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Saleib GKM, Jonker MF, Van Vledder MG, Verhofstad MHJ, Paping MA, Leijendekkers RA, Van Waes OJF. Patients' Preferences for Bone-Anchored Prostheses After Lower-Extremity Amputation: A 2-Center Discrete Choice Experiment in The Netherlands (PREFER-BAP-1). J Bone Joint Surg Am 2024:00004623-990000000-01193. [PMID: 39241087 DOI: 10.2106/jbjs.24.00204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2024]
Abstract
BACKGROUND The rising popularity and use of a bone-anchored prosthesis (BAP) involving an osseointegrated implant for patients with lower-limb amputations experiencing socket-related issues have led to increased interest in the measurement of clinical and functional outcomes. However, the value of BAP treatment characteristics from the patient perspective has not yet been investigated. This study aimed to determine the relative importance of specific BAP characteristics, and the effect of complications in quality-of-life (QoL) points and monetary utility decrement (loss [€]), using a 2-center discrete choice experiment (DCE) conducted in The Netherlands. METHODS A DCE was developed that included the most salient characteristics of BAP treatment based on a review of the literature and qualitative and quantitative methods. The following characteristics were selected: QoL change, short- and long-term complications, osseointegrated implant survival, and out-of-pocket contributions (costs). Patients aged 18 to 99 years who were eligible for, or had already received, an osseointegrated implant were invited to participate, after informed consent, to elicit BAP treatment preferences. A Bayesian mixed logit model was used. RESULTS Two hundred and forty-seven completed surveys were collected; 64% of the patients were male, 73% had undergone a transfemoral amputation, and 33% had >36 months of experience with a BAP. Patients considered long-term complications and QoL the most important characteristics. Long-term complications were 3.4 times more important than short-term complications. Opting out was undesirable, and patients valued better and beneficial levels (associated with better outcomes) of BAP characteristics positively. Implant removal was the level with the greatest loss among all complications, at 1.15 (95% credible interval [CI], 0.96 to 1.38) QoL points and €16,940 (95% CI, €14,780 to €19,040) loss. CONCLUSIONS To our knowledge, this is the first study to use a DCE to elicit patients' preferences regarding BAP treatment, outcomes, and related complications; we found that patients strongly care about long-term complications. The results suggest that osseointegrated implant teams and policy-makers should consider these areas when proposing treatment protocols. Furthermore, policy and clinical guidelines for BAP treatment could be enhanced by our results with respect to patients' perspectives, management of patients' expectations, and associated losses in QoL points and monetary loss secondary to complications. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gabriel-Kyrillos M Saleib
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marcel F Jonker
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mark G Van Vledder
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Osseointegration Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maria A Paping
- Osseointegration Center Rotterdam, Rotterdam, The Netherlands
- Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Ruud A Leijendekkers
- Orthopedic Research Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Oscar J F Van Waes
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Osseointegration Center Rotterdam, Rotterdam, The Netherlands
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Rehani M, Stafinski T, Round J, Jones CA, Hebert JS. Bone-anchored prostheses for transfemoral amputation: a systematic review of outcomes, complications, patient experiences, and cost-effectiveness. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1336042. [PMID: 38628292 PMCID: PMC11018971 DOI: 10.3389/fresc.2024.1336042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/05/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
- Mayank Rehani
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Tania Stafinski
- Health Technology and Policy Unit, School of Public Health, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada
| | - C. Allyson Jones
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Jacqueline S. Hebert
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
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Miller A, Jeyapalina S, Agarwal JP, Beck JP. Association between blood markers and the progression of osseointegration in percutaneous prostheses patients-A pilot study. J Biomed Mater Res B Appl Biomater 2024; 112:e35398. [PMID: 38456331 DOI: 10.1002/jbm.b.35398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
Patients implanted with osseointegrated (OI) prosthetic systems have reported vastly improved upper and lower extremity prosthetic function compared with their previous experience with socket-suspension systems. However, OI systems have been associated with superficial and deep-bone infections and implant loosening due, in part, to a failure of the osseointegration process. Although monitoring the osseointegration using circulating biomarkers has clinical relevance for understanding the progression of osseointegration with these devices, it has yet to be established. Ten patients were enrolled in this study. Blood samples were collected at pre-selected times, starting before implantation surgery, and continuing to 12 months after the second surgery. Bone formation markers, bone resorption markers, and circulating amino acids were measured from blood samples. A linear mixed model was generated for each marker, incorporating patient ID and age with the normalized marker value as the response variable. Post hoc comparisons were made between 1 week before Stage 1 Surgery and all subsequent time points for each marker, followed by multiple testing corrections. Serial radiographic imaging of the residual limb containing the implant was obtained during follow-up, and the cortical index (CI) was calculated for the bone at the porous region of the device. Two markers of bone formation, specifically bone-specific alkaline phosphatase (Bone-ALP) and amino-terminal propeptide of type I procollagen (PINP), exhibited significant increases when compared with the baseline levels of unloaded residual bone prior to the initial surgery, and they subsequently returned to their baseline levels by the 12-month mark. Patients who experienced clinically robust osseointegration experienced increased cortical bone thickness at the porous coated region of the device. A medium correlation was observed between Bone-ALP and the porous CI values up to PoS2-M1 (p = .056), while no correlation was observed for PINP. An increase in bone formation markers and the lack of change observed in bone resorption markers likely reflect increased cortical bone formation induced by the end-loading design of the Utah OI device used in this study. A more extensive study is required to validate the correlation observed between Bone-ALP and porous CI values.
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Affiliation(s)
- Andrew Miller
- Research, George E. Wahlen Department of Veteran Affairs Medical Center, Salt Lake City, Utah, USA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah School of Engineering, Salt Lake City, Utah, USA
| | - Sujee Jeyapalina
- Research, George E. Wahlen Department of Veteran Affairs Medical Center, Salt Lake City, Utah, USA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah School of Engineering, Salt Lake City, Utah, USA
| | - Jayant P Agarwal
- Research, George E. Wahlen Department of Veteran Affairs Medical Center, Salt Lake City, Utah, USA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | - James Peter Beck
- Research, George E. Wahlen Department of Veteran Affairs Medical Center, Salt Lake City, Utah, USA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah, USA
- Department of Orthopaedics, University of Utah, School of Medicine, Salt Lake City, Utah, USA
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Alam SH, Hoellwarth J, Tetsworth K, Oomatia A, Taylor T, Al Muderis M. Development of an evidence-based diagnostic algorithm for infection in patients with transcutaneous osseointegration following amputation. J Bone Jt Infect 2024; 9:49-57. [PMID: 38600998 PMCID: PMC11002918 DOI: 10.5194/jbji-9-49-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/21/2023] [Indexed: 04/12/2024] Open
Abstract
Introduction: Transcutaneous osseointegration following amputation (TOFA) confers better mobility and quality of life for most patients versus socket prosthesis rehabilitation. Peri-TOFA infection remains the most frequent complication and lacks an evidence-based diagnostic algorithm. This study's objective was to investigate preoperative factors associated with positive intraoperative cultures among patients suspected of having peri-TOFA infection in order to create an evidence-based diagnostic algorithm. Methods: We conducted a retrospective study of 83 surgeries (70 patients) performed to manage suspected lower-extremity peri-TOFA infection at a specialty orthopedic practice and tertiary referral hospital in a major urban center. The diagnosis of infection was defined as positive intraoperative cultures. Preoperative patient history (fevers, subjective pain, increased drainage), physician examination findings (local cellulitis, purulent discharge, implant looseness), and laboratory data (white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and external swab culture) were evaluated for association with subsequent positive intraoperative cultures using regression and area under receiver-operator curve (AUC) modeling. Results: Peri-implant limb pain (highly correlated with infection), ESR > 30 (highly correlated against infection), positive preoperative swab (moderately correlated with infection), gross implant motion (moderately correlated against infection), and erythema or cellulitis of the transcutaneous region (mildly correlated with infection) were variables included in the best AUC model, which achieved an 85 % positive predictive value. Other clinical findings and laboratory values (notably CRP and WBC) were non-predictive of infection. Conclusions: This seminal investigation to develop a preoperative diagnostic algorithm for peri-TOFA infection suggests that the clinical examination remains paramount. Further evaluation of a wider spectrum of clinical, laboratory, and imaging data, consistently and routinely collected with prospective data techniques in larger cohorts of patients, is necessary to create a robust predictive algorithm.
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Affiliation(s)
- Shafaf Hasin Alam
- Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, Queensland, 4102, Australia
| | - Jason S. Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Atiya Oomatia
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Tristen N. Taylor
- Baylor College of Medicine, Houston TX. 1 Baylor Plaza, Houston, TX 77030, USA
| | - Munjed Al Muderis
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
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Saleib MKM, Van Lieshout EMM, Verduin D, De Graaff HP, Paping MA, Verhofstad MHJ, Van Waes OJF. Activities of daily living in lower limb amputees with a bone-anchored prosthesis: a retrospective case series with 24 months' follow-up. Acta Orthop 2023; 94:499-504. [PMID: 37830879 PMCID: PMC10573365 DOI: 10.2340/17453674.2023.19670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/28/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Little is known about the activities of daily living (ADL) of patients with a bone-anchored prosthesis (BAP). We aimed to objectively measure ADL without and with BAP during standard care of follow-up. Our secondary aim was to measure mobility and walking ability. PATIENTS AND METHODS Patients aged 18-99 years who underwent surgery for transfemoral or transtibial BAP between September 11, 2017, and February 11, 2021, were eligible for inclusion in this retrospective case series of patients with socket prosthesis. ADL was measured with a continuous recording activity monitor (hours [h]) before surgery, and at 6, 12, and 24 months with BAP. Mobility and walking ability were assessed by the Timed Up and Go test (TUG) (seconds [s]) and 6 Minute Walk Test (6MWT) (meters [m]), respectively. RESULTS 48 of the 57 eligible patients provided informed consent and were included. Their age was 59 (1st quartile to 3rd quartile 51-63) years. Total daily activity before BAP was 1.6 h (0.82-2.1) and increased to 2.1 h (1.4-2.5) at 6, 2.0 h (1.5-2.7) at 12, and 2.7 h (2.0-3.3) at 24 months with BAP. Daily walking increased from 1.3 h (0.79-1.9) before BAP to 1.8 h (1.6-2.3) at 6, to 1.7 h (1.2-2.4) at 12, and 2.0 h (1.6-2.6) at 24 months. Median TUG decreased from 12 s (9.1-14) before BAP to 8.9 s (7.7-10) at 24 months. Mean 6MWT increased from 272 m (SD 92) before BAP to 348 m (SD 68) at 24 months. CONCLUSION Objective measurements on ADL positively changed in patients with BAP. This effect was also seen in mobility and walking ability at 24 months.
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Affiliation(s)
- Michael-Kyrillos M Saleib
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam.
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam
| | - Dorien Verduin
- Rijndam Rehabilitation, Rotterdam; Osseointegration Center Rotterdam, Rotterdam, The Netherlands
| | - Heleen P De Graaff
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam; Osseointegration Center Rotterdam, Rotterdam, The Netherlands
| | - Maria A Paping
- Rijndam Rehabilitation, Rotterdam; Osseointegration Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam
| | - Oscar J F Van Waes
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam; Osseointegration Center Rotterdam, Rotterdam, The Netherlands
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Haidary A, Hoellwarth JS, Tetsworth K, Oomatia A, Al Muderis M. Transcutaneous osseointegration for amputees with burn trauma. Burns 2023; 49:1052-1061. [PMID: 36907716 DOI: 10.1016/j.burns.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/14/2023] [Accepted: 02/19/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Transcutaneous osseointegration for amputees (TOFA) surgically implants a prosthetic anchor into the residual limb's bone, enabling direct skeletal connection to a prosthetic limb and eliminating the socket. TOFA has demonstrated significant mobility and quality of life benefits for most amputees, but concerns regarding its safety for patients with burned skin have limited its use. This is the first report of the use of TOFA for burned amputees. METHODS Retrospective chart review was performed of five patients (eight limbs) with a history of burn trauma and subsequent osseointegration. The primary outcome was adverse events such as infection and additional surgery. Secondary outcomes included mobility and quality of life changes. RESULTS The five patients (eight limbs) had an average follow-up time of 3.8 ± 1.7 (range 2.1-6.6) years. We found no issues of skin compatibility or pain associated with the TOFA implant. Three patients underwent subsequent surgical debridement, one of whom had both implants removed and eventually reimplanted. K-level mobility improved (K2 +, 0/5 vs 4/5). Other mobility and quality of life outcomes comparisons are limited by available data. CONCLUSION TOFA is safe and compatible for amputees with a history of burn trauma. Rehabilitation capacity is influenced more by the patient's overall medical and physical capacity than their specific burn injury. Judicious use of TOFA for appropriately selected burn amputees seems safe and merited.
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Affiliation(s)
- Amanullah Haidary
- Western Sydney University School of Medicine, Building 30 Campbelltown Campus, Campbelltown, NSW, Australia.
| | - Jason S Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia.
| | - Atiya Oomatia
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia.
| | - Munjed Al Muderis
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia.
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Hoellwarth JS, Oomatia A, Tetsworth K, Vrazas E, Al Muderis M. Bone density changes after five or more years of unilateral lower extremity osseointegration: Observational cohort study. Bone Rep 2023; 18:101682. [PMID: 37205925 PMCID: PMC10189091 DOI: 10.1016/j.bonr.2023.101682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/21/2023] Open
Abstract
Context Rehabilitation following lower extremity amputation presents multiple challenges, many related to the traditional prosthesis (TP) socket. Without skeletal loading, bone density also rapidly decreases. Transcutaneous osseointegration for amputees (TOFA) surgically implants a metal prosthesis attachment directly into the residual bone, facilitating direct skeletal loading. Quality of life and mobility are consistently reported to be significantly superior with TOFA than TP. Objective To investigate how femoral neck bone mineral density (BMD, g/cm2) changes for unilateral transfemoral and transtibial amputees at least five years following single-stage press-fit osseointegration. Methods Registry review was performed of five transfemoral and four transtibial unilateral amputees who had dual x-ray absorptiometry (DXA) performed preoperatively and after at least five years. The average BMD was compared using Student's t-test (significance p < .05). First, all nine Amputated versus Intact limbs. Second, the five patients with local disuse osteoporosis (ipsilateral femoral neck T-score < -2.5) versus the four whose T-score was greater than -2.5. Results The average Amputated Limb BMD was significantly less than the Intact Limb, both Before Osseointegration (0.658 ± 0.150 vs 0.929 ± 0.089, p < .001) and After Osseointegration (0.720 ± 0.096 vs 0.853 ± 0.116, p = .018). The Intact Limb BMD decreased significantly during the study period (0.929 ± 0.089 to 0.853 ± 0.116, p = .020), while the Amputated Limb BMD increased a not statistically significant amount (0.658 ± 0.150 to 0.720 ± 0.096, p = .347). By coincidence, all transfemoral amputees had local disuse osteoporosis (BMD 0.545 ± 0.066), and all transtibial patients did not (BMD 0.800 ± 0.081, p = .003). The local disuse osteoporosis cohort eventually had a greater average BMD (not statistically significant) than the cohort without local disuse osteoporosis (0.739 ± 0.100 vs 0.697 ± 0.101, p = .556). Conclusions Single-stage press-fit TOFA may facilitate significant BMD improvement to unilateral lower extremity amputees with local disuse osteoporosis.
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Affiliation(s)
- Jason Shih Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Center, Hospital for Special Surgery, 535 East 70th Street, New York 10021, NY, USA
- Corresponding author.
| | - Atiya Oomatia
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Elisabeth Vrazas
- Macquarie School of Medicine Macquarie University, Suite 305, Level 3/2 Technology Pl, Macquarie Park, NSW 2109, Australia
| | - Munjed Al Muderis
- Limb Reconstruction Centre, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
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Benca E, Ferrante B, Unger E, Strassl A, Hirtler L, Brånemark R, Windhager R, Hobusch GM. Patient-Specific Guides for Accurate and Precise Positioning of Osseointegrated Implants in Transfemoral Amputations: A Proof-of-Concept In Vitro Study. Medicina (B Aires) 2023; 59:medicina59030429. [PMID: 36984430 PMCID: PMC10051876 DOI: 10.3390/medicina59030429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/24/2023] Open
Abstract
Background and Objectives: The treatment of transfemoral amputees using osseointegrated implants for prosthetic anchorage requires accurate implant positioning when using threaded bone-anchoring implants due to the curvature of the femur and the risk of cortical penetration in misaligned implants. This study investigated the accuracy and precision in implant positioning using additively manufactured case-specific positioning guides. Materials and Methods: The geometry and density distribution of twenty anatomic specimens of human femora were assessed in quantitative computed tomography (QCT) scanning. The imaging series were used to create digital 3D specimen models, preoperatively plan the optimal implant position and manufacture specimen-specific positioning guides. Following the surgical bone preparation and insertion of the fixture (threaded bone-anchoring element) (OPRA; Integrum AB, Mölndal, Sweden), a second QCT imaging series and 3D model design were conducted to assess the operatively achieved implant position. The 3D models were registered and the deviations of the intraoperatively achieved implant position from the preoperatively planned implant position were analyzed as follows. The achieved, compared to the planned implant position, was presented as resulting mean hip abduction or adduction (A/A) and extension or flexion (E/F) and mean implant axis offset in medial or lateral (M/L) and anterior or posterior (A/P) direction measured at the most distal implant axis point. Results: The achieved implant position deviated from the preoperative plan by 0.33 ± 0.33° (A/A) and 0.68 ± 0.66° (E/F) and 0.62 ± 0.55 mm (M/L) and 0.68 ± 0.56 mm (A/P), respectively. Conclusions: Using case-specific guides, it was feasible to achieve not only accurate but also precise positioning of the implants compared to the preoperative plan. Thus, their design and application in the clinical routine should be considered, especially in absence of viable alternatives.
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Affiliation(s)
- Emir Benca
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-40980
| | - Beatrice Ferrante
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Ewald Unger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas Strassl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Lena Hirtler
- Division of Anatomy, Centre for Anatomy and Cell Biology, Medical University of Vienna, 1090 Vienna, Austria
| | - Rickard Brånemark
- Department of Orthopaedics, Gothenburg University, 40530 Gothenburg, Sweden
- Biomechatronics Group, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Gerhard M. Hobusch
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria
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Krause K, Richter K, Beyer T, Aschoff HH, Fischer DC, Mittlmeier T. Elective transfemoral amputation and simultaneous implantation of a transcutaneous osseointegrated prosthesis stem as salvage treatment after knee joint arthrodesis with poor function: A case report. Front Surg 2022; 9:918303. [PMID: 36111228 PMCID: PMC9469837 DOI: 10.3389/fsurg.2022.918303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Surgical reconstruction of anterior cruciate ligament ruptures is a well-established procedure, and although it is for the vast majority of patients without severe complications, total knee joint arthroplasty, arthrodesis of the knee, and finally transfemoral amputation have to be considered in the worst-case scenario. The case We report a case of a patient with a 13-year history of recurrent failure after anterior cruciate ligament reconstruction. She claimed she had severely impaired mobility secondary to a knee joint arthrodesis via an Ilizarov circular frame 2 years ago and chronic immobilizing pain, making a permanent medication with opioids necessary. She was aware of the therapeutic options and asked for transfemoral amputation and concomitant supply with a transcutaneous osseointegrated prosthesis system (TOPS). Procedures After careful evaluation and clinical work-up, the indication for transfemoral amputation and concomitant implantation of the prosthetic stem into the femoral cavity was secured. Six weeks after the creation of the stoma for coupling of the artificial limb and onset of physiotherapy, balance and gait training were scheduled. Full weight-bearing and walking without crutches were allowed 12 weeks after the index procedure. This sequence of events was paralleled by a series of pre-defined examinations, that is, questionnaires and mobility scores addressing the situation of transfemoral amputees, as well as standardized clinical gait analysis. The latter was performed before surgery and 6, 9, and 18 months after the index procedure. Outcome At the time of the index procedure, opioids could be tapered to zero, and the patient quickly regained her walking abilities during the rehabilitation period. Clinical gait analysis confirmed the restoration of bilateral symmetry by mutual approximation of kinematics and kinetics to a standard gait pattern. Conclusion The outcome of our patient strengthens the therapeutic potential of a unilateral transfemoral amputation in combination with TOPS. Nevertheless, long-term follow-up is necessary to detect future complications of this approach.
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Affiliation(s)
- Katharina Krause
- Department of Traumatology, Hand and Reconstructive Surgery, University Medical Centre Rostock, Rostock, Germany
- Department of Pediatrics, University Medical Centre Rostock, Rostock, Germany
| | - Katherina Richter
- Department of Traumatology, Hand and Reconstructive Surgery, University Medical Centre Rostock, Rostock, Germany
- Department of Pediatrics, University Medical Centre Rostock, Rostock, Germany
| | - Thomas Beyer
- Department of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Rostock, Germany
| | - Horst Heinrich Aschoff
- Department of Traumatology, Hand and Reconstructive Surgery, University Medical Centre Rostock, Rostock, Germany
| | | | - Thomas Mittlmeier
- Department of Traumatology, Hand and Reconstructive Surgery, University Medical Centre Rostock, Rostock, Germany
- Correspondence: Thomas Mittlmeier
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10
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Ghadhab S, Bilem I, Guay-Bégin AA, Chevallier P, Auger FA, Ruel J, Pauthe E, Laroche G. Fibronectin grafting to enhance skin sealing around transcutaneous titanium implant. J Biomed Mater Res A 2021; 109:2187-2198. [PMID: 33931940 DOI: 10.1002/jbm.a.37204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/09/2021] [Accepted: 04/16/2021] [Indexed: 11/08/2022]
Abstract
Intraosseous transcutaneous amputation prosthesis is a new approach in orthopedic implants that overcomes socket prosthesis problems. Its long-term performance requires a tight skin-implant seal to prevent infections. In this study, fibronectin (Fn), a widely used adhesion protein, was adsorbed or grafted onto titanium alloy. Fn grafting was performed using two different linking arms, dopamine/glutaric anhydride or phosphonate. The characterization of Fn-modified surfaces showed that Fn grating via phosphonate has led to the highest amount of Fn cell-binding site (RGD, arginine, glycine, and aspartate) available on the surface. Interestingly, cell culture studies revealed a strong correlation between the amount of available RGD ligands and cellular behavior, since enhanced proliferation and spreading of fibroblasts were noticed on Fn-grafted surfaces via phosphonate. In addition, an original in vitro mechanical test, inspired from the real situation, to better predict clinical outcomes after implant insertion, has been developed. Tensile test data showed that the adhesion strength of a bio-engineered dermal tissue was significantly higher around Fn-grafted surfaces via phosphonate, as compared to untreated surfaces. This study sheds light on the importance of an appropriate selection of the linking arm to tightly control the spatial conformation of biomolecules on the material surface, and consequently cell interactions at the interface tissue/implant.
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Affiliation(s)
- Souhaila Ghadhab
- Laboratoire d'Ingénierie de Surface (LIS), Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay⎜, Québec, Canada.,Centre de Recherche sur les Matériaux Avancés (CERMA), Département de Génie des Mines, de la Métallurgie et des Matériaux, Université Laval, Québec, Canada
| | - Ibrahim Bilem
- Laboratoire d'Ingénierie de Surface (LIS), Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay⎜, Québec, Canada
| | - Andrée-Anne Guay-Bégin
- Laboratoire d'Ingénierie de Surface (LIS), Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay⎜, Québec, Canada
| | - Pascale Chevallier
- Laboratoire d'Ingénierie de Surface (LIS), Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay⎜, Québec, Canada.,Centre de Recherche sur les Matériaux Avancés (CERMA), Département de Génie des Mines, de la Métallurgie et des Matériaux, Université Laval, Québec, Canada
| | - François A Auger
- CHU de Québec-Université Laval, LOEX, Aile-R, 1401 18ième Rue, Québec, Québec, G1J 1Z4, Canada
| | - Jean Ruel
- Département de Génie mécanique, Université Laval, Québec, Canada
| | - Emmanuel Pauthe
- Biomaterials for Health Research Group, ERRMECe, Équipe de recherche sur les Relations Matrice Extracellulaire-Cellules (EA1391), Institut des matériaux I-MAT (FD4122), CY Tech, CY Cergy Paris University, Maison Internationale de la Recherche (MIR), Cergy, France
| | - Gaétan Laroche
- Laboratoire d'Ingénierie de Surface (LIS), Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay⎜, Québec, Canada.,Centre de Recherche sur les Matériaux Avancés (CERMA), Département de Génie des Mines, de la Métallurgie et des Matériaux, Université Laval, Québec, Canada
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11
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Haque R, Al-Jawazneh S, Hoellwarth J, Akhtar MA, Doshi K, Tan YC, Lu WYR, Roberts C, Al Muderis M. Osseointegrated reconstruction and rehabilitation of transtibial amputees: the Osseointegration Group of Australia surgical technique and protocol for a prospective cohort study. BMJ Open 2020; 10:e038346. [PMID: 33082192 PMCID: PMC7577069 DOI: 10.1136/bmjopen-2020-038346] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Lower extremity amputation uniformly impairs a person's vocational, social and recreational capacity. Rehabilitation in traditional socket prostheses (TSP) is associated with a spectrum of complications involving the socket-residuum interface which lead to reduced prosthetic use and quality of life. Osseointegration has recently emerged as a novel concept to overcome these complications by eliminating this interface and anchoring the prosthesis directly to bone. Though the complications of TSPs affect both transfemoral and transtibial amputees, Osseointegration has been predominantly performed in transfemoral ones assuming a greater benefit/risk ratio. However, as the safety of the procedure has been established, we intend to extend the concept to transtibial amputees and document the outcomes. METHODS AND ANALYSIS This is protocol for a prospective cohort study, with patient enrolment started in 2014 and expected to be completed by 2022. The inclusion criteria are age over 18 years, unilateral, bilateral and mixed transtibial amputation and experiencing socket-related problems. All patients receive osseointegrated implants, the type of which depend on the length of the residuum and quality of bone, which are press-fitted into the residual bone. Objective functional outcomes comprising 6-Minute Walk Test, Timed Up-and-Go test and K-level, subjective patient-reported-quality-of-life outcomes (Short Form Health Survey 36, daily prosthetic wear hours, prosthetic wear satisfaction) and adverse events are recorded preoperatively and at postoperative follow-up intervals of 3, 6, 12 months and yearly, and compared with the preoperative values using appropriate statistical tests. Multivariable multilevel logistic regression will be performed with a focus to identify factors associated with outcomes and adverse events, specifically infection, periprosthetic fracture, implant fracture and aseptic loosening. ETHICS AND DISSEMINATION The Ethics approval for the study has been received from the University of Notre Dame, Sydney, Australia (014153S). The outcomes of this study will be disseminated by publications in peer-reviewed academic journals and scientific presentations at relevant orthopaedic conferences.
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Affiliation(s)
- Russel Haque
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Shakib Al-Jawazneh
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | | | - Karan Doshi
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Yao Chang Tan
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - William Yenn-Ru Lu
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Claudia Roberts
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
| | - Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
- The Limb Reconstruction Discipline, Macquarie University Hospital, North Ryde BC, New South Wales, Australia
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12
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Harandi VJ, Ackland DC, Haddara R, Cofré Lizama LE, Graf M, Galea MP, Lee PVS. Individual muscle contributions to hip joint-contact forces during walking in unilateral transfemoral amputees with osseointegrated prostheses. Comput Methods Biomech Biomed Engin 2020; 23:1071-1081. [PMID: 32691622 DOI: 10.1080/10255842.2020.1786686] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Direct skeletal attachment of prostheses in transfemoral amputees circumvents skin-interface complications associated with conventional sockets; however, joint pain and musculoskeletal disease is known to occur postoperatively. This study quantified hip contact forces and the roles of individual muscles in producing hip contact forces during walking in transfemoral amputees with osseointegrated prostheses. Musculoskeletal models were developed for four transfemoral amputees. Gluteus maximus and gluteus medius were the major contributors to the hip contact forces, and the intact limb hip muscles demonstrated greater contributions to hip contact forces than those of the residual limb. The findings may be useful for mitigating walking asymmetry.
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Affiliation(s)
| | | | - Raneem Haddara
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - L Eduardo Cofré Lizama
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Mark Graf
- Department of Allied Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Mary Pauline Galea
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Peter Vee Sin Lee
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
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13
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14
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Dakhil N, Evin M, Llari M, Mo F, Thefenne L, Liu T, Behr M. Is skin pressure a relevant factor for socket assessment in patients with lower limb amputation? Technol Health Care 2019; 27:669-677. [PMID: 31033471 DOI: 10.3233/thc-191637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prosthetic rehabilitation improves the overall quality of life of patients, despite discomfort and medical complications. No quantitative assessment of prosthesis-patient interaction is used in routine protocols and prosthesis quality still results from the manufacturer's know-how. OBJECTIVE Our objective is to investigate whether pressure can be a relevant factor for assessing socket adequacy. METHODS A total of 8 transtibial amputee volunteers took part in this experimental study. The protocol included static standing and 2 minutes walking tests while the stump-to-socket interface pressures were measured. Questionnaires on comfort and pain were also conducted. RESULTS During static standing test, maximum pressures were recorded in the proximal region of the leg, with a peak value reaching 121.1 ± 31.6 kPa. During dynamic tests, maximum pressures of 254.1 ± 61.2 kPa were recorded during the loading phase of the step. A significant correlation was found between the pain score and static maximum recorded pressure (r= 0.81). CONCLUSIONS The protocol proposed and evaluated in this study is a repeatable, easy-to-set quantified analysis of the patient to socket interaction while standing and walking. This approach is likely to improve feedback for prosthesis manufacturers and consequently the overall design of prostheses.
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Affiliation(s)
- Nawfal Dakhil
- Aix-Marseille University, IFSTTAR, Laboratoire de Biomécanique Appliquée, Marseille, France
| | - Morgane Evin
- Aix-Marseille University, IFSTTAR, Laboratoire de Biomécanique Appliquée, Marseille, France
| | - Maxime Llari
- Aix-Marseille University, IFSTTAR, Laboratoire de Biomécanique Appliquée, Marseille, France
| | - Fuhao Mo
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan, China
| | - Laurent Thefenne
- Service de Médecine Physique et Réadaptation, Hôpital Laveran, Marseille, France
| | - Tang Liu
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Michel Behr
- Aix-Marseille University, IFSTTAR, Laboratoire de Biomécanique Appliquée, Marseille, France
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15
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Complications of bone-anchored prostheses for individuals with an extremity amputation: A systematic review. PLoS One 2018; 13:e0201821. [PMID: 30092081 PMCID: PMC6084937 DOI: 10.1371/journal.pone.0201821] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study aimed to provide an overview of device-related complications occurring in individuals with an upper or lower extremity amputation treated with a screw, press-fit or other type of bone-anchored implant as well as interventions related to these complications. METHOD A systematic literature search was conducted in the MEDLINE, Cochrane, EMBASE, CINAHL and Web of Science databases. The included studies reported on device-related complications and interventions occurring in individuals with bone-anchored prostheses. The outcomes evaluated were death, infection, bone/device breakage, implant loosening, soft tissue complications, systemic events, antibiotic and surgical treatment. Subgroup analyses were performed for the following groups: a) implant type (screw, press-fit and other types of implants) and b) level of amputation (transfemoral, transtibial and upper extremity amputation). RESULTS Of 309 studies, 12 cohort studies were eligible for inclusion, all of which had methodological shortcomings and 12 studies were excluded due to complete overlap of patient data. Implant infection were rare in certain transfemoral implants (screw: 2-11%, press-fit: 0-3%, Compress: 0%) but common in transtibial implants (29%). The same was observed for implant loosening, in transfemoral (screw: 6%, press-fit: 0-3%, Compress: 0%), transtibial implants (29%) as well as for upper extremity implants (13-23%). Intramedullary device breakage were rare in transfemoral implants (screw: 0%, press-fit: 1%, Compress: unknown) but frequent in individuals with transradial implants (27%) and absent in transtibial implants. Soft tissue infections and complications were common and underreported in most articles. CONCLUSIONS Major complications (e.g. implant infection, implant loosening and intramedullary device breakage) are rare in transfemoral bone-anchored prosthesis and seem to occur less frequently in individuals with press-fit implants. Minor complications, such as soft tissue infections and complications, are common but are substantially influenced by the learning curve, implant design and surgical technique. Data for patients treated with a transtibial, upper extremity or Compress implant are underreported, precluding definitive conclusions. There is a need for either an international database to report on or a standard core set of complications as well as the need to follow classification systems that result in unequivocal data.
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16
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Leijendekkers RA, Marra MA, Ploegmakers MJM, Van Hinte G, Frölke JP, Van De Meent H, Staal JB, Hoogeboom TJ, Verdonschot N. Magnetic-resonance-imaging-based three-dimensional muscle reconstruction of hip abductor muscle volume in a person with a transfemoral bone-anchored prosthesis: A feasibility study. Physiother Theory Pract 2018; 35:495-504. [PMID: 29589767 DOI: 10.1080/09593985.2018.1453902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Persons with transfemoral amputation typically have severe muscle atrophy of the residual limb. The effect of bone-anchored prosthesis use on existing muscle atrophy is unknown. A potentially feasible method to evaluate this is magnetic resonance imaging (MRI)-based three-dimensional (3D) muscle reconstruction. We aimed to (1) examine the feasibility of MRI-based 3D muscle reconstruction technique in a person with a cobalt-chrome-molybdenum transfemoral bone-anchored prosthesis; and (2) describe the change of hip abductor muscle volume over time. METHODS In this single case, 1-year follow-up study we reconstructed the 3D hip abductor muscle volumes semiautomatically from MRI scans at baseline, 6- and 12-month follow-up. The number of adverse events, difficulties in data analysis, time investment and participants' burden determined the level of feasibility. RESULTS We included a man (70 years) with a transfemoral amputation who received a bone-anchored prosthesis after 52 years of socket prosthesis use. No adverse events occurred. The accuracy of the 3D reconstruction was potentially reduced by severe adipose tissue interposition. Data analysis was time-intensive (115 h). Participants' burden was limited to 3-h time investment. Compared to baseline, the total hip abductor volume of both the residual limb (6 month: 5.5%; 12 month: 7.4%) and sound limb (6 month: 7.8%; 12 month: 5.5%) increased. CONCLUSION The presented technique appears feasible to follow muscle volume changes over time in a person with a cobalt-chrome-molybdenum transfemoral bone-anchored prosthesis in an experimental setting. Future research should focus on analysis of muscle tissue composition and the feasibility in bone-anchored prostheses of other alloys.
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Affiliation(s)
- Ruud A Leijendekkers
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , Netherlands
| | - Marco A Marra
- b Radboud Institute for Health Sciences, Orthopaedic Research Laboratory , Radboud University Medical Centre , Nijmegen , Netherlands
| | - Marieke J M Ploegmakers
- c Department of Radiology and Nuclear Medicine , Radboud University Medical Centre , Nijmegen , Netherlands
| | - Gerben Van Hinte
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , Netherlands
| | - Jan Paul Frölke
- d Department of Surgery , Radboud University Medical Centre , Nijmegen , Netherlands
| | - Hendrik Van De Meent
- e Department of Rehabilitation , Radboud University Medical Centre , Nijmegen , Netherlands
| | - J Bart Staal
- f Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre , Nijmegen , Netherlands.,g Research group Musculoskeletal Rehabilitation, HAN University of Applied Sciences , Nijmegen , Netherlands
| | - Thomas J Hoogeboom
- f Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre , Nijmegen , Netherlands
| | - Nico Verdonschot
- b Radboud Institute for Health Sciences, Orthopaedic Research Laboratory , Radboud University Medical Centre , Nijmegen , Netherlands.,h Laboratory for Biomechanical Engineering, University of Twente , Enschede , Netherlands
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17
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Hansen CH, Hansen RL, Jørgensen PH, Petersen KK, Norlyk A. The process of becoming a user of an osseointegrated prosthesis following transfemoral amputation: a qualitative study. Disabil Rehabil 2017; 41:276-283. [PMID: 28960110 DOI: 10.1080/09638288.2017.1385651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate what characterizes the process of becoming a user of an osseointegrated prosthesis following transfemoral amputation. METHOD The study is based on the descriptive phenomenological framework Reflective Lifeworld Research. Data were collected through in-depth interviews with seven participants who had undergone transfemoral implant surgery and currently used their osseointegrated prosthesis. Data were analyzed according to the guidelines given in Reflective Lifeworld Research. RESULTS The essential meaning of becoming a user of an osseointegrated prosthesis is characterized by determination to achieve rehabilitation results as well as a struggle to get familiar with the new prosthesis. When familiar with the prosthesis, participants begin to experience radical improvements in their everyday life, compared to their life with the socket suspended prosthesis. The essential meaning is elaborated on in four constituents: Determination to achieve rehabilitation results with the short training prosthesis, struggling to get familiar with the osseointegrated prosthesis, experiencing improvements in everyday life and reconnecting with one's prior self-perception. CONCLUSION All the participants experienced increased action space and a more positive outlook on life. However, it took determination and stamina to become a user of an osseointegrated prosthesis, and participants faced several challenges throughout this process. Consequently, it remains important to raise awareness of the difficulties faced during this process. Implications for Rehabilitation The findings from this study suggest an increased healthcare support to users of an transfemoral osseointegrated prosthesis in the period of rehabilitation and adjustment, as the results of being able to use the osseointegrated prosthesis may outweigh the obstacles of getting there. Implementation of long-term follow-up and psychosocial support initiatives may improve the adjustment process following osseointegration. Support of patients with an osseointegrated prosthesis may be facilitated through formation of specific rehabilitation groups together with increased use of information technology such as social media and relevant online communities which provide forums for interaction and dialog with people in similar situations.
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Affiliation(s)
- Cathrine Hjorth Hansen
- a Section for Nursing, Department of Public Health , Aarhus University , Aarhus , Denmark
| | - Rehne Lessman Hansen
- b Department of Orthopaedic Surgery , University Hospital of Aarhus , Aarhus , Denmark
| | | | - Klaus Kjaer Petersen
- b Department of Orthopaedic Surgery , University Hospital of Aarhus , Aarhus , Denmark
| | - Annelise Norlyk
- c Section for Nursing, Department of Public Health , Aarhus University/VIA University College , Aarhus , Denmark
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18
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Davenport P, Noroozi S, Sewell P, Zahedi S. Systematic Review of Studies Examining Transtibial Prosthetic Socket Pressures with Changes in Device Alignment. J Med Biol Eng 2017; 37:1-17. [PMID: 28286462 PMCID: PMC5325859 DOI: 10.1007/s40846-017-0217-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/30/2016] [Indexed: 11/27/2022]
Abstract
Suitable lower-limb prosthetic sockets must provide an adequate distribution of the pressures created from standing and ambulation. A systematic search for articles reporting socket pressure changes in response to device alignment perturbation was carried out, identifying 11 studies. These were then evaluated using the American Academy of Orthotists and Prosthetists guidelines for a state-of-the-science review. Each study used a design where participants acted as their own controls. Results were available for 52 individuals and five forms of alignment perturbation. Four studies were rated as having moderate internal and external validity, the remainder were considered to have low validity. Significant limitations in study design, reporting quality and in representation of results and the suitability of calculations of statistical significance were evident across articles. Despite the high inhomogeneity of study designs, moderate evidence supports repeatable changes in pressure distribution for specific induced changes in component alignment. However, there also appears to be a significant individual component to alignment responses. Future studies should aim to include greater detail in the presentation of results to better support later meta-analyses.
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Affiliation(s)
- Philip Davenport
- Department of Design and Engineering, Bournemouth University, Poole, UK
| | | | | | - Saeed Zahedi
- Chas A Blatchford and Sons Ltd., Basingstoke, UK
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19
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Leijendekkers RA, van Hinte G, Nijhuis-van der Sanden MW, Staal JB. Gait rehabilitation for a patient with an osseointegrated prosthesis following transfemoral amputation. Physiother Theory Pract 2017; 33:147-161. [PMID: 28045571 DOI: 10.1080/09593985.2016.1265620] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In patients with a transfemoral amputation socket-related problems are associated with reduced prosthetic use, activity, and quality of life. Furthermore, gait asymmetries are present that may explain secondary complaints. Bone-anchored prostheses (BAPs) may help these patients. Two types of BAP are available, screw and press-fit implants. Rehabilitation following surgery for a press-fit BAP is poorly described. PURPOSE To describe a rehabilitation program designed to minimize compensation strategies and increase activity using a case-report of an active, 70-year-old man with a traumatic transfemoral amputation who had used a socket prosthesis for 52 years and received a press-fit BAP [Endo-Exo Femoral Prosthesis - EEFP]. INTERVENTION A 13-week physiotherapy program. OUTCOMES Outcomes were assessed before surgery, at the end of rehabilitation, and six-month and one-year follow-ups. After rehabilitation gait had improved, the patient had more arm movement, more pelvic shift, less hip rotation during swing phase on the prosthetic side, and absence of vaulting on the sound side. Isometric hip abductor strength was 15% higher on the sound side and 16% higher on the prosthetic side, and walking distance increased from 200 m to 1500 m. At the six-month follow-up, the patient had lower back complications and reduced hip abductor strength and walking distance. At one-year follow-up, walking distance had recovered to 1000 m and gait pattern had improved again, with yielding and absence of terminal impact on the prosthetic side. CONCLUSION The described rehabilitation program may be an effective method of improving gait in patients with an EEFP even after long-term socket usage.
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Affiliation(s)
- Ruud A Leijendekkers
- a Radboud University Medical Center , Department of Orthopedics, Physical Therapy , Nijmegen , The Netherlands
| | - Gerben van Hinte
- a Radboud University Medical Center , Department of Orthopedics, Physical Therapy , Nijmegen , The Netherlands
| | - Maria Wg Nijhuis-van der Sanden
- a Radboud University Medical Center , Department of Orthopedics, Physical Therapy , Nijmegen , The Netherlands.,b Radboud University Medical Center , Scientific Center for Quality of Care , Nijmegen , The Netherlands
| | - J Bart Staal
- b Radboud University Medical Center , Scientific Center for Quality of Care , Nijmegen , The Netherlands
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20
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Leijendekkers RA, Staal JB, van Hinte G, Frölke JP, van de Meent H, Atsma F, Nijhuis-van der Sanden MWG, Hoogeboom TJ. Long-term outcomes following lower extremity press-fit bone-anchored prosthesis surgery: a 5-year longitudinal study protocol. BMC Musculoskelet Disord 2016; 17:484. [PMID: 27876030 PMCID: PMC5120460 DOI: 10.1186/s12891-016-1341-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with lower extremity amputation frequently suffer from socket-related problems. This seriously limits prosthesis use, level of activity and health-related quality of life (HRQoL). An additional problem in patients with lower extremity amputation are asymmetries in gait kinematics possibly accounting for back pain. Bone-anchored prostheses (BAPs) are a possible solution for socket-related problems. Knowledge concerning the level of function, activity and HRQoL after surgery is limited. The aims of this ongoing study are to: a) describe changes in the level of function, activity, HRQoL and satisfaction over time compared to baseline before surgery; b) examine potential predictors for changes in kinematics, prosthetic use, walking ability, HRQoL, prosthesis comfort over time and level of stump pain at follow-up; c) examine potential mechanisms for change of back pain over time by identifying determinants, moderators and mediators. METHODS/DESIGN A prospective 5-year longitudinal study with multiple follow-ups. All adults, between May 2014 and May 2018, with lower extremity amputation receiving a press-fit BAP are enrolled consecutively. Patients with socket-related problems and trauma, tumour resection or stable vascular disease as cause of primary amputation will be included. Exclusion criteria are severe cognitive or psychiatric disorders. Follow-ups are planned at six-months, one-, two- and five-years after BAP surgery. The main study outcomes follow, in part, the ICF classification: a) level of function defined as kinematics in coronal plane, hip abductor strength, prosthetic use, back pain and stump pain; b) level of activity defined as mobility level and walking ability; c) HRQoL; d) satisfaction defined as prosthesis comfort and global perceived effect. Changes over time for the continuous outcomes and the dichotomized outcome (back pain) will be analysed using generalised estimating equations (GEE). Multivariate GEE will be used to identify potential predictors for change of coronal plane kinematics, prosthetic use, walking ability, HRQoL, prosthesis comfort and for the level of post-operative stump pain. Finally, potential mechanisms for change in back pain frequency will be explored using coronal plane kinematics as a potential determinant, stump pain as moderator and hip abductor strength as mediator. DISCUSSION This study may identify predictors for clinically relevant outcome measures. TRIAL REGISTRATION NTR5776 . Registered 11 March 2016, retrospectively registered.
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Affiliation(s)
- Ruud A Leijendekkers
- Department of Orthopaedics, Physical Therapy, Radboud university medical centre, Geert Grooteplein-Zuid 10, 6525GA, Nijmegen, The Netherlands.
- Master Clinical Health Sciences, Program in Physical Therapy Science, University Utrecht and University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - J Bart Staal
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical centre, Nijmegen, The Netherlands
- Research group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Gerben van Hinte
- Department of Orthopaedics, Physical Therapy, Radboud university medical centre, Geert Grooteplein-Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Jan Paul Frölke
- Department of Surgery, Radboud university medical centre, Nijmegen, The Netherlands
| | - Hendrik van de Meent
- Department of Rehabilitation, Radboud university medical centre, Nijmegen, The Netherlands
| | - Femke Atsma
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical centre, Nijmegen, The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Department of Orthopaedics, Physical Therapy, Radboud university medical centre, Geert Grooteplein-Zuid 10, 6525GA, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical centre, Nijmegen, The Netherlands
- Department of Rehabilitation, Radboud university medical centre, Nijmegen, The Netherlands
| | - Thomas J Hoogeboom
- Radboud Institute for Health Sciences, IQ healthcare, Radboud university medical centre, Nijmegen, The Netherlands
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21
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Leijendekkers RA, van Hinte G, Frölke JP, van de Meent H, Nijhuis-van der Sanden MWG, Staal JB. Comparison of bone-anchored prostheses and socket prostheses for patients with a lower extremity amputation: a systematic review. Disabil Rehabil 2016; 39:1045-1058. [PMID: 27494092 DOI: 10.1080/09638288.2016.1186752] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to provide an overview of a) the used measurement instruments in studies evaluating effects on quality of life (QoL), function, activity and participation level in patients with a lower extremity amputation using bone-anchored prostheses compared to socket prostheses and b) the effects themselves. METHOD A systematic literature search was conducted in MEDLINE, Cochrane, EMBASE, CINAHL and Web of Science. Included studies compared QoL, function, activity and/or participation level in patients with bone-anchored or socket prostheses. A best-evidence synthesis was performed. RESULTS Out of 226 studies, five cohort and two cross-sectional studies were eligible for inclusion, all had methodological shortcomings. These studies used 10 different measurement instruments and two separate questions to assess outcome. Bone-anchored prostheses were associated with better condition-specific QoL and better outcomes on several of the physical QoL subscales, outcomes on the physical bodily pain subscale were inconclusive. Outcomes on function and activity level increased, no change was found at participation level. The level of evidence was limited. CONCLUSIONS There is a need for a standard set of instruments. There was limited evidence that bone-anchored prostheses resulted in higher QoL, function and activity levels than socket prostheses, in patients with socket-related problems. Implications for Rehabilitation Use of bone-anchored prostheses in combination with intensive outpatient rehabilitation may improve QoL, function and activity level compared with socket prosthesis use in patients with a transfemoral amputation and socket-related problems. All clinicians and researchers involved with bone-anchored prostheses should use and publish data on QoL, function, activity and participation level. There needs to be an agreement on a standard set of instruments so that interventions for patients with a lower extremity amputation are assessed consistently.
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Affiliation(s)
- Ruud A Leijendekkers
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands.,b Master Clinical Health Sciences, Program in Physical Therapy Science , University Utrecht and University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Gerben van Hinte
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Jan Paul Frölke
- c Department of Surgery , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Hendrik van de Meent
- d Department of Rehabilitation , Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- a Department of Orthopaedics , Physical Therapy, Radboud University Medical Centre , Nijmegen , The Netherlands.,e Scientific Centre for Quality of Care, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - J Bart Staal
- e Scientific Centre for Quality of Care, Radboud University Medical Centre , Nijmegen , The Netherlands.,f Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences , Nijmegen , The Netherlands
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22
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Cumberworth J, Kieffer WKM, Harry LE, Rogers BA. Perioperative management of traumatic limb amputations due to civilian trauma: current practice and future directions. J Perioper Pract 2016; 25:262-6. [PMID: 26845788 DOI: 10.1177/175045891502501203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traumatic limb amputations are serious injuries. They require urgent multidisciplinary management and emergency surgical intervention to save life and, where possible, preserve limb function. It is therefore vital that perioperative management follows established evidence-based principles to optimise outcomes. In recent years a vast quantity of research on traumatic amputations in the military setting has been published, but civilian injuries, which often have strikingly different mechanisms, have been neglected. This article reviews existing information on epidemiology, pathophysiology, perioperative management strategies, outcomes and future directions in the field.
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