Improving outcomes for amputees: The health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees

Delivery of UK military upper limb prosthetics: current concepts and future directions

Upper limb prosthetics have a challenging task. A natural upper limb combines strength, coordination and dexterity to accomplish daily activities such as eating, writing, working and social interaction. Artificially replicating these functions requires a prosthetic with composite, synchronous motor function while maintaining sensory feedback and skeletal stability. Achieving these functions requires interfaces between biology and machine across nerve, muscle, bone and skin. This leads to issues related to infection, foreign material encapsulation and implant stability, and electrical signal transduction and interpretation. Over the last 20 years the advent of technologies such as osseointegration, targeted muscle reinnervation, implantable myoelectric sensors, peripheral nerve interfaces and pattern recognition technology has sought to address these problems.Due to many advances in prehospital care, truncated timelines to damage control surgery and improved combat personal protective equipment, the numbers of amputees have increased with more patients surviving injury. From October 2001 to March 2019 there were 333 amputees from Afghanistan and Iraq compared with 457 fatalities over a similar period. Over a third of these were significant multiple amputees. With a functional, robust upper limb prosthetic which mirrors or exceeds normal function, injured service personnel could be returned to an active combat role. This has benefits for their physical and mental health, improves employability prospects and allows Defence to retain some of its most highly motivated and skilled people who represent significant financial investment.

Analyzing research trends and developments in osseointegration in patients with extremity amputations: Systematic bibliometric analysis and research recommendations

BACKGROUND

Bone-anchored protheses (BAPs) by means of osseointegrated implants are increasingly being used in amputees with socket-related issues. Clinical advancements are being published by more and more centers worldwide. Although the number of publications and interest in BAP is growing, a systematic evaluation of scholarly output is lacking.

OBJECTIVE

To identify scholarly output, understand research trends and make research recommendations in the clinical field of BAP.

METHODS

Systematic searches in Medline All, Embase, Web of Science Core Collection, Cochrane Library, and Google Scholar were completed in February 2023. The results were deduplicated, screened, and assessed for quality by independent reviewers. Inclusion criteria were as follows: clinical studies and BAP in the extremities. Articles were excluded if they were animal or fundamental studies, nonclinical reports, had a study population less than 10 patients, or BAP was performed in areas other than extremities.

RESULTS

One hundred twelve articles were included and published between 1993 and 2023. An annual growth rate of 10.3% was found and research was published in 62 different journals. Prosthetics and Orthotics International, Clinical Orthopaedics and Related Research and The Bone & Joint Journal were the most prolific journals. Hagberg K, Aschoff HH, and Branemark R were major contributors to BAP research. Collaborations are predominantly among high-income countries. Main research trends were on rehabilitation, questionnaires, complication managements, and implant treatment.

CONCLUSIONS

Research on BAP shows an increasing global trend, highlighting key research areas and authors. A unified global research agenda, stakeholders' collaborations, and consensus are essential for addressing knowledge gaps and development future direction of BAP.

Amputation Surgery: Review of New and Emerging Techniques

Major upper and lower extremity amputations are increasingly being performed for peripheral vascular disease, infectious etiologies, trauma, and oncologic purposes. Attention to technique and emerging treatments for the residual peripheral nerve is critical to prosthetic wear and quality of life following these life changing events. Here, we detail advancements in amputation surgery including targeted muscle reinnervation, regenerative peripheral nerve interface, and the use of osseointegrated implants.

Quality of life in young people with limb loss: a systematic review

PURPOSE

Life after any amputation can be significantly altered and can have a significant impact on quality of life (QoL). However, most of the evidence base involves older aged amputees, therefore there is a lack of understanding about the impact of amputation on QoL and the factors that predict QoL in younger amputees. The aim of this review is to identify the factors that predict QoL in young amputees.

METHODS

MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science were searched to identify articles that measured QoL in young amputees. Articles were independently assessed by two assessors. Data was extracted from the selected articles and a narrative synthesis performed.

RESULTS

18 articles were included in this review. QoL outcome measures varied between studies. The quality of evidence was generally low. This review identified, gender, age, cause of amputation, level of amputation, phantom pain, ability to use a prosthesis, physical function, depression, anxiety, body image, type of prosthesis as predictors of QoL.

CONCLUSION

This review identified modifiable and non-modifiable predictors of QoL in young amputees. Future research needs to focus on exploring the modifiable predictors of QoL as these are the aspects that can be improved to enhance QoL.

Bone-anchored prostheses for transfemoral amputation: a systematic review of outcomes, complications, patient experiences, and cost-effectiveness

Introduction

Bone-anchored prostheses (BAP) are an advanced reconstructive surgical approach for individuals who had transfemoral amputation and are unable to use the conventional socket-suspension systems for their prostheses. Access to this technology has been limited in part due to the lag between the start of a new procedure and the availability of evidence that is required before making decisions about widespread provision. This systematic review presents as a single resource up-to-date information on aspects most relevant to decision makers, i.e., clinical efficacy, safety parameters, patient experiences, and health economic outcomes of this technology.

Methods

A systematic search of the literature was conducted by an information specialist in PubMed, MEDLINE, Embase, CINAHL, Cochrane Library, the Core Collection of Web of Science, CADTH's Grey Matters, and Google Scholar up until May 31, 2023. Peer-reviewed original research articles on the outcomes of clinical effectiveness (health-related quality of life, mobility, and prosthesis usage), complications and adverse events, patient experiences, and health economic outcomes were included. The quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and ROBINS-I, as appropriate.

Results

Fifty studies met the inclusion criteria, of which 12 were excluded. Thirty-eight studies were finally included in this review, of which 21 reported on clinical outcomes and complications, 9 case series and 1 cohort study focused specifically on complications and adverse events, and 2 and 5 qualitative studies reported on patient experience and health economic assessments, respectively. The most common study design is a single-arm trial (pre-/post-intervention design) with varying lengths of follow-up.

Discussion

The clinical efficacy of this technology is evident in selected populations. Overall, patients reported increased health-related quality of life, mobility, and prosthesis usage post-intervention. The most common complication is a superficial or soft-tissue infection, and more serious complications are rare. Patient-reported experiences have generally been positive. Evidence indicates that bone-anchored implants for prosthesis fixation are cost-effective for those individuals who face significant challenges in using socket-suspension systems, although they may offer no additional advantage to those who are functioning well with their socket-suspended prostheses.

Mechanical load applied by Intraosseous Transcutaneous Amputation Prosthesis (ITAP) during walking on level and sloped treadmill: A case study

This proof of concept study presents a method to collect and analyse kinetic data from one participant with a transfemoral amputation fitted with a percutaneous osseointegrated implant walking on a level and sloped treadmill. We describe the construction of and results from a bespoke wireless six axis load cell built into one participant's prosthetic assembly. The load cell does not clinically compromise the participant in any way and is an initial milestone in the development of a light-weight wireless load cell for use with percutaneous osseointegrated implants. In this case, it is the first time that kinetic data from a participant fitted with an Intraosseous Transcutaneous Amputation Prosthesis has been published. We propose that the data can be used to model the load transfer to the host bone, with several clinically significant applications. The raw dynamic data are made available and quasi-static load cases for each functional phase of gait are presented. Peak forces obtained in the medio-lateral (X), cranio-caudal (Y) and antero-posterior (Z) axes over level ground respectively were -243.8 N (0.24 BW), 1321.5 N (1.31 BW) and -421.8 N (0.42 BW); uphill were -141.0 N (0.14 BW), 1604.2 N (1.59 BW), -498.1 N (0.49 BW); downhill were -206.0 N (0.20 BW), 1103.9 N (1.09 BW), -547.2 N (0.54 BW). The kinetics broadly followed able bodied gait patterns with some gait strategies consistent in participants with other implant designs or prosthetic socket connections, for example offloading the artificial limb downhill.