Transtibial Osseointegration for Patients with Peripheral Vascular Disease

Abstract

Background: The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI). Methods: Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded. Results: All patients’ mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis. Conclusions: All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient’s death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Bone density changes after five or more years of unilateral lower extremity osseointegration: Observational cohort study

“…Overall, patients considered for osseointegration are skeletally mature adults who either 1) report pain or mobility dissatisfaction with their TP; 2) have an intact limb with incapacitating pain, complex deformity, or profound distal weakness, whose functional capacity is considered likely to be improved by amputation; or 3) are recent amputees preferring osseointegration to TP rehabilitation. Comorbidities such as diabetes mellitus ( Jawazneh et al, 2017 ), peripheral vascular disease ( Akhtar et al, 2021 ), and other comorbidities ( Hoellwarth et al, 2021 ; Akhtar et al, 2022 ; Hoellwarth et al, 2022b ; Hoellwarth et al, 2022c ; Hoellwarth et al, 2022d ) do not appear to necessitate contraindication. The only situations we consider particularly rigid contraindications to osseointegration are modifiable compromises to successful bone and/or wound healing, such as active infection or malignancy, though upon treatment of those modifiable compromises most patients can be suitable.…”

Osseointegration Following Transfemoral Amputation After Infected Total Knee Replacement: A Case Series of 10 Patients With a Mean Follow-up of 5 Years

“…Video 1 shows the gait difference for a patient using a TSP and following TOFA. Historically, TOFA was assumed to be too risky for some patient populations although several recent studies have identified that press-fit TOFA is in fact beneficial for many of such populations [ [18] , [19] , [20] ]. Patients with a history of TKR PJI resulting in TFA or KF is another population that has been generally overlooked and not previously studied.…”

Transcutaneous osseointegration for amputees

“…While peripheral vascular disease and diabetes were long considered contraindications, early clinical experience in carefully selected patients has been consistently positive, and this is no longer true. 16 Two completely different designs of implants currently dominate the market, both titanium. 3 The Swedish Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA TM ) implant is a cannulated screw-type implant that remains essentially unchanged since it was first introduced in 1990 and is the only TOFA implant that has been granted FDA approval.…”