Croydon Tram Derailment – Osseointegration & Targeted Muscle Reinnervation

I acted for SK in his claim for damages after he suffered a life-changing injury in the Croydon Tram Derailment on 09 November 2016. This article details SK’s rehabilitation journey and in particular focuses on his decision to undergo surgery for osseointegration (OI) and targeted muscle reinnervation (TMR).

Case Background

SK was aged 24 years old at the time of the accident on 09 November 2016. He was a fitness fanatic; he enjoyed parkour, running, and playing football.

In the summer of 2016, he completed a City & Guilds course on basic electrical work and then started work as a practical electrician within the film industry. This was an interesting and financially lucrative career. At the time of the accident, SK was 10 days into working on the film ‘Murder on the Orient Express’.

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Our Client’s Accident

SK left his home just after 6 am on the morning of 09 November 2016 to travel to work at Longcross Studios.  He boarded a tram at Fieldway Station and intended to travel to East Croydon Station. Even though the tram was crowded with other passengers, SK was able to get a seat.

Shortly after the tram left Lloyds Park Station, SK heard a woman scream, and at the same time, the tram carriage began to tip over onto its side. SK was suddenly thrown from his seat and the carriage was plunged into darkness and complete silence. I will not detail the catastrophic images that greeted SK when his sight adjusted to the conditions; that is his story to tell once he is ready.

However, I am able to say that in the process of being thrown across the tram, SK’s left arm went through the broken window of the tram. His left arm was stretched above his head and was trapped underneath the side of the tram.

The emergency services attended the scene and SK was very grateful for the assistance he received from everyone, but particularly the team from the London Air Ambulance. He was one of the last survivors to be removed from the tram and he was taken to St George’s Hospital by road ambulance.

There were 7 fatalities arising from this incident and 19 people suffered serious injuries.

Liability

Whilst the formal legal proceedings into this matter continue, the insurer for the two main Defendants, Tramtrack Croydon Limited and Tram Operations Limited (part of Transport for London), admitted liability for the civil claims on 13 March 2017.

Initial Medical Treatment

Following the incident, SK was admitted to St George’s Hospital in South London, and he was diagnosed with a complex crush injury to his left arm, left sided rib fractures, and a left sided pneumothorax.

He underwent surgery to his left arm on the same day, but the damage to the arm was so severe that his surgeons could not salvage it and he underwent a transhumeral amputation.

SK’s family had been notified that he had not turned up for work at Longcross Studio and were frantically travelling around local hospitals trying to locate him. SK was eventually identified by the tattoos on his body and his family were present at the hospital when he came around from the general anaesthetic.

SK underwent further surgery on 11 November 2016 to refashion his stump. He was subsequently assessed by the pain management team. SK received significant support from his parents, elder sister, and his girlfriend whilst admitted to hospital.

Rehabilitation

I met with SK at St George’s Hospital a few days after the accident.  SK was clear from the first moment I met him that his main focus was ensuring he made the best possible recovery following his accident; that included access to the best and most advanced prosthetic limbs available on the market.

Within days of my instruction, I was able to establish contact with the insurers for the two Defendants and to secure from them an early interim payment to be offset against ongoing losses. In addition, I was able to secure funding for case management and rehabilitation under the Rehabilitation Code.

The Defendant’s insurers agreed to fund the assistance from a case manager, Angeline Jha, who has significant experience in amputee rehabilitation.

Within days of SK’s discharge from hospital, Angeline arranged for SK to have a prosthetic assessment with Abdo Haidar of the London Prosthetic Centre in Kingston.

SK’s main aim was to purchase a myoelectric prosthesis as soon as practicable.

Abdo recommended a prosthetic prescription of an Ottobock Dynamic elbow with a Bebionic Electronic hand. Abdo did not recommend that SK use an electronic wrist rotator as his residual stump was too long which meant there would be a significant difference in the length of his arms.

Myoelectric limbs are secured to the residual limb with a suction socket and are then further supported by a harness which is strapped over one of the shoulders (in SK’s case, his right shoulder).

Sensors are placed on the residual stump and connected to the myoelectric limb. The limb and electronic hand are controlled by contracting the biceps and triceps muscles. I secured a significant interim payment so that SK could purchase the myoelectric limb and he took delivery of this by early February 2017 (less than three months from the initial injury).

Angeline employed a specialist treating team including an occupational therapist, physiotherapist, personal trainer, consultant psychiatrist and consultant psychologist to assist SK as he adapted to life as an amputee.

SK did not have a driving licence at the time of the accident and was desperate to pass it so he could regain some level of independence. Funds were secured for SK to specially adapt his vehicle and to undertake specialist driving lessons. SK passed his driving test in the early part of 2017.

SK started specialist prosthetic training so he could develop his control of the myoelectric limb. This involved assistance from a prosthetist, occupational therapist and a physiotherapist. In addition, SK visited a company called Blatchfords to purchase a bespoke made prosthetic limb for use in the gym and generally for exercise.

Whilst SK was interested in purchasing a purely cosmetic prosthetic limb in the longer term, he wanted to focus on mastering control of his myoelectric limb and building his physical fitness before investigating this further.

SK attempted to return to work as an electrician for a few weeks during the summer months of 2017 and he was able to carry out very basic electrical works using a combination of his myoelectric arm and gym arm.

However, he felt that he was not able to complete the work very quickly and that his colleagues had to make allowances for him; he subsequently decided to investigate other opportunities.

In October 2017, SK attended a two week inpatient rehabilitation course provided by Remedy Rehabilitation to further enhance his ability to use his myoelectric arm, to improve his physical fitness, and to receive vocational counselling. Following completion of his course, SK obtained a role as a trainee site manager within a demolition business.

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Osseointegration (OI) and Targeted Muscle Reinnervation (TMR)

By the summer of 2018, SK had reached a plateau with his prosthetic recovery. Whilst he had developed a good level of functional control of his myoelectric limb, he experienced a number of problems with it as summarised below:

1. He found that the limb was heavy to wear for long periods of time and that caused fatigue (both physical and mental);
2. He found the harness/socket arrangement was uncomfortable to wear especially in warmer weather and this would cause him to sweat;
3. He found that the electrode system could be unreliable/temperamental in certain situations and that the cuff holding the system would regularly slip out of place.

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SK was aware that he could potentially undergo surgery to improve his prosthetic recovery and he wanted to explore this. The surgical options available at that time are outlined below:

Osseointegration (OI)

This involves the insertion of a bone anchored implant directly into the residual bone of an amputee’s stump.

The transcutaneous part of the bone-anchor is passed through the skin providing a secure point of fixation for an external prosthesis. In this way, the prosthesis is now directly connected to the residual bone without the need for a conventional prosthetic socket and is said to be directly fixed to the skeleton.

This would effectively remove SK’s issue with the weight of the myoelectric arm as it would be taken directly through the implant and bone. It would also remove the need to wear a harness completely.

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Targeted Muscle Reinnervation (TMR)

This is a surgical procedure used to improve the control of upper limb prostheses and, additionally, can reduce neuromas and phantom limb pain.

In TMR surgery, the nerve stumps in the residual limb are transferred to new muscle targets which would have otherwise been redundant as they were used to move parts of the limb which have been amputated.

The reinnervated muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of myoelectric prosthetic limbs.

In most cases, the user must wear some of prosthetic sleeve/cuff into which the cutaneous electrodes have been embedded and the electrodes are then positioned directly over the reinnervated muscles.

Electrical impulses generated by voluntary contraction of the muscles beneath the skin are detected by the electrodes and it allows the user to control their myoelectric prosthesis.

In July 2018, I arranged for SK to meet with Consultant Plastic Surgeon, Mr Norbert Kang, at the Royal Free Hospital.

Mr Kang had set up an amputee service called Relimb with his colleague, Mr Martin Woollard, which was designed to be a one-stop bespoke service to amputees.

Mr Kang worked closely with Professor Al Muderis and his Osseointegration Group of Australia (OGAP).

Relimb offered OI and TMR surgery in the UK at the Royal Free Hospital using the OGAP-OPL implant.

I should explain at this point that there is another OI implant available on the market called OPRA™ (Osseointegrated Prosthesis for the Rehabilitation of Amputees) developed by a company called Integrum.

Relimb did not offer surgery using this implant at the time SK was being assessed and I will return to this issue later in this article.

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SK underwent a full assessment with Relimb to ensure he was a suitable candidate to undergo OI and TMR surgery. Following the assessment SK was told he was a suitable candidate, but he decided not to proceed with the surgery immediately as he wanted to spend some time researching risks of the surgery and what potential benefits he might experience as a prosthetic user.

He spoke with other amputees who had undergone OI and TMR to obtain a better understanding of the reality of undergoing the surgery. He also spoke to surgeons across the world and attended workshops.

I obtained the views of the medico legal experts, which included the benefits normally achieved, but also a clear explanation of the risks of the surgery which included further fracture of the residual humerus, osteomyelitis, and cellulitis. The experts also warned of the psychological strain the surgery can put on someone.

SK also had to consider how the surgery would affect his professional and family life. He had grown into the role as a trainee site manager, and he knew undergoing the surgery would result in a lengthy absence from work.

SK was also in a settled relationship with his partner and they had a baby girl together; he appreciated that if he underwent the surgery, it would put more strain on his partner.

SK took almost a year to decide to undergo the OI and TMR surgery.

It was then my role to secure a significant further interim payment to allow him to do so. The interim payment was not only to fund the cost of the OI and TMR surgery on a private basis, but also to fund a completely new prosthetic prescription as the limbs SK had already purchased would not be compatible with an OI implant. He also needed funds to cover the time he was away from work.

I was able to secure a significant further voluntary interim payment from the Defendant which ensured SK had sufficient funds to pay for the surgery, purchase new prosthetic limbs, and to cover his general living expenses whilst he was signed off work.

SK underwent the surgery on 31 August 2019, and it was successful from a technical point of view. The bone anchor was safely inserted onto the residual humerus. SK suffered with an infection in his stump but that eventually cleared up with a course of antibiotics.

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By the end of September 2019, SK had commenced a course of prosthetic rehabilitation with Dorset Orthopaedic which began with loading the implant with weights to build up his strength until such a time that he could tolerate the weight of his new myoelectric prosthesis through the implant.

SK made quick progress with his weight training and, furthermore, very early training using a new electrode system with his reinnervated muscles showed incredibly promising results. He took delivery of his new myoelectric arm at the end of November 2019 and shortly after a new gym arm was provided.

SK was happy with the outcome of the OI aspect of the surgery in that the weight issue with his myoelectric limb was removed; it also made using his gym arm easier and it felt more natural when making movements.

The TMR aspect of the surgery was also initially positive. SK showed excellent progress with controlling his myoelectric limb and his phantom limb pain reduced significantly.

SK’s main problem was with the cuff/sleeve which was designed to hold the external electrode system in place on his residual limb. The initial cuff design was too bulky, and it slipped down his arm which meant the electrodes were not in the correct position and his ability to use the arm was impacted.

SK’s prosthetic team worked hard to find a fix to this problem, but the situation was further complicated by the Covid-19 pandemic which meant he was unable to attend the clinic regularly to work on the issue.

He was not able to return to work as the demolition industry suffered significantly during the pandemic. SK then suffered a further setback in that the soft tissues in his residual limb became detached from the implant and he had to undergo revision surgery under the care of Dr Kang.

SK and his prosthetic team went through around five different designs for the cuff/sleeve before finding a workable solution which was in the form of a tight silicone sleeve designed by CoApt.

This sleeve sat securely next to his skin, so the electrodes remained in place, and it was still durable enough to protect the electrode system from damage. SK went on to make significant progress mastering the controls of his myoelectric prosthesis.

Once the issues with the myoelectric limb had been resolved, SK concentrated on improving his physical fitness and part of this included purchasing a bespoke made bike limb which enabled him to undertake long cycle rides. He combined this with long distance running and regular gym workouts.

External Electrode System

It was anticipated before SK underwent the surgery that the external electrode system used to control the myoelectric arm could potentially be problematic. Applying electrodes to the amputees’ residual limb, or in some cases to the chest, naturally brings about potential issues ensuring they remain in the right place.

SK’s treating surgeon identified that it was an ongoing area of research to see whether the electrode system could be inserted into the arm or chest to completely remove the need for an external system.

He recommended that those advising SK should include provision for the potential future costs of undergoing surgery to implant an electrode system in the future. That brought about the question of when this might be possible, how much it would cost, and the potential risks around the same.

I had to investigate this issue quite thoroughly to ensure that SK was able to potentially claim the costs of undergoing this procedure in the future.

I spoke with the leading clinicians in this area of research, and it was quite clear that, whilst technically possible, there was still some way to go before clinical trials in humans could even start; research at that time had been predominantly limited to trials in sheep.

I was told that the Covid-19 pandemic had resulted in funding for medical research being directed towards effective vaccinations rather than other areas such as prosthetic development.

During the course of my investigations, I spoke with Professor Max Ortiz Catalan, who leads the bionics research group at Chalmers University of Technology in Gothenburg.

Professor Ortiz Catalan works with Integrum who developed the OPRA OI implant and had devised a system whereby electrodes were internally implanted on the nerves and muscles that were severed during the amputation.

The electrodes then run through the OPRA implant (it has a hollow centre) and directly into the myoelectric arm, completely removing the need for an external electrode system. Please see the follow the link to an article written in the Swedish press about one of Professor Ortiz Catalan’s patients (this can easily be translated into English).

At the time I spoke with Professor Ortiz Catalan, this implanted electrode system was not commercially available, and it was still only provided within medical trials. To my knowledge that position has not changed.

Before undergoing the surgery, SK was given advice about whether to choose the OPL or OPRA OI implant, and opted for the OPL implant on the basis that he would in the long term be able to benefit from a more sophisticated electrode system which allowed for greater sensitivity and control.

The Litigation

For the most part the parties worked together in a sensible and amicable way. For example, once it was clear that SK would undergo OI and TMR surgery in August 2019, the parties agreed an open limitation moratorium determinable on 28 days’ notice.

The Defendant provided voluntary interim payments throughout the claim and at no point was SK forced to make an application for the same.

However, settlement discussions undertaken in September 2021 were a complete disaster which led to SK instructing me to end the limitation moratorium and issue court proceedings.

The parties re-attempted settlement discussions just over 12 months later in December 2022, just before the exchange of expert evidence. Fortunately, and after a significant shift in one party’s position, the case was amicably concluded.

SK’s claim settled for a significant amount. Some of the heads of loss which were claimed are detailed below:

Loss of Earnings

A significant claim for past and future loss of earnings. SK had a very promising career in front of him as a practical electrician in the film industry. Several witness statements were taken from comparators setting out SK’s potential career path and this was supplemented by expert employment evidence.

Care & Assistance

SK preferred not to receive professionally employed assistance at home and established a high level of independence. When he did need help, he relied on his family or his partner.

However, I obtained expert evidence which indicated that he would have increasing care needs as he aged and was less able to use his prosthetic limbs. A significant claim for future care and equipment was included.

Prosthetics

SK made a claim for the following:

1. An everyday myoelectric arm (Ottobock Dynamic Elbow), Co-Apt recognition system, wrist rotator, and I-limb quantum electronic hand.
2. A second myoelectric arm with the same prescription above but to be used when his primary everyday arm requires repairs and/or maintenance.
3. A bespoke made gym arm with various different terminal devices;
4. A bespoke made bicycle arm to be used primarily to ride bicycles but with capability to be used on motorcycles;
5. A cosmetic arm.

These arms were generally claimed on the basis that they would last for 5 to 6 year cycles (with ongoing maintenance costs) and then need to be replaced. Given SK’s young age at the time of settlement, it resulted in a significant future claim.

Prosthetic limbs do require ongoing and regular maintenance which often means they are sent away to the manufacturer for days or weeks at a time. This potentially leaves the amputee without their prosthetic limbs for significant periods of time and brings about the possibility of claiming for ‘double-ups’ to ensure the amputee has access to the limbs they rely upon to get through their daily lives.

Claims for ‘double-ups’ for any prosthetic limbs are generally controversial, and Defendants will often argue that they are not reasonably required given that prosthetic clinics are able to offer loaner units whilst repairs/maintenance works are being carried out.

Although prosthetic experts will generally agree that loaner units should be readily available, this is not always my client’s experience.

I understand it is a very different situation when the prosthetic limbs are bespoke made or have high costs. In order to justify claims for ‘double ups’, it is important that the client keeps an accurate record of when repair works have taken place, how long the repairs have taken, if they were provided with a loaner, and how long it took for the loaner to be provided.

If you have first-hand evidence that loaner units are not being provided as promised or within a reasonable timeframe, then it is powerful evidence to support the cost of these claims.

I also included a contingency claim for the potential cost of undergoing surgery to implant an electrode system based on the most up-to-date information on when this was likely to be commercially available.

Finally, I asked my prosthetics expert to comment on how the cost of prosthetics, especially upper limb prosthetics has increased exponentially over the last 15 to 20 years and to provide some data on the issue.

A Claimant settling their case on current evidence is likely to be undercompensated when in say 10 years’ time a new more expensive product comes to market.  I included a contingency to soften the blow of this potential development.

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Conclusion

SK’s case took longer than most amputation cases to resolve primarily due to his decision to undergo OI and TMR surgery. I was able to ensure the claim remained open to ensure that the surgery was a success and I had good understanding of his likely long time needs.

SK is in a very good place, most probably the best, since this accident has happened. He is exercising regularly and is now running marathons.  He is looking forward to the next stage in his life.

I hope this article provides amputees and fellow practitioners with some helpful information about some typical issues that arise in personal injury claims.