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Muderis MA, Tan YC, Lu W, Tetsworth K, Axelrod D, Haque R, Akhtar MA, Roberts C, Doshi K, Al-Jawazneh S, Hoellwarth JS. Transtibial osseointegration following unilateral traumatic amputation: An observational study of patients with at least two years follow-up. Injury 2024; 55:111568. [PMID: 38669890 DOI: 10.1016/j.injury.2024.111568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024]
Abstract
IMPORTANCE Most patients use a traditional socket prosthesis (TSP) to ambulate independently following transtibial amputation. However, these patients generally require prosthesis repairs more than twice annually and an entirely new prosthesis every two years. Furthermore, transtibial amputation patients have four times the skin ulceration rate of transfemoral patients, prompting more frequent prosthesis refitting and diminished use. Trans-Tibial osseointegration (TTOI) is a promising technique to address the limitations of TSP, but remains understudied with only four cohorts totaling 41 total procedures reported previously. Continued concerns regarding the risk of infection and questions as to functional capacity postoperatively have slowed adoption of TTOI worldwide. OBJECTIVE This study reports the changes in mobility, quality of life (QOL), and the safety profile of the largest described cohort of patients with unilateral TTOI following traumatic amputation. DESIGN Retrospective observational cohort study. The cohort consisted of patients with data outcomes collected before and after osseointegration intervention. SETTING A large, tertiary referral, major metropolitan center. PARTICIPANTS Twenty-one skeletally mature adults who had failed socket prosthesis rehabilitation, with at least two years of post-osseointegration follow-up. MAIN OUTCOMES AND MEASURES Mobility was evaluated by K-level, Timed Up and Go (TUG), and Six Minute Walk Test (6MWT). QOL was assessed by survey: daily prosthesis wear hours, prosthesis problem experience, general contentment with prosthesis, and Short Form 36 (SF36). Adverse events included any relevant unplanned surgery such as for infection, fracture, implant loosening, or implant failure. RESULTS All patients demonstrated statistically significant improvement post osseointegration surgery with respect to K-level, TUG, 6MWT, prosthesis wear hours, prosthesis problem experience, general prosthesis contentment score, and SF36 Physical Component Score (p < 0.01 for all). Three patients had four unplanned surgeries: two soft tissue refashionings, and one soft tissue debridement followed eventually by implant removal. No deaths, postoperative systemic complications, more proximal amputations, or periprosthetic fractures occurred. CONCLUSIONS AND RELEVANCE TTOI is likely to confer mobility and QOL improvements to patients dissatisfied with TSP rehabilitation following unilateral traumatic transtibial amputation. Adverse events are relatively infrequent and not further disabling. Judicious use of TTOI seems reasonable for properly selected patients. LEVEL OF EVIDENCE 2 (Therapeutic investigation, Observational study with dramatic effect).
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Affiliation(s)
- Munjed Al Muderis
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Yao Chang Tan
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - William Lu
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Daniel Axelrod
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Queensland, Australia.
| | - Russel Haque
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Muhammad Adeel Akhtar
- NHS Fife, UK; University of Edinburgh College of Medicine & Veterinary Medicine, UK; University of St. Andrews School of Medicine, UK
| | - Claudia Roberts
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Karan Doshi
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Shakib Al-Jawazneh
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia
| | - Jason Shih Hoellwarth
- Department of Orthopaedic Surgery, Macquarie University Hospital, Macquarie University, Macquarie Park, Australia; Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
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García-Ávila J, González-Gallegos CP, Segura-Ibarra V, Vazquez E, Garcia-Lopez E, Rodríguez CA, Vargas-Martínez A, Cuan-Urquizo E, Ramírez-Cedillo E. Dynamic topology optimization of 3D-Printed transtibial orthopedic implant using tunable isotropic porous metamaterials. J Mech Behav Biomed Mater 2024; 153:106479. [PMID: 38492502 DOI: 10.1016/j.jmbbm.2024.106479] [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: 12/09/2023] [Revised: 02/07/2024] [Accepted: 02/24/2024] [Indexed: 03/18/2024]
Abstract
In this paper, we introduce the design and manufacturing process of a transtibial orthopedic implant. We used medical-grade polyurethane polymer resin to fabricate a 3D porous architected implant with tunable isotropy, employing a high-speed printing method known as Continuous Liquid Interface Production (CLIP). Our objective is to enhance the weight-bearing capabilities of the bone structures in the residual limb, thereby circumventing the traditional reliance on a natural bridge. To achieve a custom-made design, we acquire the topology and morphology of the residual limb as well as the bone structure of the tibia and fibula, utilizing computed tomography (CT) and high-resolution 3D scanning. We employed a dynamic topological optimization method, informed by gait cycle data, to effectively reduce the mass of the implant. This approach, which differs from conventional static methods, enables the quantification of variations in applied forces over time. Using the Euler-Lagrange energy approach, we propose the equations of motion for a homologous multibody model with three degrees of freedom. The versatility of the Solid Isotropic Material with Penalization (SIMP) method facilitates the integration of homogenization methods for microscale porous architectures into the optimized domain. The design of these porous architectures is based on a bias-driven tuning symmetry isotropy of a Triply Periodic Minimal Surface (Schwarz Primitive surface). The internal porosity of the structure significantly reduces weight without compromising the isotropic behavior of the implant.
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Affiliation(s)
- Josué García-Ávila
- Department of Mechanical Engineering, Stanford University, Stanford, CA, 94305-2004, USA
| | | | - Victor Segura-Ibarra
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico
| | - Elisa Vazquez
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico
| | - Erika Garcia-Lopez
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico
| | - Ciro A Rodríguez
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico; Laboratorio Nacional de Manufactura Aditiva y Digital (MADiT), Autopista Al Aeropuerto, Km., 9.5, Calle Alianza Norte #100, Parque PIIT, Apodaca, 66629, Mexico
| | - Adriana Vargas-Martínez
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico
| | - Enrique Cuan-Urquizo
- Tecnológico de Monterrey, Institute of Advanced Materials for Sustainable Manufacturing, Monterrey, Mexico
| | - Erick Ramírez-Cedillo
- Tecnologico de Monterrey, School of Engineering and Sciences, Av. Eugenio Garza Sada Sur 2501, Monterrey, Mexico; Laboratorio Nacional de Manufactura Aditiva y Digital (MADiT), Autopista Al Aeropuerto, Km., 9.5, Calle Alianza Norte #100, Parque PIIT, Apodaca, 66629, Mexico; 3D Factory, Ramón Treviño 1109, Monterrey, Mexico.
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Osseoperception in transcutaneous osseointegrated prosthetic systems (TOPS) after transfemoral amputation: a prospective study. Arch Orthop Trauma Surg 2023; 143:603-610. [PMID: 34345935 DOI: 10.1007/s00402-021-04099-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endo-exo prosthetics (EEP), which belongs to the transcutaneous osseointegrated prosthetic systems (TOPS), provides an alternative bone-anchored rehabilitation method for transfemoral amputees. It led to the question of whether transmitted forces from prosthetic feet are perceptible by osseoperception resulting in proprioceptive feedback of ground conditions. OBJECTIVES The following hypotheses emerged for our trial with the null hypothesis: EEP fitting after transfemoral amputation does not influence osseoperception. Alternative hypothesis 1: EEP patients achieve better osseoperception results than transfemoral amputees fitted with socket prosthesis. Alternative hypothesis 2: EEP carriers achieve comparable results with regards to their osseoperception as non-amputees. METHODS N = 25 patients with EEP (mean age = 50,6 ± 9,4, male/female = 15/10) N = 25 patients with socket prostheses (mean age = 52,6 ± 13,1, male/female = 19/6) and N = 25 healthy volunteers were included in the experimental case-control study. In three blinded test modules (V1, V2, V3), the participants had to identify different degrees of shore hardness (c) of different materials (rubber balls (shore = 5-25c), foam cushions (shore = 5-30c), foam mats (shore = 5-30c) with their prosthetic foot (or a personally defined foot in healthy volunteers) without footwear and had to rank them into the correct order according to their tactile sensation and the degree of hardness. A maximum of 10 points could be scored per run. RESULTS This experimental observational study included N = 75 participants. The mean age for the entire cohort was 42.8 ± 16.6 years and the BMI was 26.0 ± 4.8. Our results show a significant level of differences in tactile osseoperception between all groups (p < 0.001). A correlation between the mean values of V1-3 and the PMQ2.0 as well as the mean values of K-Level and the prosthesis wearing time per day showed for PMQ (r = 0.387, p = 0.006) and K-level (r = 0.448, p = 0.001) which is a moderate effect according to Cohen. CONCLUSION Our study results suggest that the EEP treatment can lead to an improvement in tactile sensory perception via the bone-anchored implant, which can lead to an increase in quality of life and improved gait safety.
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Örgel M, Aschoff HH, Sedlacek L, Graulich T, Krettek C, Roth S, Ranker A. Twenty-four months of bacterial colonialization and infection rates in patients with transcutaneous osseointegrated prosthetic systems after lower limb amputation—A prospective analysis. Front Microbiol 2022; 13:1002211. [DOI: 10.3389/fmicb.2022.1002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTranscutaneous osseointegrated prosthesis systems (TOPS) are alternative rehabilitation methods to socket prosthetics, after limb amputation. TOPS compromise a two-step surgery: starting with the implantation of the stem which is then followed by the creation of the transcutaneous stoma through which the exoprosthesis can be connected. Immediately after surgery, this opening is permanently exposed to pathogens. This study aimed to investigate the dynamics of bacterial colonization of the stoma to analyze whether obligate bacterial colonization leads to a risk of periprosthetic infections after TOPS treatment.MethodsThis prospective study analyzed data from 66 patients (aged 26–75 years) after TOPS treatment between 2017 and 2019. Microbiological swabs from the stoma were analyzed on the first postoperative day and 3, 6, 12, and 24 months after stoma creation. Infection rates, laboratory values (CRP, leukocyte count, hemoglobin), and body temperature were recorded at these points in time. Statistical analysis was performed using SPSS 28.ResultsThe results show the formation of a stable environment dominated by Gram-positive bacteria in the stoma of TOPS patients over 24 months. Staphylococcus aureus, Staphylococcus spp., and Streptococcus spp. were the most common species found. With regard to the cohort up to the 3 months follow-up, 7.9% (five patients) developed infections surrounding the TOPS procedure. In relation to the whole cohort with loss to follow-up of 80.3% at the 24 months follow-up the infection rates increased up to 38.3%.ConclusionThe soft tissue inside and around the transcutaneous stoma is colonialized by multiple taxa and changes over time. A stable Gram-positive dominated bacterial taxa could be a protective factor for ascending periprosthetic infections and could possibly explain the relatively low infection rate in this study as well as in literature.
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Hoellwarth J, Reif T, Henry M, Miller A, Kaidi A, Rozbruch S. Unexpected positive intraoperative cultures (UPIC) at index osseointegration do not lead to increased postoperative infectious events. J Bone Jt Infect 2022; 7:155-162. [PMID: 35937089 PMCID: PMC9350876 DOI: 10.5194/jbji-7-155-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: The most common complication following transcutaneous
osseointegration for amputees is infection. Although an obvious source of
contamination is the permanent stoma, operative site contamination at the time
of implantation may be an additional source. This study investigates the impact
of unexpected positive intraoperative cultures (UPIC) on postoperative
infection. Methods: Charts were reviewed for 8 patients with UPIC
and 22 patients with negative intraoperative cultures (NIC) who had at least 1
year of post-osseointegration follow-up. All patients had 24 h of routine
postoperative antibiotic prophylaxis, with UPIC receiving additional antibiotics
guided by culture results. The main outcome measure was postoperative infection
intervention, which was graded as (0) none, (1) antibiotics unrelated to the
initial surgery, (2) operative debridement with implant retention, or (3)
implant removal. Results: The UPIC vs. NIC rate of infection
management was as follows: Grade 0, 6/8 = 75 % vs. 14/22 = 64 %, p= 0.682; Grade 1, 2/8 = 25 % vs. 8/22 = 36.4 % (Fisher's p= 0.682); Grade 2, 1/8 = 12.5 % vs. 0/22 = 0 % (Fisher's p= 0.267); Grade 3, 0/8 = 0 % vs. 1/22 = 4.5 % (Fisher's p= 1.000). No differences were statistically significant.
Conclusions: UPIC at index osseointegration, managed with
directed postoperative antibiotics, does not appear to increase the risk of
additional infection management. The therapeutic benefit of providing additional
directed antibiotics versus no additional antibiotics following UPIC is unknown
and did not appear to increase the risk of other adverse outcomes in our
cohort.
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Affiliation(s)
- Jason S. Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - Taylor J. Reif
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - Michael W. Henry
- Infectious Disease Service, Hospital for Special Surgery, Weill
Cornell Medical College, 535 East 70th Street, New York, NY 10021,
USA
| | - Andy O. Miller
- Infectious Disease Service, Hospital for Special Surgery, Weill
Cornell Medical College, 535 East 70th Street, New York, NY 10021,
USA
| | - Austin C. Kaidi
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - S. Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
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6
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Richter K, Krause K, Rotter R, Fischer DC, Aschoff HH, Mittlmeier T. [Functional rehabilitation after transfemoral amputation : Shaft prosthesis or endo-exo prosthesis?]. Unfallchirurg 2022; 125:266-274. [PMID: 35212810 DOI: 10.1007/s00113-022-01148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND After transfemoral amputation a prosthesis is required to restore autonomous standing and bipedal locomotion. Attachment of the prosthesis can be achieved either classically via socket suspension with a shaft in the stump or directly via implantation of an intramedullary transcutaneous femoral prosthesis (osseointegrated prosthesis). AIM A fully instrumented gait analysis should enable objectification of the anticipated advantages of the EEP with respect to the gait pattern and individual mobility. MATERIAL AND METHODS In two patients with a unilateral transfemoral amputation a comprehensive gait analysis was carried out prior to and 6 months (patient 1) or 11 and 20 months (patient 2) after switching from a socket prosthesis to an EEP. This was carried out in the Gait Realtime Analysis Interactive Lab (GRAIL), a fully instrumented gait laboratory with virtual reality and enables assessment close to the conditions of daily life. RESULTS In both cases the gait analysis confirmed the advantages associated with an EEP for the transmission of force to the prosthesis and the accompanying improvement in gait symmetry.
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Affiliation(s)
- Katherina Richter
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland.,Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Katharina Krause
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland.,Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Robert Rotter
- Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Dagmar-C Fischer
- Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Horst-H Aschoff
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Thomas Mittlmeier
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland. .,Klinik und Poliklinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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Örgel M, Schwarze F, Graulich T, Krettek C, Weidemann F, Aschoff HH, Winkelmann M, Ranker A. Comparison of functional outcome and patient satisfaction between patients with socket prosthesis and patients treated with transcutaneous osseointegrated prosthetic systems (TOPS) after transfemoral amputation. Eur J Trauma Emerg Surg 2022; 48:4867-4876. [PMID: 35717545 PMCID: PMC9712408 DOI: 10.1007/s00068-022-02018-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/23/2022] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Marcus Örgel
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Frederik Schwarze
- Orthopedic, Trauma and Sportsmedicine Department, KRH Klinikum Agnes Karll Laatzen, Hildesheimer Straße 158, 30880 Laatzen, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Friederike Weidemann
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Horst-Heinrich Aschoff
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Marcel Winkelmann
- Trauma Department, Hannover Medical School (MHH), Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Alexander Ranker
- Department of Physical Medicine and Rehabilitation, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Schnadthorst PG, Schulze C, Althoff M, Willy C, Lison A. Mehrstufige Rehabilitation bei osseointegrierter Prothesenversorgung. REHABILITATION 2021; 60:302-309. [PMID: 34655067 DOI: 10.1055/a-1491-6674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Schnadthorst PG, Lison A, Schulze C. Rehabilitation of Patients with Osseointegrated Prosthesis after Transfemoral Amputation - Literature-based Recommendation for Postoperative Rehabilitative Procedure. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34555855 DOI: 10.1055/a-1545-5486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
| | - Andreas Lison
- Bundeswehr Centre of Sports Medicine, Warendorf, Germany
| | - Christoph Schulze
- Bundeswehr Centre of Sports Medicine, Warendorf, Germany.,University Medicine Rostock, Department of Orthopaedic Surgery, Rostock, Germany
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10
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Akhtar MA, Hoellwarth JS, Al-Jawazneh S, Lu W, Roberts C, Al Muderis M. Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up. JB JS Open Access 2021; 6:JBJSOA-D-20-00113. [PMID: 34235362 PMCID: PMC8238302 DOI: 10.2106/jbjs.oa.20.00113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI). Methods Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded. Results All patients' mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis. Conclusions All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient's death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Muhammad Adeel Akhtar
- Trauma and Orthopaedic Department, Victoria Hospital Kirkcaldy, NHS Fife, Kirkcaldy, Scotland, United Kingdom.,Norwest Private Hospital, Bella Vista, New South Wales, Australia.,University of Edinburgh, Edinburgh, Scotland, United Kingdom.,University of St Andrews, St. Andrews, Scotland, United Kingdom.,Australian School of Advanced Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - Jason Shih Hoellwarth
- Australian School of Advanced Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - Shakib Al-Jawazneh
- Australian School of Advanced Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - William Lu
- Biomaterials and Tissue Engineering Research Unit, School of AMME, University of Sydney, Sydney, New South Wales, Australia
| | - Claudia Roberts
- Norwest Private Hospital, Bella Vista, New South Wales, Australia.,Australian School of Advanced Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - Munjed Al Muderis
- Norwest Private Hospital, Bella Vista, New South Wales, Australia.,University of St Andrews, St. Andrews, Scotland, United Kingdom.,School of Medicine, The University of Notre Dame Australia, Auburn, New South Wales, Australia
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11
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Beck JP, Grogan M, Bennett BT, Jeyapalina S, Agarwal J, Bartow-McKenney C, Bugayev J, Kubiak E, Sinclair S, Grice E. Analysis of the Stomal Microbiota of a Percutaneous Osseointegrated Prosthesis: A Longitudinal Prospective Cohort Study. J Orthop Res 2019; 37:2645-2654. [PMID: 31317568 DOI: 10.1002/jor.24421] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/10/2019] [Indexed: 02/04/2023]
Abstract
Percutaneous osseointegrated (OI) prostheses (POPs) are used to skeletally attach artificial limbs in amputees. While any permanent percutaneous interface is at risk of becoming infected by the resident microbiota colonizing the stoma, most of these patients remain infection-free. Avoidance of infection likely depends upon a mechanically and/or biologically stable skin-to-implant interface. The ultimate question remains, "why do some stomata become infected while others do not?" The answer might be found in the dynamic bacterial communities of the patient and within the stomal site itself. This study is an appendix to the first Food and Drug Administration approved prospective early feasibility study of OI prosthetic docking, in which, 10 transfemoral amputees were implanted with a unique POP device. In this analytical, longitudinal cohort study, each patient's skin and stomal microbiota were analyzed from the initial surgery to 1 year following the second-stage surgery. During each follow-up visit, three swab samples-stomal, device thigh skin and contralateral thigh skin-were obtained. DNA was extracted, and bacterial 16S ribosomal RNA (rRNA) genes were amplified and sequenced to profile microbial communities. The stomal microbiota were distinct from the microbiota on the adjacent thigh skin and the skin of the contralateral thigh, with a significantly increased abundance of Staphylococcus aureus within the stoma. Early on stomal microbiota were characterized by high diversity and high relative abundance of obligate anaerobes. Over time, the stomal microbiota shifted and stabilized in communities of lower diversity dominated by Streptococcus, Corynebacterium, and/or Staphylococcus spp. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2645-2654, 2019.
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Affiliation(s)
- James Peter Beck
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Orthopaedic and Plastic Surgery Research Laboratory, University of Utah, DVA SLC HCS, Research 151, 500 Foothill Drive, Salt Lake City, Utah, 84148
| | - Max Grogan
- Departments of Dermatology and Microbiology, University of Pennsylvania, 1007 BRB II/III, 421 Curie Blvd, Philadelphia, Pennsylvania, 19104
| | - Brian T Bennett
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Sujee Jeyapalina
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Jay Agarwal
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
| | - Casey Bartow-McKenney
- Departments of Dermatology and Microbiology, University of Pennsylvania, 1007 BRB II/III, 421 Curie Blvd, Philadelphia, Pennsylvania, 19104
| | - Julia Bugayev
- Departments of Dermatology and Microbiology, University of Pennsylvania, 1007 BRB II/III, 421 Curie Blvd, Philadelphia, Pennsylvania, 19104
| | - Erik Kubiak
- Department of Orthopaedics, University of Nevada, Las Vegas, Nevada
| | - Sarina Sinclair
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Orthopaedic and Plastic Surgery Research Laboratory, University of Utah, DVA SLC HCS, Research 151, 500 Foothill Drive, Salt Lake City, Utah, 84148
| | - Elizabeth Grice
- Departments of Dermatology and Microbiology, University of Pennsylvania, 1007 BRB II/III, 421 Curie Blvd, Philadelphia, Pennsylvania, 19104
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12
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Jeyapalina S, Beck JP, Drew A, Bloebaum RD, Bachus KN. Variation in bone response to the placement of percutaneous osseointegrated endoprostheses: A 24-month follow-up in sheep. PLoS One 2019; 14:e0221850. [PMID: 31652276 PMCID: PMC6814231 DOI: 10.1371/journal.pone.0221850] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/18/2019] [Indexed: 11/19/2022] Open
Abstract
Percutaneous osseointegrated (OI) devices for amputees are metallic endoprostheses, that are surgically implanted into the residual stump bone and protrude through the skin, allowing attachment of an exoprosthetic limb. In contrast to standard socket suspension systems, these percutaneous OI devices provide superior attachment platforms for artificial limbs. However, bone adaptation, which includes atrophy and/or hypertrophy along the extent of the host bone-endoprosthetic interface, is seen clinically and depends upon where along the bone the device ultimately transfers loading forces to the skeletal system. The goal of this study was to determine if a percutaneous OI device, designed with a porous coated distal region and an end-loading collar, could promote and maintain stable bone attachment. A total of eight, 18 to 24-month old, mixed-breed sheep were surgically implanted with a percutaneous OI device. For 24-months, the animals were allowed to bear weight as tolerated and were monitored for signs of bone remodelling. At necropsy, the endoprosthesis and the surrounding tissues were harvested, radiographically imaged, and histomorphometrically analyzed to determine the periprosthetic bone adaptation in five animals. Bone growth into the porous coating was achieved in all five animals. Serial radiographic data showed stress-shielding related bone adaptation occurs based on the placement of the endoprosthetic stem. When collar placement and achieved end-bearing against the transected bone, distal bone conservation/hypertrophy was observed. The results supported the use of a distally loading and distally porous coated percutaneous OI device to achieve distal host bone maintenance.
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Affiliation(s)
- Sujee Jeyapalina
- Research, Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, The University of Utah, Salt Lake City, Utah, United States of America
- * E-mail: (KNB); (SJ)
| | - James Peter Beck
- Research, Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Alex Drew
- Department of Bioengineering, University of Utah College of Engineering, The University of Utah, Salt Lake City, Utah, United States of America
- Orthopaedic Research Laboratories, Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Roy D. Bloebaum
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
- Bone and Joint Research Laboratory, Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Kent N. Bachus
- Research, Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
- Department of Bioengineering, University of Utah College of Engineering, The University of Utah, Salt Lake City, Utah, United States of America
- Orthopaedic Research Laboratories, Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
- * E-mail: (KNB); (SJ)
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13
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Leijendekkers RA, van Hinte G, Frölke JP, van de Meent H, Atsma F, Nijhuis-van der Sanden MWG, Hoogeboom TJ. Functional performance and safety of bone-anchored prostheses in persons with a transfemoral or transtibial amputation: a prospective one-year follow-up cohort study. Clin Rehabil 2019; 33:450-464. [PMID: 30537856 PMCID: PMC6416705 DOI: 10.1177/0269215518815215] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/01/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES: (1) To compare level of function, activity, health-related quality of life (HRQoL) and satisfaction in persons with a lower extremity amputation before surgery and 6- and 12-months after implantation of an osseointegration implant and (2) to report adverse events. DESIGN: Prospective cohort study. SETTING: University medical centre. SUBJECTS: A total of 40 consecutive persons (median age: 56 years) who received a transfemoral (31) or transtibial (9) osseointegration implant, between April 2014 and March 2016. INTERVENTION: Osseointegration implant surgery followed by a predefined rehabilitation programme. MAIN MEASURES: Hip abductor strength, prosthetic use, back pain frequency, postoperative pain, mobility level (Timed-Up and Go (TUG) and wheelchair-boundedness), walking ability (6 minute walking test (6MWT) and walking distance in daily life), HRQoL, satisfaction regarding the prosthesis, and adverse events. RESULTS: Strength, prosthetic use, walking distance, HRQoL, and satisfaction level increased significantly at 6- and 12-month follow-up compared to baseline ( P ⩽ 0.002). The TUG showed no change at 6-month follow-up ( P = 0.420) but improved significantly at 12-month follow-up compared to baseline ( P = 0.005). Wheelchair-boundedness decreased from 12/40 participants at baseline to 0 at follow-ups. The 6MWT ( P ⩾ 0.038) and back pain ( P ⩾ 0.437) did not change over time. Stump pain was present in 28/39 and 22/40 of the participants at 6-and 12-month follow-up, respectively. The major adverse events were managed successfully and included three dual-cone breakages and four bone fractures. An uneventful course was completed by 19/31 transfemoral and 4/9 transtibial bone-anchored prostheses users. CONCLUSION: Bone-anchored prostheses lead to improved performance and appear to be safe, so they might be considered for persons with socket-related problems.
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Affiliation(s)
- Ruud A Leijendekkers
- Department of Orthopaedics, Physical
Therapy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerben van Hinte
- Department of Orthopaedics, Physical
Therapy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Paul Frölke
- Department of Surgery, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Hendrik van de Meent
- Department of Rehabilitation, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Femke Atsma
- Department of IQ Healthcare, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Maria WG Nijhuis-van der Sanden
- Department of Orthopaedics, Physical
Therapy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Rehabilitation, Radboud
University Medical Center, Nijmegen, The Netherlands
- Department of IQ Healthcare, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Thomas J Hoogeboom
- Department of IQ Healthcare, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
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14
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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: 32] [Impact Index Per Article: 5.3] [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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15
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Thesleff A, Brånemark R, Håkansson B, Ortiz-Catalan M. Biomechanical Characterisation of Bone-anchored Implant Systems for Amputation Limb Prostheses: A Systematic Review. Ann Biomed Eng 2018; 46:377-391. [PMID: 29327257 PMCID: PMC5809556 DOI: 10.1007/s10439-017-1976-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/28/2017] [Indexed: 01/06/2023]
Abstract
Bone-anchored limb prostheses allow for the direct transfer of external loads from the prosthesis to the skeleton, eliminating the need for a socket and the associated problems of poor fit, discomfort, and limited range of movement. A percutaneous implant system for direct skeletal attachment of an external limb must provide a long-term, mechanically stable interface to the bone, along with an infection barrier to the external environment. In addition, the mechanical integrity of the implant system and bone must be preserved despite constant stresses induced by the limb prosthesis. Three different percutaneous implant systems for direct skeletal attachment of external limb prostheses are currently clinically available and a few others are under investigation in human subjects. These systems employ different strategies and have undergone design changes with a view to fulfilling the aforementioned requirements. This review summarises such strategies and design changes, providing an overview of the biomechanical characteristics of current percutaneous implant systems for direct skeletal attachment of amputation limb prostheses.
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Affiliation(s)
- Alexander Thesleff
- Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- Integrum AB, Mölndal, Sweden
| | - Rickard Brånemark
- International Centre for Osseointegration Research, Education and Surgery (iCORES), Department of Orthopaedics, University of California, San Francisco, CA, USA
- Department of Orthopaedics, Gothenburg University, Gothenburg, Sweden
| | - Bo Håkansson
- Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Max Ortiz-Catalan
- Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden.
- Integrum AB, Mölndal, Sweden.
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