Residual Amputee Limb Segment Lengthening

Chavan, A.; Muderis, Munjed Al; Tetsworth, Kevin; Rustamov, IlkhomjonDexter; Hoellwarth, JasonShih

doi:10.4103/jllr.jllr_17_22

Cited by 3 publications

(4 citation statements)

References 41 publications

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“…Alternatives include socket modification, bone lengthening and/or soft-tissue contouring 13 , Krukenberg-type reconstructions 14 , or accepting the situation. An alternative implant is a screw-type osseointegration implant.…”

Section: Alternativesmentioning

confidence: 99%

“…or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure. Alternatives: Alternatives include socket modification, bone lengthening and/or soft-tissue contouring 13 , Krukenbergtype reconstructions 14 , or accepting the situation. An alternative implant is a screw-type osseointegration implant.…”

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confidence: 99%

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Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation

Hoellwarth,

Tetsworth,

Al Muderis

2024

JBJS Essential Surgical Techniques

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Background: Upper limb (UL) amputation is disabling. ULs are necessary for many domains of life 1 , and few effective motor and sensory replacements are accessible 2 . Approximately 41,000 people in the United States have UL amputation proximal to the fingers 3 , two-thirds of (all) traumatic amputations are UL 4 , and 80% of UL amputations are performed for trauma-related etiologies 5 . Socket prosthesis (SP) abandonment remains high because of the lack of sensation, limited prosthesis control, perceived weight, and difficulty comfortably wearing the SP 6 . Transcutaneous osseointegration 7,8 surgically inserts a bone-anchored implant, passed through a transcutaneous portal to attach a terminal device, improving amputee rehabilitation by reducing perceived weight, conferring osseoperception 9 , and increasing wear time 10 . Without the socket, all residual skin and musculature remain available for transcutaneous myoelectrodes. The present article describes single-stage radius and ulna press-fit osseointegration (PFOI) after trans-forearm amputation. Description: This technique resembles a lower-extremity PFOI 11,12 . Importantly, at-risk nerves and vessels are different, and implant impaction must be gentler as a result. The surgery is indicated for patients who are dissatisfied with SP rehabilitation or declining alternative rehabilitative options, and who are motivated and enabled to procure, train with, and utilize a forearm prosthesis. An engaged prosthetist is critical. Surgical steps are exposure, bone-end and canal preparation, first implant insertion (in the operative video shown, in the radius), purse-string muscle closure, confirmation that radius-ulna motion remains, performing the prior steps for the other bone (in the video, the ulna), and closure (including potential nerve reconstruction, soft-tissue contouring, and portal creation). Although the patient in the operative video did not require nerve procedures to address pain or to create targets for transcutaneous myoelectrodes, targeted muscle reinnervation or a regenerative peripheral nerve interface procedure could be performed following exposure. Alternatives: Alternatives include socket modification, bone lengthening and/or soft-tissue contouring 13 , Krukenberg-type reconstructions 14 , or accepting the situation. An alternative implant is a screw-type osseointegration implant. Our preference for press-fit implants is based on considerations such as our practice’s 12-year history of >1,000 PFOI surgeries; that the screw-type implant requires sufficient cortical thickness for the threads 15 , which is compromised in some patients; the lower cost per implant; that the procedure is performed in 1 instead of 2 surgical episodes 15,16 ; and the documented suitability of press-fit implants for patients with challenging anatomy or comorbidities 17–19 . Rationale: PFOI can be provided for amputees having difficulty with socket wear. PFOI usually provides superior prosthesis stability, which can confer better prosthesis control versus nonoperative and other operative options in patients expressing dissatisfaction for reasons such as those mentioned above, or for poor fit, compromised energy transfer, skin pinching, compression, and abrasions. For patients who want myoelectric control of their prosthesis but who are unable because the optimal myoelectric location is obstructed by the socket, osseointegration may provide access for the electrodes by eliminating the socket. Expected Outcomes: Only 3 trans-forearm osseointegration 20–22 publications totaling 10 limbs could be identified, limiting the ability to determine generalizable outcomes. Osseointegrated prostheses, being skeletally anchored, feel lighter to patients than SPs, which should confer better outcomes. In 1 patient, multiple implant fractures and infection prompted additional surgeries. Periprosthetic bone fractures and non-infectious loosening have not been documented for UL osseointegration. Important Tips: Osseointegration eliminates the socket, relieving socket-based pain. However, neurogenic pain relief requires specific nerve procedures.Osseointegration provides a prosthesis connection. Nerve- or muscle-based prosthesis control requires separate, potentially integrated planning.Osseointegrated prostheses confer osseoperception (i.e., mechanical force transmission), not “normal” skin-mediated afferent sensation (i.e., light touch, temperature, pain) or native proprioception.Prostheses must be individualized to the patient’s elbow flexion and radioulnar rotation. An attentive prosthetist must be ensured preoperatively.Achieving the demonstrated outcomes requires more therapy and retraining than walking with an osseointegrated lower-extremity prosthesis. Patients must expect at least several months of spending multiple hours daily engaging in self-directed rehabilitation.Prosthesis utilization decision aids 23 may minimize non-beneficial surgeries. Acronyms and Abbreviations: UL = upper limbSP = socket prosthesisPFOI = press-fit osseointegrationperi-pros fx = periprosthetic fractureMRI = magnetic resonance imagingCT = computed tomography

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Section: Alternativesmentioning

confidence: 99%

mentioning

confidence: 99%

Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation

Hoellwarth,

Tetsworth,

Al Muderis

2024

JBJS Essential Surgical Techniques

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“…Larger-diameter cobalt-chromium and steel implants were found to have greater resistance to bending forces than titanium nails. Finally, in a systematic review of limb segment lengthening in amputees, Chavan et al concluded that, despite potential complications such as segment overlengthening, the potential for improved prosthetic fitting and use makes this a beneficial option in this group of patients 46 .…”

Section: Limb Lengtheningmentioning

confidence: 99%

What’s New in Limb Lengthening and Deformity Correction

Bafor

Iobst

2023

Journal of Bone and Joint Surgery

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“…5) and dramatically improve prosthesis control. [49][50][51] Patient and system factors are potentially more pronounced with amputation. Patients without the ability to receive regular prosthetic care may comparatively benefit from "heroic" attempts at limb salvage.…”

Section: Optimize Amputationsmentioning

confidence: 99%

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Lansford

McCarthy

Souza

et al. 2023

OTA International: The Open Access Journal of Orthopaedic Trauma

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Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are “spare parts” that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function. Level of Evidence: 5.

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Residual Amputee Limb Segment Lengthening

Cited by 3 publications

References 41 publications

Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation

Single-Stage Press-Fit Osseointegration of the Radius and Ulna for Rehabilitation After Trans-Forearm Amputation

What’s New in Limb Lengthening and Deformity Correction

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

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