Osseointegration for lower-extremity amputees, while increasing in frequency, remains in its relative infancy compared with traditional socket-based prostheses.» Ideal candidates for osseointegration have documented failure of a traditional prosthesis and should be skeletally mature, have adequate bone stock, demonstrate an ability to adhere to a longitudinal rehabilitation protocol, and be in an otherwise good state of health.

Background Patients with transfemoral and transtibial amputations generally rely on socket-suspended (SS) prostheses for ambulation. The use of these aids can be complicated by poor fit, leading to tissue damage, pain at the socket-limb interface, and inability to ambulate. Osseointegrated implants (OIs) directly anchor a prosthesis to the patient’s residual limb, eliminating these issues. However, they require customized components and additional surgeries. The purpose of this study was to conduct the first cost–benefit analysis of OI prostheses compared to SS prostheses for lower limb amputees in the United States. Methods A retrospective chart review was performed on all patients who received unilateral lower limb OI prostheses at our institution. Costs were calculated in a bottom-up approach using Current Procedural Terminology codes. Utilities and SS prosthesis costs were derived from previous studies. A Monte Carlo model was used to project costs and lifetime quality-adjusted life years for OI and SS prostheses, and the incremental cost-effectiveness ratio (ICER) of OI compared SS prostheses was determined. Results Twenty-five patients (12 female) were included in the study. The mean follow-up was 17 months postimplantation. The average cost of OI surgery was $54,463. Twenty percent of patients required preimplantation soft tissue revision surgery ($49,191). Complication rates per year and average costs were as follows: soft tissue infection (29%, $435), bone/implant infection (11%, $11,721), neuroma development (14%, $14,659), and mechanical failure (17%, $46,513). The ICER was $44,660. A cost-effectiveness acceptability curve demonstrated that OI was favored over SS in 78% of cases at a willingness-to-pay of $100,000 per quality-adjusted life year. In a 1-way sensitivity analysis, the ICER was most sensitive to the mechanical failure rate, mechanical failure cost, and prior SS prosthesis costs. Conclusions The model shows that OI prostheses provide a higher quality of life at affordable costs when compared to poorly tolerated SS prostheses in patients with lower limb amputations in the United States. The cost-effectiveness is largely determined by the patient's previous SS prosthesis costs and is limited by the frequency and costs of OI mechanical failure. More research must be done to understand the long-term benefits and risks of OI prostheses.

Background: Elbow flexion at late portions of the pitch has been associated with increased elbow varus torque, a kinetic surrogate associated with injury risk. Direct examinations of injury incidence with elbow flexion angles have not been conducted in professional pitchers. Purpose: To compare elbow and shoulder injury incidence among professional baseball players stratified by degree of elbow flexion at ball release (BR). Study Design: Descriptive laboratory study. Methods: Professional pitchers (N = 314) were instructed to pitch between 8 and 12 fastballs while being evaluated using motion capture technology. Upper extremity injury incidence was recorded upon interview. Pitchers were subsequently subdivided into 3 groups based on increasing elbow flexion at BR. Analysis of variance was used to compare participant characteristics and kinematic and peak kinetic variables. An odds ratio (OR) was calculated to determine the risk of having a previous upper extremity injury based on the degree of elbow flexion at BR. Results: A total of 116 pitchers (132 documented injuries) had a previous upper extremity injury, with elbow injury (76 injuries; 57.6%) being the most common. Evaluation of kinetic values showed that pitchers with the smallest elbow flexion at BR had significantly less peak elbow flexion torque than did those with greatest elbow flexion at BR (3.8 ± 0.5 vs 4.1 ± 0.6 %weight × height; P = .003). Pitchers who demonstrated a greater than average degree of elbow flexion at BR when pitching were more likely to have a history of elbow injury (OR, 1.97; 95% CI, 1.14-3.40; P = .015) and olecranon spur formation or stress fracture (OR, 5.79; 95% CI, 1.25-26.85; P = .025). Conclusion: Pitchers with greater elbow flexion at BR had significantly higher odds of previous injury of the elbow and olecranon. Increasing elbow flexion has been shown to place the medial elbow in a position to carry a greater amount of load, which may be exacerbated during the final moments of the pitching motion. Professional pitchers can consider decreasing elbow flexion at BR as a potential, modifiable risk factor for elbow injury, in particular for olecranon spur formation and fracture. Clinical Relevance: This study attempts to associate injury incidence with a modifiable, kinematic variable for an at-risk population.

Purpose Lower-limb osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses, which are often associated with poor fit, soft tissue damage, and pain. Osseointegration eliminates the socket-skin interface and allows for weight-bearing directly on the skeletal system. However, these prostheses can also be complicated by postoperative issues that can negatively impact mobility and quality of life. Little is known about the incidence of or risk factors for these complications as few centers currently perform the procedure. Methods A retrospective analysis was performed on all patients who underwent single-stage lower limb osseointegration at our institution between 2017 and 2021. Patient demographics, medical history, operative data, and outcomes were collected. Fisher exact test and unpaired t tests were performed to identify risk factors for each adverse outcome, and time-to-event survival curves were generated. Results Sixty patients met our study criteria: 42 males and 18 females with 35 transfemoral and 25 transtibial amputations. The cohort had an average age of 48 years (range, 25–70 years) and follow-up period of 22 months (range, 6–47 months). Indications for amputation were trauma (50), prior surgical complication (5), cancer (4), and infection (1). Postoperatively, 25 patients developed soft tissue infections, 5 developed osteomyelitis, 6 had symptomatic neuromas, and 7 required soft tissue revisions. Soft tissue infections were positively correlated with obesity and female sex. Neuroma development was associated with increased age at osseointegration. Neuromas and osteomyelitis were both associated with decreased center experience. Subgroup analysis by amputation etiology and anatomic location did not show significant differences in outcomes. Notably, hypertension (15), tobacco use (27), and prior site infection (23) did not correlate with worse outcomes. Forty-seven percent of soft tissue infections occurred in the 1 month after implantation, and 76% occurred in the first 4 months. Conclusions These data provide preliminary insights into risk factors for postoperative complications arising from lower limb osseointegration. These factors are both modifiable (body mass index, center experience), and unmodifiable (sex, age). As this procedure continues to expand in popularity, such results are necessary to inform best practice guidelines and optimize outcomes. Further prospective studies are needed to confirm the above trends.

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