Enthesopathy, a Cause for Persistent Peristomal Pain after Treatment with an Osseointegrated Bone-Anchor: A Retrospective Case Series

Abstract

Introduction: After limb loss, many patients undergo treatment with an osseointegrated implant. Unfortunately, some develop persistent peristomal pain after surgery. This can be sufficiently severe to reduce the speed of their rehabilitation or may halt the process altogether. The pain may be due to an enthesopathy of the residual muscles. We describe the phenomenon and outcomes of treatment in a series of patients who underwent treatment with an osseointegrated prosthetic limb, bone-anchor. Materials and Methods: Over 36 months, we followed 14 patients with symptoms consistent with enthesopathy. Thirteen had undergone treatment with a transfemoral bone-anchor and one underwent treatment with a transhumeral bone-anchor. One patient had a bilateral transfemoral amputation. Analysis of the patients' ages, heights, weight at the time of surgery, length of residual femur, or preoperative dual-energy x-ray absorptiometry scans showed no correlation with the development of enthesopathy pain. Thirteen patients received steroid injections. Most received at least one injection of Adcortyl™ and bupivacaine. Patients were then encouraged to follow a program of physiotherapy to stretch out their enthesis, after injection. Results: All patients experienced relief from their symptoms, but only two were rendered completely pain free. The remaining 11 patients gained sufficient control of their symptoms to allow them to continue daily use of their prosthesis with less difficulty or, where rehabilitation had been delayed or halted completely, to resume this process. Conclusion: Enthesopathy seems to be a common phenomenon after bone-anchor surgery in individuals with transfemoral amputation. Steroid injections can help to relieve pain, allowing physiotherapy to be carried out. Patients undergoing treatment with a bone-anchor should be advised of the possibility of enthesopathy pain but can be reassured that there is a solution that works well in most cases. Clinical Relevance: This article may be of benefit to clinicians who are struggling to manage patients with persistent peristomal pain after insertion of a bone-anchor. It may also encourage further research into measures for securing the soft tissues around the stoma for patients undergoing bone-anchor surgery.