Bone-anchored prostheses in patients with traumatic bilateral transfemoral amputations: rehabilitation description and outcome in 12 cases treated with the OPRA implant system

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.

Osseointegration for Lower-Extremity Amputees: Operative Considerations from the Plastic Surgeon's Perspective

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Osseointegration for lower-extremity amputees, while increasing in frequency, remains in its relative infancy compared with traditional socket-based prostheses.

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Ideal candidates for osseointegration have documented failure of a traditional prosthesis and should be skeletally mature, have adequate bone stock, demonstrate an ability to adhere to a longitudinal rehabilitation protocol, and be in an otherwise good state of health.

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Lowering the reoperation rate for soft-tissue complications depends heavily on surgical technique and on the implant device itself; the current gold standard involves a smooth implant surface for dermal contact as well as maximal skin resection to prevent skin breakdown against the prosthesis. This may include the need for thighplasty to optimize skin reduction.

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Interdisciplinary peripheral nerve management, such as targeted muscle reinnervation, performed in tandem with a plastic surgery team can treat existing and prevent future symptomatic neuromas, ultimately improving pain outcomes.

Prosthesis satisfaction and quality of life in US service members with combat-related major lower-limb amputation

BACKGROUND

Military amputee patient care programs offer extensive services, including advanced prosthetic devices, to restore function and improve quality of life (QOL) among veterans and service members with combat-related limb loss, but research on satisfaction with these devices is limited.

OBJECTIVE

To assess prosthesis satisfaction and QOL in US service members and veterans with combat-related major lower-limb amputation.

STUDY DESIGN

Cross-sectional study.

METHODS

Eighty-six participants with combat-related major lower-limb amputation completed the Orthotics and Prosthetics Users' Survey (OPUS) Satisfaction with Device scale and Quality of Well-Being Scale, Self-Administered, for the Wounded Warrior Recovery Project.

RESULTS

Most participants (62%-88%) responded Agree or Strongly Agree to OPUS Satisfaction with Device items on the fit, weight, comfort, ease of donning, appearance, and durability of their prosthesis. By contrast, the majority of participants (55%-79%) responded Disagree or Strongly Disagree to items on clothes being free of wear and tear, skin free of abrasions and irritations, and the affordability of their prosthesis. In linear regression analysis, total OPUS Satisfaction with Device score was positively associated with Quality of Well-Being Scale, Self-Administered score (β = 0.0058; P = 0.004).

CONCLUSIONS

Findings indicate the majority of participants were satisfied with the overall functionality of their prosthesis, but dissatisfied with the effect of their prosthesis on clothing and skin, as well as expenses related to their prosthesis. Additionally, prosthesis satisfaction was positively associated with QOL.

Comparison of functional outcome and patient satisfaction between patients with socket prosthesis and patients treated with transcutaneous osseointegrated prosthetic systems (TOPS) after transfemoral amputation

PURPOSE

The aim of this retrospective analysis was to investigate and evaluate differences in functional outcome and satisfaction of patients treated with a TOPS and patients using socket prosthesis after transfemoral amputation.

METHODS

This retrospective comprehensive analysis included patients from a single hospital, and was conducted between February 2017 and December 2018. Overall n = 139 patients with prosthesis were included and divided into two comparable groups (socket- and TOPS group). Incomplete data sets were excluded. This led to n = 36 participants for the socket- and n = 33 for the TOPS group. Functional outcome and satisfaction were evaluated by Patient Reported Outcome Measures (PROMs). The used PROMs were: Questionnaire for Persons with a Transfemoral Amputation (Q-TFA), EQ5D-5L, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Prosthesis Mobility Questionnaire (PMQ 2.0) and Functional Independence Measure (FIM).

RESULTS

Significant results in favor of TOPS patients were identified for the EQ-5D 5L (p = 0.004), Q-TFA (p = 0.000), SAT-PRO (p = 0.000) and PMQ 2.0 (p = 0.000). For FIM, no statistical significance was found (p = 0.318).

CONCLUSION

In this study, transfemoral amputees treated with an osseointegrated prosthetic attachment (TOPS) showed significantly higher scores for mobility and satisfaction. This demonstrates the high potential of TOPS in the prosthetic treatment of patients with transfemoral amputation with regard to their functional abilities in daily life.

Patient-reported Outcome Measures following Traumatic Lower Extremity Amputation: A Systematic Review and Meta-analysis

BACKGROUND

Outcomes after traumatic major lower extremity amputation (MLEA) have focused on surgical complications, despite the life-altering impact on patients. With advances in the surgical management of MLEA, a heightened need for consistent reporting of patient-centered outcomes (PCO) remains. This meta-analysis assesses articles for the prevalence and methods of PCO reporting among traumatic MLEA studies.

METHODS

An electronic database search was completed using Ovid MEDLINE for studies published between 2000 and 2020. Studies were included that reported any outcome of traumatic MLEA. Weighted means of outcomes were calculated when data were available. The prevalence of PCO was assessed in the categories of physical function, quality of life (QOL), psychosocial, and pain. Trends in PCO reporting were analyzed using Pearson's chi-squared test and analysis of variance when appropriate.

RESULTS

In total, 7001 studies were screened, yielding 156 articles for inclusion. PCO were evaluated in 94 (60.3%) studies; 83 (53.2%) reported physical function and mobility outcomes, 33 (21.2%) reported QOL and satisfaction measures, 38 (24.4%) reported psychosocial data, and 43 (27.6%) reported pain outcomes. There was no change in prevalence of PCO reporting when comparing 5-year intervals between 2000 and 2020 (P = 0.557).

CONCLUSIONS

Optimization of function and QOL following traumatic MLEA has become a cornerstone of surgical success; however, only 60% of studies report PCO, with no trend over the last two decades suggesting improvement. As healthcare progresses toward patient-centered care, this inconsistent means of reporting PCO calls for improved inclusion and standardization of instruments to assess function, QOL, and other patient-focused measures.

Mehrstufige Rehabilitation bei osseointegrierter Prothesenversorgung

Die erfolgreiche Wiederherstellung der Gehfähigkeit nach Amputation einer unteren Extremität ist eine große Herausforderung. Transkutane osseointegrierte Prothesen gewinnen als modernes Behandlungsverfahren zunehmend an Bedeutung. Diese Kasuistik vergleicht die mehrstufige Rehabilitation eines Patienten, welcher primär mittels schaftgeführter und sekundär mittels osseointegrierter Prothese versorgt wurde.

Rehabilitation of Patients with Osseointegrated Prosthesis after Transfemoral Amputation - Literature-based Recommendation for Postoperative Rehabilitative Procedure

BACKGROUND

Osseointegrative implantation after amputation of the lower extremity is a special treatment option. Physiotherapeutic treatment is important for the functional outcome. This study systematically evaluated existing follow-up treatment protocols to establish a literature-based recommendation for postoperative rehabilitation procedures.

METHODOLOGY

A PubMed literature search was conducted on December 10, 2020, using the following search terms: (osseo-integrat* OR endo-exo OR boneanchored OR bone anchored) AND (prosthe*) AND (leg OR lower limb* OR lower extremit* OR transfem* OR transtib*) AND (rehabilitation). 113 publications were found in this context. 10 of them met inclusion criteria. The Cochrane risk of bias tool was used to determine the publications' quality.

RESULTS

Three systematic rehabilitation protocols have been described: Osseointegrated Prostheses for the Rehabilitation of Amputees protocol, Osseointegration Group of Australia Accelerated protocol and Radboud Amputation: rehabilitation protocol for endo-exo femoral prosthesis. There are clear differences in the duration of the rehabilitation protocols. The quality of published studies is limited due to the high risk of bias and low evidence levels (mainly III - V). A concept for long-term rehabilitation has not been described yet.

CONCLUSIONS

There are various protocols for rehabilitation after treatment with osseointegrative prosthesis. Gradually increasing axial weight bearing started shortly after surgery; step-by-step gait training, adaptation of the prosthesis to the new biomechanics and critical patient selection and pre-operative training have been proven useful for successful rehabilitation. Controlled comparative studies, standardised outcome measurements or comparative studies between different protocols are not available. Models for multi-level long-term care have not been described in the literature so far.