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Written on 22nd June 2020 by Claire Roantree

Amputations are relatively rare but that is little consolation if you are coming to terms with the loss of a limb or another part of your body.

For 2018-9, there were nearly 18,000 finished consultant episodes (FCE) in NHS hospitals across England where amputation was performed. The most common type of amputation performed involved the lower limbs.

When an arm or other extremity is amputated, a prosthetic device, or prosthesis, can play an important role in rehabilitation.

A prosthesis is attached to the residual limb by a socket which is custom made usually from a plaster cast of the residual limb. Sometimes friction between the residual limb and socket can cause pain and discomfort and limit wearing time.  There can be issues with the size and shape of a residual limb which can mean revision surgery is needed and this can result in a delay in beginning to use a prosthetic limb.  

For many people, an artificial limb can improve mobility and the ability to manage daily activities, as well as provide the means to stay independent.

It can take several months before a prosthetic limb can be fitted. But one might not be suitable for you – especially if it is a lower prosthetic limb. This will depend on:

  • How much muscle strength there is in the remaining section of the limb
  • Your overall health
  • What a prosthetic limb is expected to perform (depending on occupation and hobbies)
  • Whether the aim is to use it for a range of activities

As specialist amputation solicitors, we are acutely aware of the challenges our clients face using a prosthetic limb.  We act for clients who might have experienced amputation as a result of traumatic injury or as a result of poor medical treatment. 

No matter the cause of the amputation or when it happens, we know that many amputees experience residual limb and socket comfort problems.  This can mean that their use of conventional prosthetic limbs can be significantly limited.  This in turn has an impact on mobility and their ability to regain a degree of independence.

Since the 1990s, a surgical procedure called Osseointegration has been used to try to overcome some of these issues.  Osseointegration is a form of surgery which replaces the need for an amputee to wear a socket which is traditionally attached to their prosthesis. A permanent metal implant is inserted into the bone of the arm or leg and this implant penetrates through the skin. The prosthesis is attached to the implant with a connector. 

The surgery is still relatively new and the long term factors unknown, but it has become increasingly more popular in active adult amputees who cannot tolerate socket use any longer and want to increase their daily activities and improve their quality of life.

Claire Roantree and Julie Marsh are excited to discuss Osseointegration with Dr Matija Krkovic, one of the UK’s leading Orthopaedic and Trauma Surgeons at Cambridge’s Addenbrookes Hospital, to bring awareness to the pros and cons of Osseointegration vs conventional prosthesis. Matija has been working as a Consultant Trauma and Orthopaedic surgeon in the NHS since 2007. He is actively involved in research within Orthopaedics and is responsible for training the next generation of surgeons.

  1. Why do patients opt for Osseointegration?

Often, patients will opt for Osseointegration (OI) when they are unable to control their prosthetic limb, or if the socket has to be repositioned frequently.

These are the main reasons in my opinion.

However, there are other reasons as well. These include profuse sweating of the stump (particularly in hot weather), stump skin irritation and inability to control the stump due to the muscle wasting as a result of the injury and recovery period.

In cases like these, OI represents a good solution.

  1. What are the benefits of Osseointegration?

The main benefit of OI is that patients are able to control their prosthetic limb with increased precision and strength. This means that they are able to use their prosthetic limb for longer and they may not need to use any additional walking aids, although this also depends on their other injuries. The patient’s ability to walk and their walking distance will improve as well. This can result in more independent in day-to-day life.

  1. What are the risks of the surgery?

The risks of surgery can be separated into immediate intraoperative risks and postoperative risks.

The main intraoperative risk is breaking the bone when inserting the implant. We aim for a snug fit to allow good contact between the implant and the bone in order to achieve the best possible osseointegration. It is imperative that we find the right balance between the diameter of the bone canal and the thickness of the implant; if the implant is thicker than the canal, it could potentially split the bone during the insertion.

Infection with a possible wound break down represents the main postoperative risk. Therefore, appropriate use of antibiotics and meticulous surgical techniques are of paramount importance.

Periprosthetic fractures are fractures of the bone, which happen when an implant is already present. Patients with OI implants have a relatively high risk of periprosthetic fractures, anywhere between 10-25%. This means that 10-25% of all patients with OI will sustain a fracture in their lifetime.

Obviously, the most important risk in OI is that the procedure will fail and that the implant will not become osseointegrated.

  1. What aftercare is required?

After a successful OI procedure, patients need to take care of the stoma daily to try and avoid any infection.

  1. Does a patient require a trial of prosthesis before proceeding to osseo?

Yes, a patient will need to undergo a trial with a standard socket prosthesis before we discuss OI.

In my view, patients need to spend a good amount of time trying to cope with a standard socket prosthesis. We need to assess the level of the function that a patient can achieve with a socket prosthesis and determine whether a patient is going to be able to significantly improve their function with OI.

  1. Do you see patients with traumatic injury that are looking for elective amputation and osseo as one procedure? Is this recommended?

I strongly believe that patients need to trial a socket prosthesis before they encounter OI. Whilst OI and amputation can be done in one sitting, I would say that this should only be done in cases where the patient will be left with a very short stump after the amputation. The wound would also need to be infection free at the time of amputation.

  1. What counselling or psychological support is required for someone thinking about osseo?

Psychological review is very important. Patients need to have reasonable expectations of the benefits offered by OI whilst also understanding the drawbacks. The decision to have this procedure is not one that should be taken lightly.

  1. What rehab is needed after osseo? How does this differ from the rehab required after amputation?

The OI procedure is divided into two phases. During the first phase the metal stem is inserted into the bone but remains covered by the skin. At this stage, standard physio is required but the socket prosthesis can no longer be used.

The stoma is created during the second stage. Initially we attach the temporary prosthesis and once the patient has become accustomed to it, we attach the definitive prosthesis. This is followed by all the necessary measurements and fine tuning (length of the prosthesis and off-set) of the connection.

In many ways, physiotherapy after the first stage of OI is very similar to standard physio post amputation. Physio after the second stage of OI differs significantly from standard post amputation physio.

The main reason is that with OI the majority of muscles left on the stump can be trained and improved, but with a socket type of prosthesis, particularly in a high above knee amputation, only certain groups of muscles can be used for exercising.

  1. What does osseo mean for the use of prosthetics? How does it differ from amputation? Does it limit the use of prosthetics to certain types?

Providing that we are able to source the appropriate connectors, any existing prosthetic limb can be used. While there are certain differences between OI and socket prosthesis, one thing remains the same: the better the prosthesis, the better the function.

  1. Is ongoing rehabilitation/physio required on a regular basis?

For OI patients, physio rehab should be an ongoing, never-ending process. In reality, I would expect that when patients become more active and use their prosthesis regularly that they will get a sufficient amount of exercise just from their daily routine.

My recommendation is to continue with exercising/rehab forever. It should become a way of life. In my practice, I see that strong, fit limbs always perform better in any condition. This is also applicable to the users of OI and socket prosthesis patients.

  1. When is osseo available from?

OI can be safely implanted once bones stop growing. This happens when growth plates fuse that is and tends to happen at around 15-16 years of age.

  1. Is revision surgery required after osseo?

The majority of revision surgeries after OI are due to an infection or fracture. Usually, we remove bone spurs during the first stage procedure but they can still reoccur.

  1. Is more energy required to use osseo vs a conventional prosthetic?

Patients with OI require less energy for mobilising than patients with a standard socket prosthesis. This is particularly important for patients who find difficult to walk with a socket prosthesis. As the energy requirement is lower in the OI group, patients who find it very difficult to walk or cannot walk with a socket prosthesis will very likely be able to walk aided or independently after a successful OI, at the very least on shorter distances (indoors) if not also outdoors. However, it is unreasonable to expect that they will achieve the level of walking they were at before the accident. Generally speaking, we can expect a 30-50% improvement in performance after a successful OI in comparison to socket prosthesis use.

  1. What is the NHS view on osseo?

The current position of the NHS is that they do not want to engage with OI as the data available is not sufficient to support the decision on cost-effectiveness. Furthermore, there is a stigma attached to OI in the UK, largely because of a failed project carried out in the 90s, the results of which were not encouraging. More or less all of the OI implants were lost due to various problems. The NHS will get involved in any treatment required due to complications but will not insert or reinsert the implant regardless of if it is as part of the initial treatment or revision surgery.

  1. What is the rough cost of the procedure?

The cost of the procedure currently varies significantly, from centre to centre and it can be anywhere from £60,000 to £100,000.

  1. Where is it currently performed?

There are several centres around the world. The oldest is in Goteborg, Sweden followed closely by Hannover, Germany where one of the pioneers, Prof. Aschoff works. The other centres in Europe can be found in the Netherland and Italy. Speaking globally, there is a centre in Sydney, Australia where they have performed the majority of the procedures so far and there are also centres in the USA with Las Vegas being one of them. The current FDA regulations in the USA restrict US surgeons to five OI procedures a year.

  1. What are the long term issues with osseo?

I’ve mentioned above the infections and periprosthetic fractures, bone reabsorption of unloaded bone that can be the main problems.

As the whole bone is not loaded through the prosthesis, the unloaded part of the bone will start disappearing. This can result in the screw/peg, which had been inserted into the bone initially, becoming exposed (i.e. not covered by the bone). This makes the whole construct unstable and leads to imminent failure.

  1. Will someone who has osseo require removal later in life? Are they still likely to become a wheelchair user later in life?

A patient will require removal of the OI prosthesis if there are any complications (infection, loosening, fracture) or if they wish to convert back to a socket prosthesis.

The main factor for a patient when deciding whether to become a wheelchair user or not is the level of energy required for activities, i.e. walking.

Therefore, I would say that patients with successful OI will become wheelchair dependant later on in life than to patients with a socket type prosthesis.