Prosthesis Rejection Research Articles

Sex and gender differences in upper extremity prosthesis rejection: A review of literature.

Prosthesis rejection is a significant barrier to rehabilitation of persons with upper limb difference. Many individual factors can affect device rejection, including a person's sex or gender. The objective of this narrative review was to explore the reported differences between the sexes and genders in upper limb prosthesis rejection. This review considered peer-reviewed, published research studies in which the study population were adults (aged 18 and older) who had unilateral or bilateral limb difference (any level) of any etiology with current, past, or no history of prosthetic device usage. Using identified keywords, index terms, and a peer-reviewed search filter, the literature was searched in MEDLINE, Embase, and PsycInfo. The reasons for rejection, disuse, or abandonment of prosthetic devices were extracted, with the focus on reported differences between sex and genders. After searching, 29 articles were selected for full-text review and 15 were included. Only 5 of 15 articles examined differences between the sexes. Women tend to reject upper extremity prostheses more than men both before and after being fit with a device; device characteristics, such as weight and cosmesis, do not appear to be appropriately designed for women; and there may not be adequate consideration of the goals for women with limb difference(s). There is inadequate reporting of sex and gender in the literature on prosthesis rejection; future studies should report and explore these factors to determine whether the needs of the full population with limb loss are being met.

Patient-reported function, quality of life and prosthesis wear in adults born with one hand: a national cohort study.

We invited individuals aged above 16 years with a congenital transverse reduction deficiency at and above the wrist born in Norway between 1970 and 2006 to complete the short version of the Disabilities of the Arm, Shoulder and Hand Outcome Measure, the 5-Level EuroQoL-5-Dimension instrument, the RAND 36-Item Short Form Health Survey and a single-item questionnaire on arm function, appearance, pain and prosthesis wear. Of 154 eligible participants, 58 (38%) responded. Their scores were not different from the general population. All had been offered prostheses, and 56 (97%) had been fitted at a median age of 1 year (interquartile range 0-2.8). Of the participants, 37 (64%) were still prosthesis wearers, while 21 (36%) were non-wearers or using gripping devices only. Prosthesis wearers had higher levels of 'vitality' as assessed by the RAND-36 and rated their arm appearance higher, but there were no other score differences, indicating that prosthesis rejection is not associated with worse functional outcomes.Level of evidence: III.

Graft rejection in paediatric congenital heart disease.

Congenital heart disease (CHD) affects around 1.35 million neonates worldwide per annum, and surgical repair is necessary in approximately 25% of cases. Xenografts, usually of bovine or porcine origin, are often used for the surgical reconstruction. These xenografts elicit an immune response due to significant immunological incompatibilities between host and donor. Current techniques to dampen the initial hyperacute rejection response involve aldehyde fixation to crosslink xenoantigens, such as galactose-α1,3-galactose and N-glycolylneuraminic acid. While this temporarily masks the epitopes, aldehyde fixation is a suboptimal solution, degrading over time, resulting in cytotoxicity and rejection. The immune response to foreign tissue eventually leads to chronic inflammation and subsequent graft failure, necessitating reintervention to replace the defective bioprosthetic. Decellularisation to remove immunoincompatible material has been suggested as an alternative to fixation and may prove a superior solution. However, incomplete decellularisation poses a significant challenge, causing a substantial immune rejection response and subsequent graft rejection. This review discusses commercially available grafts used in surgical paediatric CHD intervention, looking specifically at bovine jugular vein conduits as a substitute to cryopreserved homografts, as well as decellularised alternatives to the aldehyde-fixed graft. Mechanisms of biological prosthesis rejection are explored, including the signalling cascades of the innate and adaptive immune response. Lastly, emerging strategies of intervention are examined, including the use of tissue from genetically modified pigs, enhanced crosslinking and decellularisation techniques, and augmentation of grafts through in vitro recellularisation or functionalisation with human surface proteins.

Home intervention for children and adolescents with unilateral trans-radial and partial carpal reduction deficiencies.

Current training interventions assessing pediatric functional motor skills do not account for children and adolescents with upper limb reductions who utilize a prosthesis. Prosthesis rejection showed that 1 out of 5 prosthesis users will reject their prosthesis due to lack of durability, lack of function, not meeting the participant’s needs, perceived lack of need, and medical restrictions indicating that prosthetic users believed they were more functional without the device. It was hypothesized that an 8-week Home Intervention program will result in significant improvements in gross manual dexterity, bimanual coordination, and the functional activities performed during the program. It was also hypothesized that the novel Prosthesis Measurement of Independent Function (PMIF) score will reflect the Home Intervention performance improvements. Five pediatric participants (ages 5–19 years) with congenital upper limb reductions were fitted with a 3D printed upper extremity prosthesis for their affected limb. Participants then completed the 8-week Home Intervention which included Training activities completed 2×/week for 8 weeks and Non-Training activities completed only at week 1 and week 8. Participant’s times were recorded along with each participant receiving a PMIF score ranging from 0 = unable to complete activity, to 7 = complete independence with activity completion. Results showed a decrease in overall averaged activity times amongst all activities. For all activities performed, individual averaged time decreased with the exception of Ball Play which increased over the 8-week intervention period. There was significant interaction for Home Intervention performance with F = 2.904 (p = 0.003). All participants increased their PMIF scores to 7 (complete independence) at the end of the 8 week intervention period. Decreases in time averages and increases in PMIF scores indicate that learning and functional use of the prostheses have occurred amongst the pediatric participants.

Mite bites, comet signs and possible mammary prosthesis rejection after returning to a vacation home: a diagnostic challenge

Pyemotes ventricosus is a free-living mite feeding on larvae or nymphs of insects, including moths, beetles, wasps and bees, that are usually found in grain, straw and firewood. When present in great number or when its food is lacking, it could accidentally bite mammals, including humans, causing a highly pruritic self-limiting dermatitis, sometimes followed by a lymphangitis known as “comet sign”.We present a singular case of mite lymphangitis that surrounds and delimitates breast prosthesis in a 30-year-old Caucasian woman. Other bite in the lower abdomen did not present comet sign. The patient got the infestation in her vacation home in the South of Italy, uninhabited for 10 months since COVID-19 confinement. We hypothesize that the previous surgery made the lymphatic vessels more prone to inflammation and we compare other insect bites that can occur vacationing in a long period uninhabited room.A delayed diagnosis of comet sign implies a retarded fumigation allowing new mite bites and, in this case, extends the patient’s preoccupation about the prosthesis rejection.

Prosthesis rejection in individuals with limb amputation: a narrative review with respect to rehabilitation.

To evaluate the refusal of the prosthesis in order to highlight elements in determining the acceptance/rejection of the prosthetic devices, and its role on rehabilitation program. A literature review through a search of the database Medline for studies published between October 2007 and May 2020 using the key words "prosthesis", "limb", and "accept"*. Nine studies were included. Women appear to be more concerned about discomfort in using body-powered devices and about prosthesis cosmetic appearance. Level of limb amputation was considered relevant for prosthesis rejection only for the upper limb. Children fitted with prosthesis before two years old were less likely to abandon the prosthesis, preschool children have a lower drop-out prevalence compared to adults and school-age children. Understating the factors for rejections is crucial for more favorable health outcomes; multiple psychological factors should be considered during the rehabilitation process of individuals with limb amputation. Rehabilitation should consider psychosocial assistance for acceptance and perception of body representation and its discrepancy with the real body.

Upper-Limb Prosthetics: Use of Video Guides to Assist With Activities of Daily Living Performance

Abstract Date Presented 03/26/20 A major concern for upper-limb prosthesis users noted by prosthetists and OTs is rate of prosthesis rejection. The creation of the video program is one strategy to counteract this concern. The purpose of the program is to provide clients with an additional resource to learn and relearn how to complete daily tasks with their prosthesis. The program in place was designed to determine how effective and helpful the videos are for prosthesis users visiting Össur Touch Solutions. Primary Author and Speaker: Veronica Balko Contributing Authors: Richard Simpson, Lynsay Whelan

Cross-sectional International Multicenter Study on Quality of Life and Reasons for Abandonment of Upper Limb Prostheses.

Background:This multicenter study aimed to examine the reasons for prosthesis rejection and assess the quality of life (QOL) among patients with upper limb deficiency.Methods:Three rehabilitation centers in Japan and 1 academic medical center in the United States participated. Patients between the age of 12 and 75 years with unilateral or bilateral upper limb absence from the level of wrist to shoulder disarticulation were included. Two questionnaires were used, an original questionnaire on prosthesis use and the EQ-5D, which were completed by both the participant and a live-in proxy.Results:Of the 367 patients with upper limb loss invited, 174 patients participated in this study. Eighty percent of the study population were male patients. The most common amputation level was transradial. Trauma was the most common cause of limb loss. The prosthesis rejection rate was 9% (n = 16). The most common reason for abandonment was a lack of prosthesis functionality. Ten of 16 prosthesis nonusers (63%) and 59 prosthesis users (38%) were unemployed or students. The mean EQ-5D utility score was significantly higher in prosthesis users than in nonusers (0.762 versus 0.628, P < 0.01). Live-in proxies significantly overestimated QOL in male patients (0.77 versus 0.807, P=0.01).Conclusions:The current prosthesis rejection rate is low. QOL was significantly higher in prosthesis users than in nonusers. More prosthesis users were employed compared with nonusers. Care should be taken not to overestimate the QOL of male patients with upper limb loss as their proxies often did.

Visual attention, EEG alpha power and T7-Fz connectivity are implicated in prosthetic hand control and can be optimized through gaze training

BackgroundProsthetic hands impose a high cognitive burden on the user that often results in fatigue, frustration and prosthesis rejection. However, efforts to directly measure this burden are sparse and little is known about the mechanisms behind it. There is also a lack of evidence-based training interventions designed to improve prosthesis hand control and reduce the mental effort required to use them. In two experiments, we provide the first direct evaluation of this cognitive burden using measurements of EEG and eye-tracking (Experiment 1), and then explore how a novel visuomotor intervention (gaze training; GT) might alleviate it (Experiment 2).MethodsIn Experiment 1, able-bodied participants (n = 20) lifted and moved a jar, first using their anatomical hand and then using a myoelectric prosthetic hand simulator. In experiment 2, a GT group (n = 12) and a movement training (MT) group (n = 12) trained with the prosthetic hand simulator over three one hour sessions in a picking up coins task, before returning for retention, delayed retention and transfer tests. The GT group received instruction regarding how to use their eyes effectively, while the MT group received movement-related instruction typical in rehabilitation.ResultsExperiment 1 revealed that when using the prosthetic hand, participants performed worse, exhibited spatial and temporal disruptions to visual attention, and exhibited a global decrease in EEG alpha power (8-12 Hz), suggesting increased cognitive effort. Experiment 2 showed that GT was the more effective method for expediting prosthesis learning, optimising visual attention, and lowering conscious control – as indexed by reduced T7-Fz connectivity. Whilst the MT group improved performance, they did not reduce hand-focused visual attention and showed increased conscious movement control. The superior benefits of GT transferred to a more complex tea-making task.ConclusionsThese experiments quantify the visual and cortical mechanisms relating to the cognitive burden experienced during prosthetic hand control. They also evidence the efficacy of a GT intervention that alleviated this burden and promoted better learning and transfer, compared to typical rehabilitation instructions. These findings have theoretical and practical implications for prosthesis rehabilitation, the development of emerging prosthesis technologies and for the general understanding of human-tool interactions.

Peromelia - congenital transverse deficiency of the upper limb: a literature review and current prosthetic treatment.

Peromelia or congenital transverse deficiency describes a truncation of the upper limb below various limb levels. Recommendations regarding treatment vary and are mainly based on expert opinions. This paper summarizes the current literature regarding the aetiology, pathogenesis and specifically treatment algorithms for children with peromelia. We performed a non-systematic review of the current literature from MEDLINE/PubMed to obtain comprehensive up-to-date information about peromelia, focusing on current recommendations for the treatment of peromelia (e.g. prosthetic fitting, external stump lengthening). The current literature lacks clear evidence as to whether prosthetic treatment is superior to prosthetic non-usage. However, based on the available studies, children with transradial or transhumeral peromelia should preferably be fitted with passive/cosmetic prostheses at the age between six and 24 months, followed by active/myoelectric devices at the age of 2.5 to four years. It remains controversial whether early myoelectric prosthetic fitting can reduce prosthesis rejection times; however, cognitive readiness and the ability to absolve a guided training programme are seen as important prerequisites for myoelectric fitting. Children with very short stumps may benefit from stump lengthening using external fixators and prosthetic modification. The treatment of children with peromelia generally requires a guided, multidisciplinary team approach. A training programme is essential to optimize individuals’ performance in the execution of activities of daily living and decrease rejection risks whenever a myoelectric device is prescribed. Myoelectric fitting should preferably be commenced at no later than four years of age. However, long-term reports on the benefits of prosthetic treatment are still pending.

Long-term results of early myoelectric prosthesis fittings: A prospective case-control study.

Different recommendations exist regarding what age is best for first-time fitting of myoelectric hand prostheses in children. To compare prosthetic skill, prosthetic use and risk for rejection over time between children fitted with myoelectric hand prostheses before or after 2½ years of age. Prospective case-control design. The cases were nine children fitted with myoelectric hand prostheses before the age of 2½ years, whereas the controls were 27 children who were fitted with myoelectric hand prostheses after the age of 2½ years. The Skills Index Ranking Scale was used to classify prosthetic skill, and prosthetic use was categorised based on wearing time and pattern. Independent samples tests were used to compare data between groups. To estimate and compare the risk of prosthesis rejection between groups and over time, survival analysis was used. Cases showed prosthetic skill early, but controls had caught up by the age of 3½ years. Cases had a significant ( p = 0.046) decrease in prosthetic use at the age of 9 years. In the long term, cases had a higher percentage of prosthesis rejection. Considering young children's development of prosthetic skill and prosthetic use over time, this study shows no additional advantages from fitting a myoelectric hand prosthesis before 2½ years of age. Clinical relevance Children may be fitted with myoelectric hand prostheses to assist in daily tasks and to prevent future over-use problems. Most children fitted with myoelectric hand prostheses before 4 years of age become regular users. No advantages of fitting myoelectric hand prostheses before 2½ years of age were observed.

Upper extremity prosthesis user perspectives on unmet needs and innovative technology.

The needs of individuals with upper limb amputation and congenital limb difference are not being fully met by current prostheses, as evidenced by prosthesis rejection, non-wear, and user reports of pain and challenging activities. Emerging technologies such as dexterous sensorized robotic limbs, osseointegrated prostheses, implantable EMG electrodes, and electrical stimulation for sensory feedback have the potential to address unmet needs, but pose additional risks. We plan to assess upper limb prosthesis user needs and perspectives on these new benefits and risks using an extensive quantitative survey. In preparation for this survey, we report here on qualitative interviews with seven individuals with upper limb amputation or congenital limb difference. Unstructured text was mined using topic modeling and the results compared with identified themes. A more complete understanding of how novel technologies could address real user concerns will inform implementation of new technologies and regulatory decision-making.

Bone-Anchored Titanium Implants in Patients with Auricular Defects: Three Years and 27 Patients' Experience.

Different surgical solutions have been proposed for reconstruction of the auricle following loss of the pinna through traumatic injury or neoplastic disease or in patients with congenital defects. Surgical treatment may involve the insertion of an autogenous rib cartilage framework or the use of a porous polymer material inserted into an expanded postauricular flap. Reconstruction with rib cartilage has yielded good results but requires more than one surgical step, and adverse events can occur both at the donor and at the acceptor site; cases of prosthesis rejection have also been described following application of the polymeric prosthesis. The use of a titanium, dowel-retained silicone prosthetic pinna, fixed to the temporal bone, has recently been proposed. This useful surgical approach is indicated particularly after resection of the pinna caused by neoplastic disease or in traumatic auricular injury. Osseointegrated titanium implants used in 27 patients in this study provided them with a safe, reliable, adhesive-free method of anchoring the auricular prostheses. The prostheses allowed recovery of normal physical appearance and all the patients reported that they were completely satisfied with the outcome of the surgical reconstruction. No surgical complications, implant failures, or prosthetic failures were encountered over six months to three years.

Stump sensibility in children with upper limb reduction deficiency

To compare stump sensibility in children with upper limb reduction deficiency with sensibility of the unaffected arm and hand. In addition, to evaluate the associations between stump sensibility, stump length and activity level. Cross-sectional study. Children and young adults aged 6-25 years with upper limb reduction deficiency. Threshold of touch was measured with Semmes-Weinstein monofilaments, stereognosis was measured with the Shape-Texture Identification test and kinaesthesia and activity level was measured with the Child Amputee Prosthetics Project - Functional Status Inventory and the Prosthetic Upper Extremity Functional Index. A total of 31 children with upper limb reduction deficiency (mean age 15 years, 3 prosthesis wearers) were investigated. The threshold of touch of the stump circumference was lower (indicating higher sensibility) than of the unaffected arm (p = 0.006), hand (p = 0.004) and stump end-point (p = < 0.001). Long stumps had higher threshold of touch (indicating lower sensibility) than short stumps (p = 0.046). Twenty-nine children recognized 1 or more shapes or textures with the stump. Kinaesthesia in the affected and unaffected sides was comparable. Sensibility was not correlated with activity level. Threshold of touch, stereognosis and kinaesthesia of the affected sides were excellent. Threshold of touch of the stump circumference was lower (indicating higher sensibility) than of the unaffected arm and hand. High stump sensibility may clarify good functioning in the children without prostheses and contribute to prosthesis rejection.

Characterization of Compensatory Trunk Movements During Prosthetic Upper Limb Reaching Tasks

Metzger AJ, Dromerick AW, Holley RJ, Lum PS. Characterization of compensatory trunk movements during prosthetic upper limb reaching tasks. ObjectiveTo characterize the compensatory movements of the trunk during functional reaching tasks performed by upper limb prosthesis users. DesignSurvey. SettingClinical laboratory at a national rehabilitation hospital. ParticipantsTranshumeral and transradial prosthesis users (n=10) and uninjured control subjects (n=10). InterventionsNot applicable. Main Outcome MeasuresThree-dimensional motion analysis data were collected during simulated reaching tasks, such as donning a cap, placing a nut, and sorting clothes. The metrics were range of motion of the trunk in the 3 anatomical directions and elbow and shoulder path distance. ResultsProsthesis users had significantly larger truncal movements than controls during all 3 reaching tasks in all 3 directions (P≤.03). Shoulder path distance in persons with amputation was larger than in controls in all 3 tasks (P<.01). Elbow path distance in persons with amputation was larger than in controls in the nut and clothes tasks (P≤.02). The subgroup of transradial prosthesis users displayed these abnormal movements despite the presence of an intact elbow. ConclusionsThe altered physiologic structure of the arm caused the individuals to develop a different motor control strategy than an intact arm. Functional limitations, such as the loss of distal degrees of freedom, required persons with amputation to use trunk displacement in place of arm/hand movement. These compensatory movements during reaching tasks may be a cause of prosthesis rejection and, in some cases, may be resolved with proper rehabilitative training. Analysis of compensatory trunk movements may also provide a useful endpoint for evaluating new prosthesis designs.

Prosthesis rejection in acquired major upper-limb amputees: a population-based survey

Purpose: To estimate the rates of primary and secondary prosthesis rejection in acquired major upper-limb amputees (ULAs), to describe the most frequently reported reasons for rejection and to estimate the influence of background factors on the risk of rejection. Method: Cross-sectional study analysing population-based questionnaire data (n = 224). Effects were analysed by logistic regression analyses and Cox regression analyses. Results: Primary prosthesis rejection was found in 4.5% whereas 13.4% had discontinued prosthesis use. The main reasons reported for primary non-wear were a perceived lack of need and discrepancies between perceived need and the prostheses available. The main reasons reported for secondary prosthesis rejection were dissatisfaction with prosthetic comfort, function and control. Primary prosthesis rejection was more likely in ULAs amputated at high age and in ULAs with proximal amputations. Secondary prosthesis rejection was more likely in proximal ULAs and in women. Conclusions: Clinicians should be aware of the increased risk of rejection in proximal ULAs, elderly ULAs and in women. Emphasising individual needs will probably facilitate successful prosthetic fitting. Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use. Further studies of the effect of prosthetic training and of the reasons for rejection of different prosthetic types are suggested.Implications for RehabilitationMost acquired major upper-limb amputees (ULAs) are fitted with prostheses after the amputation.This population-based study shows that proximal ULAs, elderly ULAs and women have an increased risk of prosthesis rejection.Emphasising individual needs may facilitate successful prosthetic fitting.Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use.

Prosthetic rehabilitation of the upper limb amputee

ABSTRACTThe loss of all or part of the arm is a catastrophic event for a patient and a significant challenge to rehabilitation professionals and prosthetic engineers. The large, upper extremity amputee population in India has, historically, been poorly served, with most having no access to support or being provided with ineffective prostheses. In recent years, the arrival of organisations like Otto Bock has made high quality service standards and devices accessible to more amputees. This review attempts to provide surgeons and other medical professionals with an overview of the multidisciplinary, multistage rehabilitation process and the solution options available. With worldwide upper extremity prosthesis rejection rates at significant levels, the review also describes some of the factors which influence the outcome. This is particularly relevant in the Indian context where the service can involve high cost investments. It is the responsibility of all contributing professionals to guide vulnerable patients through the process and try to maximise the benefit that can be obtained within the resources available.

Prosthetic rehabilitation of the upper limb amputee

The loss of all or part of the arm is a catastrophic event for a patient and a significant challenge to rehabilitation professionals and prosthetic engineers. The large, upper extremity amputee population in India has, historically, been poorly served, with most having no access to support or being provided with ineffective prostheses. In recent years, the arrival of organisations like Otto Bock has made high quality service standards and devices accessible to more amputees. This review attempts to provide surgeons and other medical professionals with an overview of the multidisciplinary, multistage rehabilitation process and the solution options available. With worldwide upper extremity prosthesis rejection rates at significant levels, the review also describes some of the factors which influence the outcome. This is particularly relevant in the Indian context where the service can involve high cost investments. It is the responsibility of all contributing professionals to guide vulnerable patients through the process and try to maximise the benefit that can be obtained within the resources available.

Unilateral Upper Extremity Transverse Deficiencies: Prosthetic Use and Function

Background Children with upper extremity transverse deficiency are assumed to have significant disability associated with their malformation, and use of prosthesis has been presumed to be necessary to reduce this disability. However, standardized methods of measuring function and prosthesis use have not been widely applied to this population, and their prosthesis rejection rates are high. Methods This article reviews the measurement of hand function in children, and evidence regarding the usefulness of prostheses for children with transverse deficiency. Results There are several different questionnaires and function tests available to measure hand function in children. Most are specialized, time consuming and incompletely validated. Conclusion Children with transverse deficiency have close to normal function and quality of life, and prosthesis use is not associated with improvements in these areas. Further research is needed to develop better methods of measuring function. Currently available prostheses may help with social acceptance or be useful as tools for specific activities, but they do not improve daily function or quality of life.

Transabdominal laparoscopic inguinal hernia repair: is there a place for biological mesh?

An ideal mesh should produce minimal foreign-body reaction and be compatible with human tissue. Studies focusing on these aspects indicate that a biological mesh acts as a scaffold for hernia repair. In this paper, we retrospectively evaluate a consecutive series of patients who underwent laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty using a biological mesh-Surgisis-fixed with fibrin glue, focusing on the feasibility of the technique and the incidence of complications, especially those related to the type of mesh implanted. Between July and September 2006, 11 patients were operated on using TAPP hernioplasty (bilateral or unilateral) and applying a Surgisis mesh affixed by a fibrin sealant. The mean overall operative time was 75 (+/-15) min. All of the surgeries were performed as a day surgery procedure. Any major or minor complications (early or late), such as prosthesis rejection and/or infection, were recorded. There was only one case of recurrence, likely due to technical error. The mean follow-up was 14.5 (+/-1) months. On the basis of this initial experience, TAPP hernioplasty with a Surgisis mesh affixed with fibrin glue is feasible, easy to perform, and effective in experienced hands, with good results. The well known characteristics of a minimally invasive and gentle approach, together with the type of mesh implanted and fixation using glue, might explain the encouraging results of this experience. Therefore, this type of mesh might be tailored to not only the sportsman or the patient with a contaminated surgical field, but may also be used in young patients, where there is a fear of leaving behind a long-term foreign body.