Lower extremity osseointegration — a review of the current experiences and expectations

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Abstract

Transcutaneous osseointegration for amputees (TOFA), an alternative approach to limb-loss rehabilitation, offers an enhanced quality of life and mobility, overcoming some challenges associated with amputation. This review presents evolution, surgical techniques, patient selection principles, and outcomes associated with TOFA. Notable points include the recognition that press-fit osseointegration techniques and implants achieve the quality of life and mobility improvements with a single surgical episode. Infection remains the most common adverse event, but uncommonly requires additional surgery, and rarely requires implant removal. Press-fit osseointegration has proven suitable for rehabilitating a broad range of patients with pelvic, transfemoral, or transtibial amputation performed to manage trauma, cancer, infection, chronic pain, and deformity. This technigue is safe for patients with vascular disease, diabetes mellitus, short residual bones, and osteoporotic residual bones. This article serves as a central resource for understanding the principles and techniques of osseointegration.

About the authors

Jason D. Gross

Hospital for Special Surgery, Osseointegration Limb Replacement Center

Author for correspondence.
Email: Grossj@hss.edu
ORCID iD: 0009-0009-7786-6949
United States, New York, NY

Matan Grunfeld

Hospital for Special Surgery, Osseointegration Limb Replacement Center

Email: Mgrunfel@student.nymc.edu
ORCID iD: 0009-0009-5630-6459
United States, New York, NY

S. Robert Rozbruch

Hospital for Special Surgery, Osseointegration Limb Replacement Center

Email: RozbruchSR@hss.edu
ORCID iD: 0000-0003-1632-4600

MD, Professor

United States, New York, NY

Taylor J. Reif

Hospital for Special Surgery, Osseointegration Limb Replacement Center

Email: reift@hss.edu
ORCID iD: 0000-0001-5220-8071
United States, New York, NY

Jason S. Hoellwarth

Hospital for Special Surgery, Osseointegration Limb Replacement Center

Email: hoellwarthj@hss.edu
ORCID iD: 0000-0001-7065-0656

MD

United States, New York, NY

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2. Figure 1. Osseointegrated Prosthetic Limb (OPL) used in the majority of articles reviewed in this manuscript: a — exploded view with the componentry arranged at approximately the proximal-distal levels, in which they would reside after being assembled and implanted in a patient who had undergone a femoral amputation (1 — proximal cap screw; 2 — OPL body; 3 — safety screw; 4 — dual cone abutment adapter; 5 — taper base screw; 6 — proximal connector; 7 — prosthetic connector. Components 6 and 7 are one of various styles of mating the dual cone (4) with a prosthetic terminal device); b — long-standing X-ray of a patient with right transfemoral amputation in the socket prosthesis, identifying the valgus hip position seen in many socket users; c — long-standing X-ray of the same patient after transfemoral osseointegration, showing the anatomic alignment of the leg; d — close-up photograph of the transcutaneous portal for the prosthesis. Note the stable skin-implant interface

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3. Figure 2. Transtibial osseointegration: a — preoperative photograph identifies this patient is using two crutches to locomote because of his inability to wear a socket prosthesis due to pain; b — X-ray in the anterior-posterior view depicting the transtibial osseointegration implant; c — standing photograph of the patient following transtibial osseointegration; d — photograph showing the patient feeling comfortable and enthusiastic enough to initiate a dance with the nurse during the postoperative visit. Note that the patient is able to plant on the osseointegrated limb confidently enough to lead his partner while having his intact leg off the ground

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4. Figure 3. Short residual bone for osseointegration: a — X-ray in the anterior-posterior view of the right femur identifying almost no bone beyond the lesser trochanter. She was a functional hip disarticulation patient due to the inability to wear a socket; b — this patient had partial hardware removal with simultaneous osseointegration, achieved excellent fixation and now ambulates without an assistive device; c — X-ray in the anterior-posterior view of the left tibia for a patient with minimal bone distal to the tibial tubercle. His residual limb was too short to use tibia-level prosthesis and he was considering transfemoral amputation prior to consultation for osseointegration; d — the patient also achieved ambulation without an assistive device with a press-fit osseointegration implant

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