Osseointegration

What is osseointegration?

This is a relatively new way of attaching a prosthesis to the body. Osseointegration is where a metal, often titanium-based, implant is inserted into a bone and the bone grows around the implant, accepting it as part of the body. This creates a sturdy, permanent bone anchor that a prosthesis can easily be attached to.

This procedure simulates the natural architecture of the body, as force travels through the bone and out into the metal implant, rather than compressing the soft tissue in a traditional socket prosthesis.

Osseointegration has been used for decades in dentistry to attach dental implants, as well as in joint replacement surgeries, but it’s only recently been used in amputation surgery. For prosthetic limbs, bone anchors can be inserted into the femur (thighbone) and tibia (lower leg bone) as well as the humerus (upper arm) and the radius and ulna (forearm bones). This page mainly discusses the procedure for the lower limb.

An important aspect of osseointegration, is the permanent opening of the skin (stoma). The stoma must be cleaned with soap and water twice a day. It only takes a few minutes, but it is necessary to prevent irritations and infections, which may require extra care or antibiotics.

Is osseointegration right for me?

If you’re an amputee with a socket prosthesis experiencing the following difficulties, you may benefit from osseointegration:

• Problems with your socket such as pain, skin problems and perspiration
• An ill-fitting prosthesis that can’t be worn for very long
• Not being able to walk fast or very far
• Discomfort when sitting down
• Increased tiredness
• Back pain because you struggle to sit or stand straight, or you limp when you walk.

However, you may not be able to have this operation due to the following reasons:

• Severe peripheral vascular disease
• Diabetes
• Current chemotherapy treatment, corticosteroid use, or immunosuppressant drugs
• Limb exposure to radiation
• Pregnancy
• Mental illness or disabling psychiatric disorder
• Osteoporosis, atrophic bone conditions
• Body weight in excess of 100 kg
• Infection
• Skin disease involving the amputated limb
• Heavy smoking history (patients must have stopped smoking at least three months before the surgery, and after treatment, smoking isn’t allowed at all).

What are the benefits of osseointegration?

Osseointegration aims to improve your quality of life, as you’ll be able to go back to doing your daily activities with ease. This includes activities such as showering, taking a bath, swimming, going to a sauna and cycling. Impact and contact sports, such as football, martial arts and skiing are discouraged as you’re more at risk of bone fractures.

As the implant is fixed directly into the bone, it provides more stability and eliminates socket-related problems. Osseointegration therefore improves your movement and mobility, including walking longer distances, makes sitting down more comfortable, and reduces soft tissue and skin irritation.

Also, because patients feel their prosthesis is part of their own body (osseoperception), this procedure can reduce phantom limb pain.

How long do the benefits of treatment last?

You normally only need a one-off operation or operations to affix the bone anchor, but you’ll need to get it checked regularly.

What happens during osseointegration?

Before surgery

If you’re suitable for surgery, you’ll go through a preparation program including physiotherapy, functional tests and investigations such as x-rays and bone scans.

There are a few things you need to do in the lead up to the operation to make sure everything goes smoothly:

• Don’t wear your prosthesis for 2 weeks before surgery – this is to minimise the risk of infection from skin abrasions or open wounds
• As part of your physiotherapy, you’ll be given crutches to take home and practice with, as well as postoperative exercises.
• 10 days before surgery you should stop taking aspirin and anti-inflammatory medications, as well as naturopathic and herbal medications.
• On the night before and the morning of operation, you’ll need to clean the area with antibacterial wash.

During surgery

The operation is usually performed under general anaesthesia, but you may also have a spinal or epidural block if you’re a lower limb patient, or a brachial plexus nerve block if you’re an upper limb patient.

Surgery times vary depending on where the bone anchor is being placed. The operation can be carried out in one or two stages, but this is what is generally involved:

1. Redundant skin and soft tissue fat are removed and muscle groups are rearranged to help operate the limb
2. The bone is reshaped and any bone spurs are removed
3. The metal implant is inserted into the bone
4. Any neuromas are removed and the residual nerves are positioned into the muscle group
5. The stump is refashioned in a cosmetic manner and the wound is closed in layers
6. A circular skin opening (stoma) is created at the base of the stump
7. An adapter is connected to the bone anchor through this opening – the remaining parts of the prosthesis can then be attached externally later on
8. A dressing is applied to the area.

After the surgery

You’ll be taken to the recovery room where you’ll be monitored, and once stable, you’ll be transferred to the ward and given pain relief.

Recovery from osseointegration

It takes about 6 to 12 weeks for osseointegration to take place, which is why you should only partially bear weight on your limb for the first 12 weeks by using crutches.

Your prosthetic will be attached to the implant between 3 to 10 weeks after surgery, depending on the quality of your bone. After this, you can continue to use crutches for another 6 weeks. Most patients can walk without crutches within about 3 months of surgery.

Short-term recovery

You’ll be observed in the hospital for 3 to 5 days. During this time:

• Your drain will be removed
• Your dressing will be reduced to make movement easier
• You’ll be instructed on how to clean the stoma
• Your lower prosthesis will be fitted
• You’ll begin weight loading under careful supervision of a physiotherapist, gradually increasing the weight of the load

Tips for managing your recovery and general living

You’ll continue seeing a physiotherapist, and once you can comfortably load half your body weight, you’ll be fitted with a light leg and you can start gait training.

Here are some more things you can do to make sure your recovery and rehabilitation goes smoothly, as well as to generally take care of your limb and prosthetic:

• Once you’re home you can start to shower and carefully clean the stoma daily with soap and water
• For the first few weeks, you should keep the surgical area wrapped in gauze to prevent infection
• Remember to build up your walking slowly to avoid any injuries
• Make sure you continue your postoperative exercises
• Try to avoid any sharp twisting movements – however if there is too much strain, the safety system in the external implant will kick in to protect you from a bone fracture.

Driving after osseointegration

You should be able to drive as soon as you feel comfortable and able to do so.

Time off work following osseointegration

If you have a sedentary role, you should be able to return to work soon after the operation, but if you have a more manual role, you should wait until you can walk without crutches.

Follow-up appointments

You’ll see a physiotherapist as an outpatient to help with your rehabilitation and gait training. You’ll also be seen by a prosthetist for the final fitting of your prosthesis 3 to 10 weeks after surgery, depending on the quality of your bone. And you’ll need to come back for regular check-ups, as elements of the prosthetic may need to be replaced over time.

Risks of osseointegration

Complications are rare but possible. Rest assured that your consultant will weigh up the risks and advantages with you when deciding if they recommend surgery. They’ll also discuss any additional risks that apply to you at your initial consultation. Here are some of the potential risks:

• In the first year after implantation you may have intensive muscle pain, which will disappear as soon as the stump muscles become fitter and stronger
• In some cases, the stoma may become irritated
• Minor infection in the stoma or bone, which can easily be treated with oral antibiotics
• Severe infection in the stoma or bone, which is rare, which would require removing the bone anchor to allow the infection to clear.

References
https://www.osseointegration.eu/what-osseointegration#:~:text=You%20are%20a%20good%20candidate,sit%2...
https://www.limbreconstructions.com/blog-posts/everything-you-need-to-know-about-osseointegration
https://www.almuderis.com.au/osseointegration-surgery/education/hips/minimally-invasive-hip-surgery/...
https://www.almuderis.com.au/osseointegration-surgery/education/osseointegration-2/information-35/su...
https://www.almuderis.com.au/osseointegration/115-post-surgery/post-surgical-information
https://www.royalfree.nhs.uk/services/services-a-z/plastic-surgery/prosthetic-limbs-and-body-parts/o...
https://www.iconinmotion.com/osseointegration/
https://www.royalfreeprivatepatients.com/treatments/osseointegration-procedure/#:~:text=Surgery%20is....
https://www.hss.edu/condition-list_osseointegration.asp#:~:text=and%20occupational%20therapists-,Wha....