Context: Transcutaneous osseointegration for amputees (TOFA) consistently confers significant improvement in mobility and quality of life (QOL) for amputees using a traditional socket prosthesis. Limb radiation therapy (XRT) Has traditionally been considered hard contraindication against TOFA but has never actually been examined. Aims: This study evaluated the changes in mobility and QOL, and also the complications, for oncologic amputees provided TOFA: 9 with XRT, and 23 with no radiation therapy (NRT). Settings and Design: A retrospective registry review of all oncologic amputees was performed. Subjects and Methods: The patients' mobility (daily prosthesis wear hours, K-level, Timed Up and Go, and 6-min walk test [6MWT]) and QOL survey data (Questionnaire for Persons with a Transfemoral Amputation) were compared before TOFA and at the latest follow-up. Statistical Analysis Used: Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Results: Regarding mobility, the cohorts were similar to one another before and after TOFA, and both cohorts improved following osseointegration (statistically significant: XRT wear hours [P = 0.029], NRT K-level [P < 0.001], and NRT 6MWT [P = 0.046]). Both cohorts' QOL was also similar before and after TOFA, and both cohorts again improved following osseointegration (significant differences: XRT problem score [P = 0.021], NRT problem score [P < 0.001], and NRT global score [P < 0.001]). Three XRT patients (33%) and one NRT patient (4%) required removal (P = 0.048). Conclusions: While radiation therapy may be associated with increased risk of postoperative implant loosening, it seems unjustifiable to flatly contraindicate osseointegration for oncologic amputees solely because of prior limb irradiation.

Aims: This study aimed to systematically review the indications, techniques, complications, and insights identified for lower extremity residual amputee limb segment lengthening. Methods: Searches in PubMed, Google Scholar, Ovid Medline, Ovid Embase, and the Journal of Limb Lengthening and Reconstruction were performed using terms including “amputee,” “residual limb,” and “stump” combined with “lengthening,” “distraction,” “histogenesis,” “osteogenesis,” and “Callotasis.” Included articles described lengthening amputated tibias or femurs (other segments excluded). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized. Descriptive statistics were performed. Results: Twenty-two studies reported lengthening 32 femurs and 31 tibias (63 total segments). Fifteen articles described a single segment, five described two to four (15 total segments), and two described five or more (31 total segments). Lengthening was performed to improve prosthesis fit (21/22 studies, 54/63 segments) or to optimize osseointegration (1/22 studies, 9/63 segments) and utilized an external fixator (52/63) or a motorized intramedullary nail (11/63). Femurs were lengthened an average of 7.7 ± 2.5 cm (60% ± 23%) and tibias 5.8 ± 1.8 cm (97% ± 53%) from a starting length of 12.5 ± 4.6 cm for femurs and 6.7 ± 2.3 cm for tibias. The most common minor problem was pin site infection. The most common major problem was over-lengthening bone beyond the soft tissue envelope, requiring flap coverage, bone excision, or knee disarticulation. Conclusions: Amputee lengthening can achieve measurable gains to improve prosthesis use. Over-lengthening can be difficult to manage, if not catastrophic. Osseointegration may be a further rehabilitation solution for amputees struggling with prosthesis problems and willing to consider surgical options.

Aims: Transcutaneous osseointegration for amputees (TOFA) provides improved mobility and quality of life for most patients versus a traditional socket prosthesis. One uncertainty regarding TOFA is whether a minimum residual bone length is necessary to achieve solid fixation. This study evaluated the relationship between residual bone length and occurrence of post-TOFA complications requiring operative intervention. Patients and Methods: A retrospective review of our osseointegration registry was performed. Inclusion criterion was index osseointegration at least 12 months prior. Chart review included demographics and whether additional surgery occurred to manage noninfected loosening, periprosthetic fracture, and infection. Occurrence rates were compared using binary logistic regression analysis and by stratifying implants as <140 versus ≥140 mm. Results: Sixty segments were included (58 patients and 2 bilateral femur amputees). The implant length averaged 129.4 ± 31.1 (48–200) mm. No noninfected loosening occurred. Six patients (10%) had infection-related post-TOFA operation, at lengths ranging from 130 to 160 mm (representing the central 60% of implant lengths): five were debridement with implant retention and one other was removed. No implants below 130 mm (n = 19, 32%) required debridement or removal. Three patients (5%) had periprosthetic fracture (all femurs), at lengths ranging from 140 to 160 mm (the central 55% of implant lengths); no implants below 140 mm (n = 22, 37%) had periprosthetic fracture. Regression identified no association between length and noninfected loosening (P = 1.000), periprosthetic fracture (P = 0.999), or infection (P = 0.124). Dichotomized <140 versus ≥140 mm rates of complication were as follows: noninfected loosening (0/22 = 0% vs. 0/38 = 0%, P = 1.000), fracture (3/38 = 7.9% vs. 0/22 = 0%, P = 0.292), and infection (5/38 = 13.2% vs. 1/22 = 4.5%, P = 0.400). Conclusion: Residual bone length does not appear to be associated with post-TOFA reoperation to address noninfected loosening, periprosthetic fracture, or infection. The "minimum necessary" length of bone to achieve stable transcutaneous osseointegration capable of supporting full body weight remains uncertain.

Context: Some patients seeking transcutaneous osseointegration for amputees (TOFA) have residual bones so short there is concern whether they provide sufficient surface to support full weight. Our strategy was to lengthen these patients' femurs with a motorized intramedullary lengthening nail (MILN) before TOFA. Aims: The aim of this study is to describe 10 transfemoral amputees' experience with MILN before TOFA, focusing on the complications of MILN and TOFA, and also the patients' preoperative and postoperative quality of life (QOL). Settings and Design: A retrospective registry review of all MILN before TOFA surgeries was performed. Subjects and Methods: The patients' operative complications during/following MILN and TOFA were investigated. Furthermore, the patients' mobility (daily prosthesis wear hours, K-level, Timed Up and Go (TUG), and 6 min Walk Test [6MWT]) and QOL survey data (Questionnaire for Persons with a Transfemoral Amputation [QTFA]) were compared at the initial consultation and at the latest follow-up using Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Statistical Analysis Used: Fisher's exact test for frequencies, and Student's t-test for means (significance, P < 0.05). Results: Seven patients had one operative complication each: Three regenerate (autograft and plating), two nail malfunctions (nail replacement), one broken linkage cable (acute length correction with autografting and fixation), and one early consolidation (re-osteotomy). All ten patients had TOFA, an average of 12.0 ± 3.9 months after MILN surgery. One patient had debridement for infection (implant retained) and one patient had the implant removed due to infection. Significant mobility improvements were K-level >2 (2/9 = 22% vs. 9/10 = 90%, P =0.006) and TUG <15 s (1/8 = 13% vs. 6/8 = 75% P = 0.041). Wear hours and 6MWT improved but not significantly. All three aspects of QTFA significantly improved: Global (44.8 ± 29.9 vs. 75.9 ± 26.8, P =0.050), mobility (50.3 ± 30.8 vs. 74.8 ± 18.2, P =.033), and problem (38.8 ± 18.6 vs. 15.6 ± 18.3, P = 0.017). Conclusions: MILN before TOFA reliably achieves stable osseointegration for amputees with short residual femurs. Amputee lengthening remains demanding, but patients report significantly improved QOL and demonstrate improved mobility following TOFA. The minimum length of bone necessary to support a full weight-bearing osseointegrated prosthesis remains unknown.

Context: Hexapod circular external fixators allow bone manipulation in all planes to correct complex deformities. However, the patient must perform the strut adjustments consistently and correctly, often multiple times daily for weeks or months, to achieve intended corrections. This presents a potential source of variability, error, and anxiety to the patient. A computer-programmed, robotic automated motorized strut adjustment technology (Maxframe Autostrut™ Multi-Axial Correction System, Orthospin Ltd., Yoqneam, Israel) has been developed which automatically adjusts the struts without patient or clinician involvement. Aims: The aims of this study were as follows: first, to determine whether the motors performed the programmed initial and residual schedules and, second, to identify technology-specific problems and their management. Settings and Design: This was a retrospective observational study of a consecutive series of the first 16 patients who had the motorized hexapod frame applied. Subjects and Methods: A chart review was performed to record demographic information, indications and goals for hexapod frame care, whether the care goals were achieved, and whether unexpected and/or adverse events occurred (such as technical difficulties and medical complications) and the management of those issues. Statistical Analysis Used: Not applicable. Results: All patients achieved the index and residual adjustments as programmed. Conclusions: The Autostrut™ system appears reliable and safe. It executes programmed index and residual adjustments as well as strut change scenarios as directed. The system recognizes unexpected mechanical or programming issues and ensures patient safety by halting progress and alerting the patient. Future versions of the technology may benefit from added features such as remote reprogramming or current strut position monitoring.