All right, good morning. I'm Jacques Cockburn, I'm from NYU. Thank you very much for joining us this time of the morning. So I'll be speaking on fingertip amputations and also introducing the talks today. We have an excellent group of speakers today, prosthetists, occupational therapists that specialize in upper extremity amputation care, and then myself and Dr. Loeffler and Dr. Aylan, who are surgeons that are committed to the care of amputees. So amputation surgery has not been a very sexy topic, and I just want to take this moment to acknowledge the fact that at 6.45 AM on a Saturday morning, people went out last night, and there are even people here to listen about amputation care. I mean, that really is impressive, right? And that really speaks to how things have changed over the past five years, because I think that you probably never would have imagined that you'd be attending a talk at ASSH on amputation care about five years ago. But things have really become very popular with a lot of members of ASSH in caring for these patients. And I'm sure that some of you probably also care for lower extremity amputees, which is pretty remarkable that hand surgeons are taking care of upper and lower extremity amputees. So then you have to ask, well, why? Why something that's been neglected for so many centuries, probably, has now become, in many respects, fashionable? And it's things like this that we see, and we see the future, and you can argue about how far in the future this is. But I think we all believe that this is, at some point, something like this we'll be able to attain. Now, the reality is far from that right now. And we do have very advanced prosthetics, and this is actually called the Luke arm. But you have all these articulations, and then you have to wonder, OK, how are we going to control these articulations? And you have a range of input devices. But the problem is that they're not intuitive. So the amputee is actually much more complex than just function and pain. The reality is that they have so many things that all interact with each other, the psychology, the appearance, the function, and the pain. And so we as hand surgeons that care for the amputee, I think part of the problem, and we'll be talking about that, and this is why we also wanted this talk to be more multidisciplinary, is that we have a tendency of focusing on the nerve pain. We have a tendency to focus on the TMR surgery. We have a tendency to focus on the applications rather than the patient. We want to learn about TMR. We want to do TMR. And we seek opportunities for TMR. But the patient is so much more than that. For us as surgeons, what we typically focus on, like I said, is the function and the pain. When you're talking about function, and we're always thinking about myoelectric prostheses, is where can we get the signal to control the device? And you have the brain, you have nerve, you have the muscle, and you have those three categories. And they all three have problems and difficulties and challenges. The brain, it's really difficult to interpret the signal. With the nerve, the signal is a very quiet signal. How can you get that nerve to provide a signal that you can use? And then the muscle is limited, and especially the more proximal amputation. Well, the advancements that we've pursued have been focused primarily on amplifying the signal from the nerve. And like I referenced, and we're not going to talk about TMR, at least I'm not going to talk about TMR, because I think all of you are very familiar with TMR, but that's one of the ways that we have discovered is an effective way to amplify the signal. For a patient like this, you can actually generate quite a few signals with TMR. And then RPNI is another competing modality. And yes, you hear people say, oh, TMR and RPNI are not competing. You can actually use them collaboratively. And I think there's some truth to that. But I think in reality, they are two different philosophies to address the amplification of the nerve signal. It's just important, like I said, we must take a moment and see what we are doing and how this actually compares to the history. It's pretty remarkable. You hear older surgeons always say, oh, I've seen this thing. I've seen this type of surgery. I've seen this technology come and go a few times already. And this is true when you look at the history for TMR and a lot of nerve surgery as it pertains to amputees. The reality is that a lot of what we're doing, not all of what we're doing, but a lot of what we're doing is very similar to people who were doing over 100 years ago. And then also, when you're looking at nerve pain, that too, we think that we've made significant strides in the care for pain with amputees. But people have been focused on this, and people have had various techniques and successes for many years, especially with Dr. Dellin and Dr. McKinnon. And we just must always remember that and put that into perspective. Now skipping to finger-level amputations, the rates of finger-level amputations have remained relatively steady over the years. However, the rates of replantation, as we know, and this is a topic that comes up very often, continues to decrease. So that means that we have an increasing number of patients out there that have finger-level amputations. And that problem is not going away. If anything, that problem might actually be increasing with the decreasing rates of replantation. And I'm sure many of you, if not all of you, are familiar with this article. And you've heard people say, oh, like, oh, you know, the index finger, if it's an isolated index finger, you don't have to replant. The function is not affected in a significant way. The middle finger can compensate for it. Now I think this is a helpful article, but I think people overemphasize the importance of this article and the thought process that goes behind it. And we minimize the morbidity of finger-level amputations. So here's a patient of mine who has amputation of the index and the middle finger on the non-dominant hand. And just look at him trying to use that Allen wrench. You see the index finger and the middle finger moving? It's really difficult. He can pinch. He can do it. But you see that middle finger and that index finger, they want to help. They want to do something. So it's very awkward for him. He's moving those fingers. He's getting no tactile resistance. Now this is more of a strength procedure that he's performing. And you can just imagine, if you had to grip something forcefully like that for anything more than 30 seconds, a minute, your forearm is going to get really fatigued. Just try to do that one time. Try to grip something forcefully with the ring finger and the small finger. We always hear that strength, your grip strength, comes from the ulnar side of your hand. It's true. But try doing it without using the index finger and the middle finger. And so one of the things that he complains about is fatigue. He gets burning pain in his forearm because the ring finger and the small finger just aren't strong enough. So I think we really minimize the functional morbidity of finger level amputations. Now the reality also is that we talked about the psychology, the appearance also being very important for these amputees, upper extremity amputees. Another thing that we've seen in our practice is that the mental health morbidity that is associated with these patients' experience does not correlate well with the level of the amputation. So I just want to stress that again. The mental health that these patients suffer from does not correlate to the level of the amputation, which means that we've had patients, several patients, who have finger level amputations who are suicidal. And so I think also appearance and function isn't less of an issue in these patients. So what are our options? There are many options, and they're relatively new, and I think most hand surgeons aren't aware of them. But no companies are listed here. But you have a lot of body-powered prostheses that are finger level. This is another device that's not body-powered, but is a stronger. So if you want a stronger grip strength, you can place the fingers in a position that you want to function and hold things forcefully. And then, of course, you have myelectric prosthetics that are not finger level, but more hand level amputations. So these are all options, and we can talk about them in detail, but I just want to introduce that concept for you that there are good options for patients with amputations at this level. Now a very important concept is, are you optimizing length of the amputation, or are you optimizing the hand for a prosthesis? Those two are very different. Typically, we always think you want to maximize length, you want to maximize length, you want to maximize length. But when you go to the lower extremity, we know that that's not the case, right? With the BKA and AKA, there's a certain length that's ideal. If a patient has a certain level of foot amputation, you go to a BKA. And they just have the hind foot, you are very likely to recommend a BKA. And so we have no qualms performing a BKA on someone with a good hind foot. And so the same thought process, it needs to take over in upper extremity amputations as well, because they're very good prosthetic options. So now what do I mean by optimizing length versus optimizing prosthesis? So let's just say you have an amputation at the finger level of the PIP joint. So you want to maximize that length, right? You want to keep that proximal phalanx for as long as you possibly can. However, if you want to optimize this patient for a prosthesis, something that reconstructs or regains the function of a PIP and a DIP joint, then you actually have to remove that PIP joint completely. So that means you have to remove probably the distal third to maybe even the distal half of the proximal phalanx. So your amputation is going to be at that level. Now for you, you may feel very uncomfortable doing that, but the reality is if you leave it long, that will inhibit their function with a prosthesis and it will make the hand look more awkward and make it very difficult to regain the normal shape of the hand because you have now the new prosthetic fingers that are disproportionately long in relation to the remaining digits. The same is true for if you have multiple finger level amputations down to the MP joint. If a patient wants a prosthesis like this, a myoelectric prosthesis that helps to regain the function of the digits, if you don't take it to this level, then once again that whole prosthesis is shifted distally. And just remember, the hand, when you do a second ray resection, the hand looks relatively normal because the overall shape of the hand has been maintained. The same is true for prosthetics. If you can maintain the overall shape of the hand, it is more natural looking and people are less self-aware of it. So that is also why if you don't take it to the proper level, the whole prosthesis is shifted distally and so the shape of the hand looks wrong. So that's what I mean by optimizing the length for the prosthetic versus optimizing the length without a prosthesis. So in conclusion, it's very important that we focus on care for the amputee, care for the individual. I think there's far too much of a focus on tools, TMR, RP&I, and looking at applications for TMR and RP&I. You have to take care of the patient and what the patient needs, not the surgery that you want to do. Also, we need to become more aware of the various hand level prosthetics. Just be aware of them. Show them to patients. That's the first start of it. And then also the concept of optimizing length versus optimizing prosthesis. Not saying that you need to optimize a prosthesis for every amputee. Not at all. But at the very least, it has to be a thought process of yours when you take the patients to the OR and also discussion that you have with the patient beforehand. So thank you very much. And the next talk is going to be Dr. Loeffler from OrthoCarolinas. I don't know if you are familiar with the OrthoCarolinas program, but I would say they probably are the leaders in the country right now with the care of the amputee. Thank you, Jacques, and thank you for the opportunity to participate in this ICL. Thank you to the audience for everyone who has shown interest in this. As Jacques said, in training and early in practice, I never would have thought that this would have been something that I really took on as an interest and something that had so much potential for growth and development. But it's been a very fun and stimulating ride, getting more acquainted with the different things that we can do as surgeons to prepare patients for prosthetics and how we can work with our colleagues who have the expertise in placing prosthetics and fitting prosthetics and getting people back to their functionality. So we really think about amputation in a new way as being more of a reconstructive procedure as opposed to an ablative procedure with an opportunity to prevent and treat chronic pain. And we know that the surgical techniques that we're now utilizing in prosthetics can enhance the physical and psychological recovery. And as we'll show in this panel, a team-based approach really results in the optimal comprehensive care of the patient. So Jacques went through a lot of this, but I'll start with the partial hand and we'll move up to the transradial level. But there are various different types of prosthetics that patients wear, anything from silicone prosthetics that have an incredible ability to replicate the normal natural appearance of the hand, passive prosthetics, and then finally moving to myoelectrics that all have different roles and a lot of patients end up wearing different prosthetics for different things. So our silicone prosthetics can look very real. That's the same hand on the left side of the screen there with the silicone glove on. We always in our notes, and when we talk to patients, this is a passive functional prosthesis as opposed to implying that it's purely there for a cosmetic value. But they can have some functional implications as well. They are fairly expensive and not quite as durable, but there's really nothing that can replace the appearance of that hand. Then you have these ratcheting-type devices that can be placed into position and can be really strong and help with grip and things like doing pull-ups or carrying things. You can have body-powered prosthetics that harness motion at a more proximal level to move the fingers as well. And then finally, myoelectric prosthetics, and the pros of those, they don't require the other hand for their use, but you can be somewhat limited in the number of EMG signals and the purity of those signals that can be detected by surface electrodes. And the interosseous muscles that control the muscles in the hand are too deep to be detected by surface electrodes. And traditionally the problem has been that powering these has not been intuitive, and people were kind of trained to do abduction and adduction, crossing the fingers to try to get an open and closed-type function with these myoelectrics at the partial hand level. So when we think about things that you can do to optimize a patient for successful prosthetic wear, really the sooner you can get them using both hands and being functional with that amputated hand, the better. We want to create a stable bony and soft tissue envelope, as Jacques said, for optimizing the fit, making the fit match the contralateral side, and that's optimizing the length of the residual limb and thinking about what type of prosthetic is going to fit on that. And it's very important to have a trusted prosthetist that you can consult with to make sure that you're setting the patient up for success. And you want to create a pain-free residual limb, because if they have problems with neuromas or they have neurotic pain in the residual limb, then you could have the best prosthetic in the world, but if they don't have the ability to wear it because of pain, then they're not going to use it. You also want to set them up for intuitive control if they're going to use a myoelectric prosthetic, because they can get very frustrated if it's not intuitive for them to control their prosthesis. So again, we have these disastrous injuries, and you have to think about where's this person going to be when the dust settles, and how do we set them up for success? So you want to create a stable bony envelope and also soft tissue coverage, and I'll show you on the left there, we have gone to much thinner coverage of the hand. The hand on the left was an attempt to salvage, and that patient had probably had 20 different surgeries to, you know, had a real forearm flap covering the end of the thumb and a residual digit there, but they had absolutely no functionality of it. And we revised that patient, and they were able to fit into a prosthesis for the first time and did very well with that. So again, like Jacques said, it's not just about as much length as possible, but optimizing that length to set someone up for appropriate wear. A PIP level can be very functional. Sometimes it means lengthening a residual thumb, for example, and doing web space deepening that can improve functionality. So I'll move on to talking about myoelectrics, and I think people have a decent understanding of this, but I just want to go over some principles of control. So we talk about kind of direct drive versus pattern recognition for control of a myoelectric. So direct drive is when you have one muscle, one sensor, one prosthetic function. You can have a two-site system, so one muscle is doing one thing, and another muscle is doing another, like open and close. But if you want different control for different fingers, for example, or you want to be able to control forearm rotation and elbow flexion and open and closing of the hand, you need – if you're using a direct drive approach, then you need to have different signals for each of those things. Pattern recognition is – think about it like listening not just to the individual instruments in an orchestra, but the whole orchestra itself, so summarizing the electrical signal that is generated from all the different muscle contractions for a desired function and harnessing that with multiple surface electrodes that can be put on an arm in this case. So pattern recognition can give intuitive control because the patient thinks whatever they want to do, and then they kind of train the prosthesis to recognize that that signal means I want to do hand close, for example. And pattern recognition is a little bit less dependent on the exact placement of the EMG electrodes as long as they're reproducible. So we talked about different strategies for minimizing pain and optimizing prosthesis wear. I just mentioned TMR in the palm. We can target lumbricals. This is a case of a symptomatic digital neuroma, a 35-year-old police officer who a dog bit off the end of the thumb, very symptomatic neuroma present there. She couldn't use her gun, so she had that radial digital nerve of the thumb transferred into the index lumbrical. And a little pearl that we learned early on with this is that you need to mobilize that lumbrical off of the flexor tendon because initially sometimes patients, when they fire that FTP, it's pulling on your transfer, and it's pulling on that muscle. You rather just mobilize the muscle and make it free so that it's not subjected to that traction. And here she is, throwing a ball, and she gets back to work as a police officer, full duty, following this with no pain. So I'll talk about strategies for partial hand control. This procedure that we developed at Ortho Carolina, my partner and I, Dr. Gaston, the starfish procedure. And as I mentioned, if you want to control individual digits on a myoelectric prosthesis, traditionally that's been, it hasn't been possible because if you look at the interosseae where they are located between the metacarpals, they're deep and they're smaller muscles, and you just can't get surface electrodes to detect signals for each one of those digits. But if you take those interosseae, for example, and transfer them to the dorsum of the hand. So, this is a cross-section, axial imaging of the metacarpals. And you can see the third and fourth DI that have been transferred to the dorsum of the hand. We're just moving them from here to here on their neurovascular pedicles. Then you can actually place a sensor over each one of those muscles, and each one of those sensors can be linked to a separate digit so that when you fire your third interosseus, for example, which you do intuitively when you're trying to flex your digit, then that muscle will contract and send the signal to the sensor and then to the prosthesis. So, just to briefly go through what that is, we elevate the extensors off of the metacarpals as a sheet. We're then going to elevate the dorsal interosseae from the metacarpals themselves, again, preserving the neurovascular pedicle. As Jacques said, if you want the prosthesis to fit correctly, you have to resect some metacarpal here so that the length of the prosthesis is optimized. And you can see how slick Dr. Gasson is at removing those metacarpals there. And then here we are, this is a critical step, actually, separating the dorsal and volar interosseae because they actually correspond to different fingers. So, you want a pure signal, so you only want to mobilize the dorsal interosseus so that you don't get a mixed signal going to your surface electrode. So, there we are planning our transfer. We're going to separate the muscles so that we can get very pure signals. And finally, we're going to place an interposition, again, to create a physical space and barrier so that when the electrodes are placed over those transferred muscles that you can get a pure signal to control. And why that's so important is because it's going to give a patient individual control, but it's going to be intuitive. So, there's Mike Jenks there in the back of the room. That's him on the left video there, showing that when you place the surface electrodes over a normal hand, you don't get any control of the prosthesis whatsoever. But right after you've done the interosseoid transfer with Starfish, as you can see on the right there, the patient is thinking to flex down an individual digit, and they can now easily get open and closed function of a prosthesis. And this was the first patient that we did Starfish on, first time he ever put on this prototype, and we're asking to do individual digits, and, you know, we were all just amazed that it actually worked. But there he goes, and can do each one individually. And within a few months, and an iteration or two later, you see the control that he has, and how he can use it to lift weights, and pick a flower, open a car door, and use a shovel. And a few years later, you're going to see unbelievable dexterity with a four-finger level partial hand that is intuitive, and the batteries on these, you know, can last all day, and patients are able to do amazing things. Even here, this young man doing zipper on his jacket there, opening and closing a door. These prosthetics also allow for gestures, which are fun for patients, and they pretty much all want to make sure that they're going to be able to extend their long finger independently to let people know what they think. So we've done about 25 or so of these so far, and all have been able to generate strong independent signals to control individual digits. And I'm still just blown away when you look at this young man who is an active duty member in the Army. The control that he has is absolutely unbelievable. And Chris Farley would have been very impressed as well. So many patients can become candidates for this, and again, it's kind of a principle as well of taking a muscle that still has intact nerve and blood supply and putting it directly underneath the skin so that a surface electrode can pick up a signal, and you can pick up multiple signals to do multiple different functions to control a prosthesis. And here's even an example of a lady who, the ulnar aspect of the hand was salvaged, but it was no function at all to her. Her wrist rested in ulnar deviation. She had no flexion of the residual digits, and really ultimately was asking for a transradial level amputation. And we thought about this and said, look, we can still keep all the interossei in the hand. They're still there, and we can transfer them up into the residual form. And we would still have the signals available to motor a myoelectric prosthesis if we can leave them on the neurovascular pedicle, and that's indeed what we did. So we did transradial level amputation, but dissected out the median ulnar nerve and all the branches and all those muscles so that we had a corresponding muscle for each digit to set her up for control of a myoelectric. So a couple other little tips. It's philosophical change of the importance of the thumb and index. So classically, the thumb has been the priority, of course, and then a more ulnar ray. Now, you know, we really like, if we can, to save thumb and index because of the sensory aspect of it for dexterity and for functioning and extension. The prostheses will set up, think about setting someone up for more of the ulnar aspect of the hand if possible. So this is an example where we're able to save the index even though it's a very stiff digit, but it is a post that the patient, you know, when they don't have their prosthesis, they still are able to pinch and get the thumb to that index. They also have the sensory component to that so they're not relying on looking at things to be able to use it. And then they can do more grasping type things with the ulnar aspect of the hand. So I think when you're, if you're able to maintain the index and thumb, there's some real benefit to doing that. Moving on to transradial level, you know, current prosthetics will open and close and you can move the thumb manually as you'll see in this case. And then pronation supination also may require the other hand to rotate it into position. And functionally, that's just not very useful to have to use one hand to make the other one in a position to work. But there are myoelectric wrist rotators there in myoelectrics that can position the thumb independently. And so we really want to set up patients so that they'll be candidates to intuitively control. So we need neuroma prevention and those different motions that I mentioned. And those can be done through, with a direct drive control or with a pattern recognition. And we have the median ulnar nerves, we just need to harness those signals and amplify them with muscles that we transfer into so that we can give that control. And as Jacques said, we use RPNI adjunctively and along with TMR, more for neuroma control than for myoelectric control. So there's various different strategies for which muscle you use as your target for the median ulnar nerve. Our management of transradial level has evolved. We started with the image on the upper right there with a large curvilinear incision giving access to all the donors and targets and these big exposures. And then as time has gone on, we've gone to making much smaller incisions. And in fact now, if we have a long enough residual limb, we'll just do a distal fish mouth type incision. We like to save the perinatal quadratus if we have a long enough residual limb that that's present and harvested on its neurovascular pedicle, transfer it more approximately into the forearm and then use that as a target. And you can also access AI and branched FPL in the distal aspect without having to go more proximal. And then you don't have any incision or any work that's been done or any muscles reinnervated at a level where the prosthesis is actually fitting in the proximal forearm. Because we've found that when a person puts on a prosthesis and they have reinnervation, muscle soreness or they still have some neuritic type pains that having the prosthesis resting on that can be limiting. So if you can avoid that, obviously that's desired and we've learned a lot from our patients and our prosthetists with the development of this algorithm. And showing there on the upper right where PQ has been preserved, this was a radiocarpal level amputation that we revised to distal third level and then used PQ to reinnervate. And then in the lower right you can see where we split the radial sensory nerve and put that into two little RP and I targets there. It just kind of addressed everything through the distal incision. So in the early days that we were putting on these, the MyoBoy with the surface electrodes that detect the signals. Now what's neat and fun for patients is you can put those electrodes on with a cuff and then allow them to just see, you know, with their phone and an app, how they can actually control a prosthesis even if they haven't been approved for it or they are not eligible to be fit for it yet. So that's very stimulating and exciting for patients and encouraging as well. We first reported on our first 16 of these about three years ago and have an updated series coming up. Their management of transradial with TMR, very low pain. We noted the reinnervated muscles. We could pick up contractions by three months. No patients with post-op neuromas and 75% in that original series were wearing their prosthesis by six months post-op with improvements of their dash. And even five years ago, that was a patient just putting their prosthesis on the first day and you can see the intuitive control and things that they're able to do with it. So in summary, for forearm level TMR, this can treat and prevent painful neuromas, potentially enhance the control and function of both current as well as future myoelectric prosthetics, so setting people up for success. If you can salvage innervated viable musculature and transfer it into the proximal limb, that can be very helpful for giving intuitive control for these prosthetics. And in terms of what muscles you target, you have to really think about it depending on what exists and what the wound and soft tissue envelope looks like, but TMR really can work well with a lot of different targets so it's not a specific recipe that has to be performed. And again, for sensory nerves, you wanna address those as well to make sure that the patient can tolerate wearing a prosthesis, so do something, RP and RTMR for those. And we can do these either acute or delayed, but in our experience, doing them acute seems to be best. Again, just trying to get people back to as normal or their new normal as soon as possible. So I'll just say a few more things about the future because this is just so exciting, and again, this is kind of what has gotten us interested in this is how much this can develop over time and how it's so awesome to just be able to offer these new technological advancements to our patients who've had these devastating injuries. So this is a patient of ours who is involved in a DOD-funded study where he had these Bluetooth nerve cuffs placed around his residual nerves with a transradial level amputation and it allows for sensory control due to sensors on the prosthesis, and here he is at a DOD meeting in Washington holding his wife's hand for the first time in seven years, and that's pretty moving because the sensation is really what makes a limb feel like it's your own as opposed to a tool or an instrument, so we're gonna see more with these sensory prosthetics, it's just gonna be incredible. You have these horrible, devastating injuries, very short residual proximal limbs, you can't fit a prosthesis on these, and so now we're doing an ICO integration for these patients, which is an unbelievable game changer as well, so the abutments, sticking out of the skin, you can more easily place a prosthetic on and off and allow fitting for patients that otherwise it would have been impossible, and you can combine that with TMR so that they have intuitive control of those by going into the chest muscles, and we look forward to hopefully doing this at the thumb level as well. Soon it's been done outside of the United States and using this dental implant technology of ICO integration, and this was a recent write-up with 25-year follow-up, so in summary, the sky really is the limit for the management of these patients, so we need to know our prosthetic options and tailor it to the needs of the patients by maximizing or optimizing their bony length with thin coverage, managed neuromas, and think about the future, because thoughtful preoperative planning can improve the likelihood of them successfully utilizing these prosthetics, and we all have a goal of a pain-free, stable limb that's the appropriate length to allow for early fitting, and like I said, know the goals and set your patients up for success. So if you haven't done any of this work, we invite you to come on over and try it because it works okay. Thank you. I just want to acknowledge again, I want to really thank all of our patients who we've learned so much from them over the years, my partner Glenn Gasson and I, incredible partnership to develop over the years and the management of these patients, and the teamwork that we have with our prosthetists and our therapists and our psychologists has really made it an incredible journey. Thanks, Brian, that was great. So I'm gonna be speaking about humerus-level amputations. My name's Omri Ayalan, I'm from NYU, and I'm gonna be basically applying a lot of the same principles that Jacques and Brian have spoken about to this level of amputation. So we all know indications for amputation, big trauma, malignancy, contracture, vascular disease, as well as starting to apply these to the brachial plexus patients who have failed multiple attempts at reconstruction. And if a patient is left with an asensate limb, sometimes an amputation can be more of a reconstructive procedure to get more function. So just like my predecessors have mentioned, I think it's very, very important to set goals and expectations with the patient because each person is gonna be different about what their goals are, what they want to be able to do, and the only way to do that is to have a real multidisciplinary approach. And in our center, we do that for every single patient. Every single patient is evaluated by the prosthetist, by the OT, as well as the surgeons, because if you don't know where you're going, then it's very much hard to get there. So now, in talking about limb length at the humerus level, this again stresses the importance of talking to your patient and figuring out what their goals are because sometimes their goals of what they want to be able to do versus what they think they can do and what is actually possible may not match up. And so, like we mentioned before, sometimes we focus on the length being important. However, sometimes that length can be inhibitive about where you're going. So these two patients can be treated very differently as well as their goals may be extremely different as well. So in thinking about the level of amputation, it's important to remember where the muscles insert. The most important one to probably think about is the deltoid insertion, which obviously, if you have a deltoid insertion, that helps you a lot with a stable and functional limb. And so now, in terms of how much space to leave, how much do you cut? You know, four inches to six inches is kind of like a good estimate, but you want to make sure that you're leaving enough space for the componentry. And especially nowadays with myoelectric prosthesis becoming more in vogue and patients are asking for them, you have to make sure that you recreate the elbow center, that it matches up with their contralateral side. And so this is, for example, is a patient who had multiple failed attempts reconstructing for a crush injury, and it just shows the reconstruction of the elbow center in terms of length. As an orthopedic surgeon, one of our first cases that we did is just, it hurts your heart to cut so much bone, but the more we do and the more our prosthetists are involved in our preoperative planning, they're always telling us to cut more, cut more, cut more, because you want to make sure that you have enough length for the prosthesis. Now, in terms of managing the humerus, you know, osteotomy can be very helpful for rotational control of the limb. You can do an angular osteotomy. This one was done with a 4.5 humerus plate, as well as like a lag screw across the osteotomy site. Depending on the patient's habitus, if their arm is thin enough, you can just shorten the humerus and do compression plating and use the condyles as the rotational control for your prosthesis. And it's just another reason why I really love these types of procedures and treating this population, because it does require creativity, as well as planning and collaboration with your whole team. Now, thinking about the musculature, there is a little bit of a debate about this, but a myodesis versus a myoplasty, you know, do you attach the muscle and the tendon to the bone, or do you connect the antagonists to each other in a myoplasty? But the most important thing is you need a stable, residual limb with a soft tissue envelope that allows a functional prosthesis to be used. You definitely don't want redundant soft tissue. This was a, and I'll go through this case in a second. And then the other thing to think about is crosstalk. If the goal is to get to a myoelectric prosthesis, you don't want those signals to be competing with each other. And so if you're, you know, if you can think about it, that if you're doing a myoplasty, you know, your biceps is firing while it's relaxing the triceps. And so in our experience, that can actually increase crosstalk. So we, at the humorous level, we prefer a myodesis. This is just an example here. Now, thinking about the anesthesia for these cases, we have started to move towards indwelling infraclavicular catheters, like an on cue pump that patients go home with. And that seems to work pretty well for pain control in the immediate post-op period. And this is another sort of adjunct that we've been developing, is involving our anesthesiologists in our management of these patients, especially as it relates to neuroma control. And you know, like Jacques mentioned and Brian about the TMR and RPNI, I think our goal as surgeons is to first realize if it's an appropriate technique to apply, meaning is their pain or their phantom limb centralized? Has it become ingrained in their circuitry in the brain or is it peripheral? And so for us, that process starts in the office, trying to determine, you know, obviously physical exam, using selective nerve blocks. And then even another adjunct I've been working on is that at the day of surgery, we bring the patient into the operating room and have them lightly sedated. And we do the block with the anesthesiologist and can actually block the nerve peripherally quite preoperatively. And that we think can ultimately decrease unnecessary surgeries on nerves, which hopefully as surgeons, we're not creating neuromas and making these patients worse. So managing the nerve, I won't belabor this because we already spoke about, but there's lots of options. But I would just say that, you know, you need to plan ahead and have a plan about what's your goal. Are you trying to get to a myoelectric prosthesis? Are you doing this just for pain control to try to control phantom limb sensations? But then the other, you know, the other reality is, you know, sometimes even intraoperatively, you may not have great targets. You know, the soft tissue envelope may not be what you expected. So you need to have kind of a plan A and a plan B. So thinking about specifically like for TMR, for the transhumeral level, you have to know how much length you have to work with, because that will alter and influence what targets you have. You can think about incision placement and the number, and that's also evolved for us in our center as well. But you know, straightforward at this level is that you have two heads of the biceps and three heads of the triceps to work with and their innervation. So like I said, this does begin in the office trying to determine if it's a central versus a peripheral situation. So we already touched on this. But in general, with nerve surgery, you want to make sure that you have your targets planned out ahead of time. Using a nerve stimulator has definitely become sort of part of our toolkit in these cases. And in terms of actual transfers, you know, you want to go closer to the neuromuscular junction to decrease the time of innervation. So for this level, this is just one of the ways that we handle these patients. But the radial nerve, commonly we transfer it to the motor branch to the lateral head of the triceps, the median nerve to the short head of the biceps, and then the ulnar nerve to the brachialis, and I'll show you that here. This is a patient of ours who had a traumatic elbow disarticulation at work from a pasta machine, a young gentleman, and had, you know, all the signs of nerve pain and struggling with day-to-day life for sure. So this was one of our earlier cases, and we did a two-incision approach, which, you know, logistically is tough because you have to flip the patient in the middle of your case, and it can increase your working time there. So we started with this patient prone, and we did the posterior work first, doing the transfer of the radial nerve as well as the osteotomy, and then did the TMR next. This is just an example of the posterior, and this is from Greg Dumanian's earlier article about technique about this procedure. And then after that, we approached the anterior side of the brachium to do the work anteriorly, which involves essentially those other two transfers, identifying the median ulnar nerves, transferring them under the heads of the biceps to do your TMR nerve connections. This is just, you know, a shot of the spaghetti. And this is a final x-ray showing the shortening osteotomy that worked well for rotational control, and this is an early post-op visit of him sort of experiencing the myoelectric control that's possible with, and I think Chris is going to talk a little bit more about this. And then just another sort of way that we approach these patients, this is a gentleman who had, you know, who has debilitating nerve pain, and essentially an asensate limb. And we've moved more towards just a one-incision approach, a big medial incision, and you can actually access the radial nerve as it comes out through the spiral groove from the medial side of the arm, which is way easier for us and for the patient. And this is just showing the TMR. And so, you know, I'm not going to belabor this point, but Brian spoke about this, but, you know, this is a patient of ours who doesn't have, you know, great options, and I think that the exciting thing about where, you know, where the momentum of this field is going is that I do think that, you know, the OI is going to be a bigger part of the discussion, and there's a lot in the news about it, and, but I think that it has a real role to help these patients, especially transhumeral patients who have a short residual limb, to be able to get into a prosthesis, and that's really what we're about is trying to get these patients functional. So I think that, I think there's a lot of exciting things to come. And thank you very much. I'm going to introduce Chris Fink. He's one of our prosthetists in the center, and we're very excited to have him. There we go. Thank you, Omri. Like you said, it's an honor to be here. I'm a prosthetist here with Hanspring, and I get to work with the Carr Clinic, which has just been kind of a dream of my career, to work with such knowledgeable, great doctors. So usually I'd have to spend a lot of time talking about prosthetics, but with such knowledgeable surgeons before me, they kind of went through a lot of the stuff here with the different types of prostheses that we normally see on patients. And yes, none is an option of a prosthetic option that I always like to talk about, but we have our passive aesthetic devices. All these are available at different levels, mainly for pushing, pulling, leg grasping of activities. Our passive mechanical ones, which have joints and different systems, again, at all different levels that they can use their contralateral limb or different objects in space to bend those joints into positions for grasp. We have our body-powered devices, again, using more proximal joints to power a more distal-level prosthesis, again, at all different levels. Our hybrid devices are ones that are combining one or more different types of control. Usually you see this with body-powered elbow joints and externally-powered terminal devices or wrists. Our external-powered is the broad category that incorporates myoelectrics or anything that uses a battery to power the device itself. So we have those. And then one that kind of gets forgotten a lot of times is activity-specific. So these, again, are level from everywhere from partial hand amputations to everywhere more proximal and are really, really successful and part of the options that we need to see on pretty much all patients. I'd say everyone can benefit from these, from simple crawling in these infants, riding a bike, which every kid needs to do, sports, weightlifting, any type of yard activities or any more activity-specific kind of things. So I guess my big thing is kind of a part of this is what are we looking for in a prosthesis? How does a prosthesis help your practice? And we can look at different kind of things. It's nothing different than you'd say to a patient in what do you look for in a surgeon, somebody who has experience in doing what you want. So why is that important in a prosthetic level? So we'll do the numbers. The numbers are very much against us and every prosthesis being equal in serving these patients. So we say there's about 2.2 million people in this year, 2022, living with a limb amputation, 185,000 new amputees per year, 35% of that is estimated to be upper limb and of that upper limb, 90 plus percent is at the partial hand level. So what does that mean for us? We estimate there's about 10,000 prosthesis maybe in the U.S. We do the numbers, that's 60,000 partial hands, 5,200 more proximal level amputations a year. That means there's less than one proximal level amputation for every prosthesis and six partial hands for every prosthesis out there. I'm seeing probably 50 to 60 patients a year with at least half of those being new. So very much against every other prosthesis out there having the same experience that I do as an upper limb specialist. So really kind of choosing and seeing who you're working with can greatly affect the outcomes of these patients. It's just like we want to go to a surgeon who's never done a procedure, you don't want to send them to a prosthetist who's never done the procedure as well. So one of the other things we want to look for is the ability to think outside the box. Just like surgeons, stuff comes up, you've got to fix it, right there and then in there. So prosthesis is no different. But all outside the box thinking is not created equal. This is an example of really good outside the box thinking. We just saw this patient two weeks ago, so he doesn't have a definitive device as our prototype. But he requested being able to wear a myoelectric prosthesis without a harness for short periods of time, which any prosthetist and maybe some of you surgeons know is very, very difficult to do if not impossible. But he said, I can take a lot of circumferential pressure around my limb. So I said, okay, let's try it. So we put basically this two panel movable system with a BOA closure. If any of you are skiing or snowboarding, you know these BOA closures, they allow a lot of compression around the limb. And you can see he has no harness on, he's able to control that limb for very short periods of time. He does get some limited blood flow and irritation if he wears it for more than about 30 minutes that tight. But if he puts the harness back on, he has great control, no problems. Now this is not so good outside the box thinking. This patient came to us from another provider looking for help and a second opinion. Very short residual limb, unable to get myocytes on her limb or suspend a prosthesis. So what they did was put touchpads on the outside of her socket. Sounds really good outside the box thinking, but she can't really reach them as you can see. She's a very large woman. She has trouble with range of motion in her other shoulder and hand to get to those spots and actually push them. And then you got to think, how does she functionally use that day to day? How does she hand an object going through a door? She needs to open the door with her sound hand. How does she hand an object to the other side? It's impossible. So extremely frustrated with that and we kind of changed that situation. So where should you amputate? And we kind of have gone all over this. But again, kind of to stress, the myth of the longer the limb, the better. This really starts limiting our options prosthetically. We can do that. We can fit anyone. But it really, if we don't pay attention to our end goal of what we do, then we have issues. So the fact is the limb length will directly affect patient's prosthetic options. So if we're thinking long term goals, success of these patients, we got to look at our prosthetic options. So getting connected with the process early on is really, really important. So these numbers and everything, this came from Care for the Combat Amputee. So the U.S. Army and the Surgeon General put these numbers out. And these are basically looking at those myoelectric prostheses with what's currently available on the market. Yes, new stuff will come. These numbers will change. But this is what we have now for powered wrists, hands, batteries, pattern recognition systems, the space that we need to fit all that stuff in. So for the transradials, you're taking 22.5 centimeters off from the lateral epicondyle of the thumb tip. In transhumorals, we're taking 14 centimeters from the olecranon to the acromion. Sounds like a lot. Yes, it is. It's pretty much a mid-level amputation on most patients or shorter. Again, it's just kind of a piece of information. It's not directly going to influence where you're going to go, but another kind of tidbit for your toolbox of how to decide where to amputate. This has already kind of been gone over, but partial hands, again, too short, too long, just right. And why that is is 10 years ago, these were our options for hands. You had an aesthetic restoration or you basically had an externally powered digit. Now over the last decade, devices like these have come out, and these are our options. We have a lot more options as far as prosthetically what we do, and that makes your level of amputation even more important in deciding what you're going to have for these patients. So to give you a little bit of an idea of what goes on in our head, it's a scary place to be. I tell patients inside a prosthetist's head, but all this stuff is going on. We're trying to figure out what their goals are, range of motion, vocational activities, pain, anything like that will help us determine the type of prostheses that we're going to put them in. But the most important one is ECPIC's patients. It starts from day one when surgery is going to be an option for them. So getting a prosthetist in early on so we can figure out prosthetically what are they hoping for, then we can help you guys guide the amputation or any procedures we are there. So if I can leave you with some take-home points is that prosthesis can help you prevent unnecessary surgeries and recommend more beneficial ones. So there's been times in the car clinic where we're sitting there and they want to amputate and they want to do something and I'm like, we don't need it. I can fit that patient with all their goals that they need exactly how they are. Now, as surgeons, you don't like to hear not amputate because that's a revenue stream. I understand that, but if the long goal is success of the patient, that is really an optimal kind of feature for them and why put any through a surgery that necessarily isn't needed. And upper limb prosthetics is a team of highly skilled professionals. So not only do we need surgeons and therapists and prosthetists, but there's social work, mental health, and all those things that go into it as well. If I could leave you with one thing is the better your teammates are, the better your team is, the better your outcomes are, and the better you guys look at surgeons. So for the next member of our team, I'd like to have Elaine Carrere come up and speak on the OT level. Hello. So my name is Elaine Carrere. I am an occupational therapist focusing in amputations. And what I'm going to talk about today is how OT can maximize upper extremity surgery. So what is the role of the occupational therapist? My role is to support the individual overcome the effects of decreased function following limb loss. So the first thing that we want to do is we want to do an occupational profile, which is basically just a conversation with the patient. It gives me a detailed understanding of what their meaningful occupations are. So if we go through all these areas of occupation, we can identify what are the activities that they're doing day-to-day. And activity analysis is the process of breaking down a task so we can understand the different components that make it successful. So we're looking at the client factors, the activity demands, what does the patient need to do, and what context and environment do they need to do it in so that they can be successful. Now, gaining all this information through the occupational profile and the activity analysis, it just gives the team a better understanding of what are the possible options for the patient. So quickly, if we're going to do a very brief activity analysis of these two individuals, on the left, you have a chef cutting herbs. On the right, you have a construction worker lifting heavy equipment. If you think about on the left, they need to be able to grasp the knife, they need more fine motor skills, more stability and mobility in their wrists and in their forearm. We also need to consider that the herbs of the vegetables may be wet, so it may cause a slippery environment, and that cooking typically has a time requirement, so the patient needs to be able to do it in a timely manner. Whereas on the picture on the right, the construction worker needs more of a gross grasp, they need more proximal control, more strength and core stability, and we're also evaluating their lower extremities. We also need to consider that they're handling dangerous objects or heavy objects, so they need to be wearing gear as well, so maybe donning a glove. So limb loss is a life-changing event that can affect an individual's ability to interact with their environment, with others, and impacts their independence. So these guidelines help us, our patients, determine a roadmap for each of these individuals. So when we're discussing options for reconstructive surgery or possible prosthetic options, I think this is a very common theme, we have to set expectations. Very commonly, an individual who has experienced this life-changing event will come in, and their goal is they just want their hand back, and we wish it was that simple. But by having communication with a team and discussing, we can educate the patient on what are the possible, what kind of function is possible with a prosthesis or after reconstructive surgery. So communicating with all the disciplines is important, so we can create a roadmap for each individual. So when I first meet the individual, there are a number of areas that I need to assess that's going to impact their function using a prosthesis. What is their current functional level? Do they have the core proximal strength to be able to tolerate wearing the prosthesis all day? How has their balance or their lower extremity strength been impacted by their limb loss? Do they have the cognition to be able to operate a myoelectric device? We want to look at their support system. Do they have support or help at home to complete their ADLs, or even keep them accountable for their home exercise program? Psychological factors are huge. We want to consistently be addressing this in all episodes of care. We need to consider the patient's self-image during the rehab process, their confidence, their financial worries, expectations. Like we said, are their goals realistic? When we're considering prosthetic options, we want to look at insurance. Will insurance cover it? That is huge that we've encountered. The team might have an idea of what they want to recommend for the patient, but insurance may not cover it. We have to think outside of the box. With a prosthetic option, is there a certain length that we need? Is there a certain range of motion that we need to maximize the function for the patient? Pre-prosthetic training is just as important as prosthetic training. In my opinion, it's actually the most important. The focus of this phase is to maximize the patient's ability to use the prosthesis, but also give them the confidence and the independence to do their daily routines even without a prosthesis because in real life, they're not going to be wearing the prosthesis all the time. This includes one-hand techniques, dominance training, scar desensitization. If you look at these pictures, the individual on the left is doing some mirror therapy, and that is to help decrease phantom limb pain. On the right, he's working with a thera-bar to work on growth grasp and his extrinsic strengthening. Once the patient is fitted, they come home with their prosthesis. Now it's time to start practicing. This also comes in stages as well. We first are going to work on donning and doffing their prosthesis, as well as creating a wearing schedule so they can tolerate wearing it for longer periods of time throughout the day. In this, we collaborate with the prosthetist to figure out what that wearing schedule is. We then move on to grasp and release and functional activities. And then this is important. When we move on to bilateral activities and they're using their prosthesis and their other limb, if the affected limb was their dominant hand prior, we want to set the expectation that it's not going to be the primary mover. It's very common that the patient will get the prosthesis and they think that they can do everything that they could prior with the prosthesis, and that's not the case. So we want to reiterate that it's more of a helping hand and a stabilizer, and this obviously takes practice. And then we move on to ADL training, doing real life things. The most important thing here is we don't want to jump into real life ADL training. We first want to mimic these activities. For example, pouring a cup of coffee. If the patient just goes into pouring a cup of coffee and that cup of coffee slips, it spills, it negatively impacts their experience of using their prosthesis. So we want to work with more simpler things like transferring cones or balls or stacking, and then getting into the real life ADL training once we feel like they're ready. So in summary, an occupational profile just gives us a better understanding of what their occupations are. The goals are identified by the patient, but the team helps to make them more realistic. And practice makes perfect. So encouraging the patients to practice at home, practice in therapy, practice in different environments, that will help to lead to better outcomes. Thank you.

prosthetics

upper extremity amputees

multidisciplinary approach

prosthetic options

passive aesthetic devices

body-powered prosthetics

myoelectric prosthetics

level of amputation

occupational therapy

function and independence