Periprosthetic osseointegration fractures are infrequent and management is familiar

Abstract

Aims Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169.

Management, outcome, and novel classification system of periprosthetic fractures in patients with transcutaneous osseointegrated prosthetic systems (TOPS)—a retrospective cohort analysis

“…There was no significant improvement in the rehabilitation results for the K-level in favor of the overweight patients compared to the normal weight patients. According to the findings of Hoellwarth et al [12], our results confirm that periprosthetic fractures after TOPS treatment do not necessarily have a negative impact onto rehabilitation success. To the present time, all fracture fixations have been rehabilitated satisfactorily.…”

“…A substantial incidence of periprosthetic fractures by falls has to be expected [8][9][10][11][12]. So far, there is only one study available about the risk of periprosthetic fractures in patients with osseointegrated implants after transfemoral amputation [12].…”

Using Stubby Prosthesis after Bilateral Transfemoral Amputation: A Biomechanical Case Study

“…In these cases, the DSF becomes an alternative to the traditional prosthetic socket. In the studies of McMenemy et al and Hoellwarth et al the DSF suspension method turned out to be safe and the percentage of periprosthetic fractures was between 2 and 3% [17,18]. In our study, the GRF measurement was used to determine the magnitude of force transferred to the thigh stumps.…”

“…For this reason, in most cases, compensation for the prostheses must solely come from the hip joints and trunk [7,[13][14][15]. Advanced technological prostheses and suspension methods (direct skeletal fixation (DSF) osseointegration-insertion of the implant into the femur) have made it possible to develop prostheses that reduce the size of asymmetry in gait [16][17][18]. However, they do not affect the gait efficiency.…”

Cementing Osseointegration Implants Results in Loosening: Case Report and Review of Literature

“…Eventual revision osseointegration can be considered once the infection is eradicated. For fractures occurring around press-fit osseointegration implants, routine fracture management (reconstruction plate and screws or dynamic hip screw stabilization) with implant retention has been uniformly successful, and patients remain more active after recovery than before osseointegration [4,5]. No complications requiring proximal amputation have occurred with press-fit style implants.…”