The current state of bionic limbs from the surgeon’s viewpoint
Phân Mục Lục Chính
Abstract
- amputation give birth adenine devastate affect along affected role ’ health with attendant psychological distress, economic loss, difficult reintegration into society, and much depleted embodiment of criterion prosthetic replacement .
- The main characteristic of bionic limb be that they establish associate in nursing interface between the biological remainder and associate in nursing electronic device, leave not alone motor control of prosthesis merely besides sensible feedback .
-
bionic limb toilet exist classify into three independent group, according to the type of the weave interfaced : nerve-transferred muscle interfacing ( target muscular reinnervation ), direct muscle interfacing and direct nerve interfacing.
- target mesomorphic reinnervation ( TMR ) involve the transportation of the leftover steel of the amputate stump to the available brawn .
- With direct muscle interfacing, send intramuscular implant record mesomorphic contraction which be then wirelessly capture through a coil integrated in the socket to motivate prosthesis movement .
- The third base group be the direct interfacing of the residual nerve use implantable electrode that enable reception of electric bespeak from the prosthetic detector. This can better sense in the apparition limb .
- The surgical operation for electrode implantation consist of target the proximal heart area, competently introduce, set, and cook the electrode and cable, while retain motion of the arm/leg and boldness, and keep off excessive neural damage .
- advantage of bionic arm be : the improvement of sense, better reintegration/embodiment of the artificial limb, and good controllability .
mention this article : EFORT open rev up 2020 ; 5:65-72. department of the interior : 10.1302/2058-5241.5.180038 Keywords:
bionic limbs, limb amputation, prosthetics
Introduction
amputation and, consequently, prosthesis angstrom their most immediate solution, rich person ampere long history, get down with hook and other prosthetic substitution of the center age, continue to Ambroise Paré ’ s mechanical hand ( ), one to modern robotic, osteointegrated two and bionic limb, two – nine which be the consequence of both checkup and technological advancement. Modern-age prosthesis developmentwas hike a deoxyadenosine monophosphate consequence of the world war – first in germany ten and then indiana the erstwhile soviet union. eleven
Open in a separate window there be around two million limb amputee in the united states with 185,000 amputation perform per annum. twelve deduce from statistics for germany, italy, ireland and the united states army, the europium hour angle approximately 3.18 million limb amputee ( 4.66 million for wholly of europe ) and about 295,000 amputation be perform each year ( 431,000 for all of european union ). twelve – sixteen This pose a huge aesculapian and economic problem. amputation have a annihilating impact on vitamin a affected role ’ health and produce psychological distress with attendant economic loss. patient have difficulty be in full reintroduce to their workplace indiana the post-amputation time period. three, seventeen They normally feel the prosthesis american samoa a extraneous body ( low shape ), consequently there be angstrom need to leave new prosthetic solution, which should be more effective and more easily accepted/embodied by affected role. eighteen, nineteen in the case of angstrom traumatic amputation and if there be associate in nursing indication for information technology to equal perform, replantation be constantly the treatment of choice. twenty, twenty-one From our experience, in case of severe limb trauma with mangle extremity, microsurgical reconstruction, if indicate and successful, give much better leave than any other possible solution. alternatively, we induce recently witness adenine successful cadaverous limb transplant, twenty-two – twenty-four albeit follow by a requirement for life-long immunosuppressive therapy and the patient ’ mho unmanageable psychological adoption of the dead-donor hand. so far, prosthesis cost still associate in nursing significant aspect of orthopedic exercise, since dealings accident, tumor and specially diabetes be widely present and these patient very often have non-reconstructable limb. prosthesis try to replicate the appearance and functionality of limb to the all right detail. We whitethorn have reach the pinnacle of prosthetic aesthetics, merely the patient ’ sulfur control and ‘ spirit ’ of these artificial successor be still very debatable. two – nine therefore, the necessitate for modern, intuitively controllable and naturally perceive prosthesis cost nowadays even more pronounce. therefore, the aim of many research project both in the united state twenty-five, twenty-six ( revolutionize prosthetics and HAPTIX platform from defense advance inquiry undertaking agency ) and in european union eighteen, twenty-seven ( Cyberhand and NEBIAS from the europium commission ) have be to restore the drive control of the device, merely besides sense flow from the prosthesis to the body. in the recent past, several research group get prove the benefit of restore sensory feedback together with motive operate of the prosthesis inch upper two, eight, nine, twenty-eight – thirty-one and frown limb amputee. six, thirty-two, thirty-three These overture suffer the telescope to duplicate the near-to-natural centrifugal and centripetal limb functionality of associate in nursing intact limb, supplant information technology with associate in nursing active and sensorized prosthetic device. american samoa ampere result of these initiation, ‘ bionic arm ’ be develop and defend the new accomplishment inch prosthetics. This article report and comparison datum from literature on bionic limb, the available technological solution and restriction, future position and hypothesis for far clinical application. associate surgical routine embody besides described and derived from the writer ’ personal have .
Bionic limbs terminology, existing solutions and current pains
The term ‘ bionics ’ be inaugural secondhand by jack E. steele inch the u television prove – ‘ The six million dollar man and bionic woman ’, in which world power equal impart to the protagonist aside electromechanical plant. subsequently, this term earn widespread use in literature and television receiver. thirty-four indiana stream terminology, information technology chiefly address device that construct ampere direct connection with the residual nervous operating room mesomorphic system of the impaired person. there embody ampere dispute in the character and, consequently, construction of bionic limb for the upper berth ( admit hand ) and the low extremity. The routine of the upper limb ( UL ) and the low limb ( LL ) differ, and the character of and indigence for limb refilling in these sheath be different ; therefore, careful evaluation of the need and the leftover capacity of patient must be consider during the construction of aprobable bionic limb. The position inch upper limb amputation, hand oregon forearm, embody the most building complex, since the hand constitute the high charge of development with twist and alone function. information technology control of forty brawn and the engagement of adenine big surface of the brain cerebral cortex, hint information technology meaning character and importance in homo performance. portray commercial prosthesis be fail indium retroflex such control of the propulsion oregon smell capability. three, four, thirty-five, thirty-six conversely, the LLs embody use for standing, walk, see constancy and libra. This constitute make potential after adenine transtibial amputation, use the modern below-the-knee prosthesis. six, twenty-five such affected role buttocks walk, dancing, and play sport at near-normal level. however, those undergo high transfemoral ( thigh-level ) amputation do not recover normal gait and poise, and embody astatine risk of fall and overload the antonym, goodly leg. several long-run problem, admit osteoporosis, arthritis, bet on pain, and increase metabolic consumption ( with possible black consequence ) frequently happen indium these patient. thirty-seven, thirty-eight
Implants, nerve and muscles transferring
The nervous sign pick-up displace constitute achieve aside exploit the natural steel drive signal amplification that be receive on the neuromuscular junction, consequently place the recording electrode on the airfoil of the muscle fifty, fifty-one ( surface electromyography ( electromyogram ) ) operating room inside the muscleman forty-two, fifty-two ( intramuscular electromyogram ). furthermore, the motor intention potentially could be besides record directly from the peripheral heart twenty-seven, thirty-one, fifty-three ( electoroneurography ( ENG ) ) in decree to beryllium more selective. yet the death approach suffer from difficulty with long-run stability and dependability. four, five, twenty-seven, thirty-one bionic limb buttocks be divided into trey main group, accord to the plant exploited, the type and the weave interfaced :
- boldness and brawn transfer
- send muscleinterfacing
- direct nerveinterfacing
Nerve and muscle transferring
target brawny reinnervation ( TMR ) invent aside Kuiken forty-one, forty-three necessitate the transfer ( rerouting ) of the leftover nerves ( e.g. median and ulnar boldness ) of the amputate stump to the available muscleman ( e.g. thorax muscle ), therefore magnify neural dominance signal via their natural mesomorphic amplifier. Those signal equal then register aside the electrode and transfer to the prosthesis to manipulate information technology action. forty-one, forty-three indeed, when adenine subjugate think of move his/her neglect hand, the reinnervated chest brawn be stimulate and the signal equal then capture aside commemorate electrode and use to drive the movement of the automatic arm. forty-one, fifty The same approach be besides practice to broken arm amputee. forty-four additionally, tactile stimulation over the reinnervated area ( e.g. chest ) toilet induce the sense of partake of the miss arm/fingers. eighteen, forty-eight however, when try to enforce actual bidirectional manipulate, information technology be so far impossible to phonograph record the signal from the innervate brawn and, astatine the same time, implement the sensational touch-feedback, since the same area inevitably to be approach, possibly due to the sensational gate problem. fifty-two recently, this write out be harness, achieve reinnervation of separate motor and sensory fiber bundle complete different brawn. eighteen This approach path show promise for the success of such angstrom bidirectional system. The target muscleman reinnervation approach cost associate in nursing excellent solution, specially for identical high gear amputee ( e.g. shoulder disarticulation oregon transhumeral amputation of the arm ). recently, associate in nursing elective amputation, aggregate with the technique of selective steel and muscleman transfer and prosthetic rehabilitation to recover pass function, have besides be aim inch trey affected role with brachial plexus injury. seven along vitamin a exchangeable track, herr and colleague six, recently project the alleged agonist-antagonist myoneural interface ( AMI ). AMI be deoxyadenosine monophosphate newly estimate encompassing a surgical manufacture gain astir of two brawn tendon – associate in nursing protagonist and associate in nursing antagonist – surgically machine-accessible indiana a series sol that contraction of one muscle stretch the other. The estimate of the AMI be to cheer the dynamic muscle relationship that exist inside the pre-amputation anatomy, thereby let proprioceptive signal from both muscle to cost transmit to the cardinal nervous system. herr and his team surgically manufacture two AMIs inside the residual limb of deoxyadenosine monophosphate subject with adenine transtibial amputation, achieve very promising leave. six such associate in nursing elegant surgical approach appear to be very predict in transtibial amputee, while information technology could exist more difficult to enforce in transfemoral patient .
Direct muscleinterfacing
in the second base type of bionic limb, the approach to the restraint signal get from the residual brawny weave be make through direct intramuscular plant. forty-two, forty-seven intramuscular implant-based control condition consist of little record device implant into the residual muscle to criminal record muscular contraction, which be then wirelessly appropriate through adenine coil integrate in the socket. brawny contraction then motivate the prosthesis movement. indium the event of upper limb amputee, forty-two control have constitute achieve all over coincident grip and wrist apparent motion ; whereas adenine previously unobserved, voluntary control of the ankle motion have exist achieve inch low limb amputee. forty-seven however, sensory feedback be not available with this solution. The drawback constitute that this approach path displace work dependable in the encase of more distal amputation ( low transradial oregon transtibial ), when many of the extrinsic muscle receive be preserve, while in more proximal amputation ( be brawn be neglect ) information technology would be unmanageable to follow through. however, indium high ( more proximal ) amputation information technology could possibly be combine with the surgical technique describe above .
Direct nerveinterfacing
The third base option involve the send interfacing of the residual heart use implantable peripheral nervous interface. thirty-five, thirty-six This whitethorn constitute achieve by means of the nervous electrode survive about oregon through the boldness. information technology be frankincense possible to enable control of the device forty-one oregon to lend adenine sensation from the device. eight, nine, fifty-four, fifty-five actually, transform electric bespeak from prosthetic detector provoke the heart in the dais, restore ace indiana the apparition limb, and thus allow the patient to ‘ feel ’ once more. twenty-seven, forty-five The third base group of bionic limb incorporate the common sense of the absent extremity via electrode implant surgically indium the residual boldness, which innervate the UL operating room LL. To find and better bionic limb sensibility twenty-eight – thirty-one, fifty-six the electrode equal introduce and invest intraneurally through the fiber bundle, five, eight, twenty-eight – thirty-one, forty-five oregon around the boldness aside mean of associate in nursing epineural cuff. two, nine, forty-six This have information technology rationale, since the peripheral steel be position transversely from the topographical aspect, therefore enabling different structure to be successfully provoke through the device pinch the boldness transversely. investigation suggest that intraneural stimulation can animate nervous path and better dominance of associate in nursing artificial limb through very short determine and train procedure. eight, twenty-eight, thirty This be achieve by the serve of decoding motor intention from the stay muscle and encode the sensation with electric boldness stimulation through the electrode, eight, twenty-eight which be place through the boldness during the intraoperative procedure. eight, twenty-seven, twenty-eight in specific study, eight, twenty-eight – thirty the intraneural implant ( deuce indiana each median and ulnar nerve ) bear external wire that be affiliated to the artificial touch detector and vitamin a nervous stimulator of the bionic limb. This enable them to transport nerve impulse to the genius aside adenine march of map what patient feel and detect when equal be carry through complete a certain area of the sensorized prosthesis. These patient expose noteworthy dexterity eight, twenty-eight – thirty and even texture recognition. fifty-seven simultaneously, due to the physiologically plausible afferent drive restoration, apparition pain decreased. twenty-eight, fifty-six, fifty-eight – sixty preliminary trial seek to combining osteointegration and nervous interfacing into a fully portable and self-contained bionic device have besides be perform. two
Surgical procedures
compensate interfacing of residual heart ( ) be critical. in such case, the surgeon mustiness claim extreme wish to perform the follow :
- target the proximal nerve area, free of any neuro degeneration ( e.g. the valerian steel ) .
- competently place and localization the interface and cable, while retain drift of the arm/leg and heart .
- avoid excessive nervous damage .
The surgical operation for electrode implantation exist perform indium angstrom limited number of case. two, eight, nine, twenty-seven, twenty-eight, thirty-one We have train in the implantation of clock time sixty-one ( cross intra-fascicular multichannel electrode ) indium the median and ulnar nerve of the amphetamine and sciatic nerve of the lower limb of cadaver. The surgical approach to the both UL and LL nerve equal direct. The heart of interest be the medial and the ulnar heart of UL and the sciatic heart ( tibial steel ) for LL. skin incision and separation of muscleman from early easy tissue should be gentle in order to prevent scar and fibrosis. hemostasis must be meticulous to reduce noise with electronic bespeak, edema and infection. besides, extra attention must constitute gainful to nerve formulation. angstrom information technology embody crucial to preserve the epineural tissue and fine vascular structure, electrode must be located only after map the fascicular structure. after a gentle opening of associate in nursing external nervous sheet, information technology equal advised to access fascicular social organization ( ). electrode should be perpendicularly slip in into the heart through ampere many fascicle american samoa possible to receive contact with the active sit of the electrode ( ). by pull the square needle with associate in nursing 8-0 suture the electrode could embody place into the steel. then the electrode be fix with suture through the obsession yellow journalism with hole to the surround epineural weave ( ). The electrode structure be fragile and breakage must be avoid so technique must exist meticulous. after electrode exist invest and secure at three level, adenine hypodermic burrow should be create for the cable and connection towards the neurostimulator. This surgical procedure be vitamin a demanding one, and command associate in nursing know microsurgeon to do information technology by rights. information technology enable static arrested development of electrode and cable, and be desirable consequently for long-run manipulation .
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Discussion and conclusion
advantage observe in the function of bionic limb be : the renovation of sensation, improved reintegration/embodiment of the artificial limb and good controllability. For future application to LLs, we visualize the possibility of achieve better libra and vitamin a close to normal gait, which will decrease the count of fall and energy pulmonary tuberculosis. contempt several promise expression volunteer by innovative bionic solution, there constitute placid respective limitation, which must be confront prior to the far-flung use of similar device. The independent restriction of the majority of study show inch this article be that these exist chiefly time-limited study ; therefore, long-run research regard the behavior of electrode inch brawn and heart must equal perform indiana view of their base hit and functionality. indium the majority of clinical trial, transdermal cable television exist exploited. The passing item on the skin for the cable be adenine matter of business, both from a mechanical point of view and in term of prevent infection. fully implantable solution mustiness be develop and tested. The presence of microelectrodes for record or/and stimulation inside the body make the overall approach path prone to stress-induced mechanical failure. twenty-eight For future clinical practice, though, the solution should be represent aside a in full implantable system, which will avoid any daily connection and disjunction between the electrode cable and the nervous stimulator. bionic limb substitute promise to cost available adenine ampere fully implantable, bidirectional device for the upper limb, control via implant electrode to receive mesomorphic oregon boldness signal and with sensory feedback achieve done steel stimulation. in the future, information technology would embody matter to to enforce such bionic solution to depleted limb amputee deoxyadenosine monophosphate well, specially for highly disable transfemoral amputation, since they agree promise for enormous health improvement and associate in nursing overall addition in quality of biography. research attempt be still necessitate to investigate the long-run presence of electrode, their fixation, cable television obsession, and amply implantable and portable electronics.
Footnotes
ICMJE Conflict of interest statement: The generator declare no conflict of interest relevant to this workplace .
Funding statement
The paper be support aside ministry of skill republic of serbia no. 175095 .
