PMC6050406

[43] Kuiken TA,Lock BA.Targeted muscle reinnervation for real-time myoelectric control of multifunction artificial arms.JAMA2009;301:619-28 PMCID:PMC3036162

[44] Hargrove LJ,Young AJ.Robotic leg control with EMG decoding in an amputee with nerve transfers.N Engl J Med2013;369:1237-42

[45] Frantz TL,West JM,Phieffer LS.Targeted muscle reinnervation at the time of major limb amputation in traumatic amputees: early experience of an effective treatment strategy to improve pain.JB JS Open Access2020;5:e0067 PMCID:PMC7418908

[46] Frost CM,Flattery SM.Regenerative peripheral nerve interfaces for real-time, proportional control of a Neuroprosthetic hand.J Neuroeng Rehabil2018;15:108 PMCID:PMC6245539

[47] Herr HM.Bionic ankle-foot prosthesis normalizes walking gait for persons with leg amputation.Proc Biol Sci2012;279:457-64 PMCID:PMC3234569

[48] Hargrove LJ,Simon AM.Intuitive control of a powered prosthetic leg during ambulation: a randomized clinical trial.JAMA2015;313:2244-52

[49] Davis TS,Hutchinson DT.Restoring motor control and sensory feedback in people with upper extremity amputations using arrays of 96 microelectrodes implanted in the median and ulnar nerves.J Neural Eng2016;13:036001

[50] Walker CF,Markle DR.Parameters of stimulation and perception in an artificial sensory feedback system.J Bioeng1977;1:251-6

[51] Badia J,Andreu D,Stieglitz T.Comparative analysis of transverse intrafascicular multichannel, longitudinal intrafascicular and multipolar cuff electrodes for the selective stimulation of nerve fascicles.J Neural Eng2011;8:036023

[52] Valle J, Navarro X. Interfaces with the peripheral nerve for the control of neuroprostheses.Int Rev Neurobiol2013;109:63-83

[53] Fisher LE,Bailey SN.Standing after spinal cord injury with four-contact nerve-cuff electrodes for quadriceps stimulation.IEEE Trans Neural Syst Rehabil Eng2008;16:473-8 PMCID:PMC2936226

[54] Caparso AV,Mansour JM.A nerve cuff electrode for controlled reshaping of nerve geometry.J Biomater Appl2009;24:247-73 PMCID:PMC3569731

[55] Schiefer MA,Triolo RJ,Tyler DJ.Selective stimulation of the human femoral nerve with a flat interface nerve electrode.J Neural Eng2010;7:26006 PMCID:PMC2915830

[56] Tyler DJ.A slowly penetrating interfascicular nerve electrode for selective activation of peripheral nerves.IEEE Trans Rehabil Eng1997;5:51-61

[57] Grinberg Y,Tyler DJ.Fascicular perineurium thickness, size, and position affect model predictions of neural excitation.IEEE Trans Neural Syst Rehabil Eng2008;16:572-81 PMCID:PMC2918421

[58] Dhillon GS,Hutchinson DT.Residual function in peripheral nerve stumps of amputees: implications for neural control of artificial limbs.J Hand Surg Am2004;29:605-15; discussion 616-8

[59] Boretius T,Pascual-Font A.A transverse intrafascicular multichannel electrode (TIME) to interface with the peripheral nerve.Biosens Bioelectron2010;26:62-9

[60] Ledbetter NM,Oby ER.Intrafascicular stimulation of monkey arm nerves evokes coordinated grasp and sensory responses.J Neurophysiol2013;109:580-90 PMCID:PMC3545468

[61] Clark GA,Warren DJ.Recording sensory and motor information from peripheral nerves with Utah Slanted Electrode Arrays.Annu Int Conf IEEE Eng Med Biol Soc2011;2011:4641-4

[62] Tan DW,Keith MW,Tyler J.A neural interface provides long-term stable natural touch perception.Sci Transl Med2014;6:257ra138 PMCID:PMC5517305

[63] Lotfi P,Chouhan AK,Romero-Ortega MI.Modality-specific axonal regeneration: toward selective regenerative neural interfaces.Front Neuroeng2011;4:11 PMCID:PMC3191531

[64] Hallin RG.Microneurography in relation to intraneural topography: somatotopic organisation of median nerve fascicles in humans.J Neurol Neurosurg Psychiatry1990;53:736-44 PMCID:PMC1014249

[65] Castro J,Avendaño C.Fiber composition of the rat sciatic nerve and its modification during regeneration through a sieve electrode.Brain Res2008;1190:65-77

[66] Panetsos F,Negredo P,Bonacasa V.Neural prostheses: electrophysiological and histological evaluation of central nervous system alterations due to long-term implants of sieve electrodes to peripheral nerves in cats.IEEE Trans Neural Syst Rehabil Eng2008;16:223-32

[67] Clements IP,Srinivasan A,Andreasen DS.Regenerative scaffold electrodes for peripheral nerve interfacing.IEEE Trans Neural Syst Rehabil Eng2013;21:554-66

[68] la Oliva N, Mueller M, Stieglitz T, Navarro X, Del Valle J. On the use of Parylene C polymer as substrate for peripheral nerve electrodes.Sci Rep2018;8:5965 PMCID:PMC5899141

[69] Howard CL,Abbas J.Residual standard deviation: validation of a new measure of dual-task cost in below-knee prosthesis users.Gait Posture2017;51:91-6

[70] Christie BP,Shell CE,Tyler DJ.Ambulatory searching task reveals importance of somatosensation for lower-limb amputees.Sci Rep2020;10:10216 PMCID:PMC7311393

[71] Biddiss EA.Upper limb prosthesis use and abandonment: a survey of the last 25 years.Prosthet Orthot Int2007;31:236-57

[72] Farinetti A,Mancini J,Nicollas R.Cochlear implant complications in 403 patients: comparative study of adults and children and review of the literature.Eur Ann Otorhinolaryngol Head Neck Dis2014;131:177-82

[73] Kumar K,Taylor RS.Complications of spinal cord stimulation, suggestions to improve outcome, and financial impact.J Neurosurg Spine2006;5:191-203

[74] Velnar T,Klobucar R.Biomaterials and host versus graft response: a short review.Bosn J Basic Med Sci2016;16:82-90 PMCID:PMC4853000

[75] Yildiz KA,Kaufman KR.Interfaces with the peripheral nervous system for the control of a neuroprosthetic limb: a review.J Neuroeng Rehabil2020;17:43 PMCID:PMC7063740