Three-year Outcomes of a Randomized Controlled Trial Comparing a 4.5-mm-Wide to a 3.75-mm-Wide Titanium Implant for Bone Conduction Hearing

Long-Term Outcomes of a Percutaneous Wide-Diameter Bone-Anchored Hearing Implant: A Clinical Evaluation of More than 800 Implants

OBJECTIVE

This study evaluates the clinical outcomes of 807 percutaneous wide-diameter bone-anchored hearing implants (BAHIs) in 701 patients. In addition, it compares patient groups and examines bone conduction device (BCD) usage.

STUDY DESIGN

Retrospective cohort study. Mean follow-up period of 3.8 years.

SETTING

Tertiary referral center.

PATIENTS

All patients implanted with a percutaneous wide-diameter BAHI until December 2020 were included. Patients were divided into age groups, "loading-time" groups, and, if applicable, specific subgroups thought to be at risk for complications postsurgery, e.g., intellectual disability and comorbidities.

MAIN OUTCOME MEASURES

Soft tissue reaction, implant survival, revision surgery, and BCD usage.

RESULTS

In 9.1% of the 5,188 observations of 807 implants, an adverse soft tissue reaction was reported according to the Holgers' scale. Significantly more (adverse) soft tissue reactions were observed in children and intellectually disabled (ID) patients (p < 0.05). Comorbidity subgroups showed no significant differences in soft tissue reactions. Implant loss percentage, including explantations, was 6.2%. Implant survival was significantly worse in patients with ID (14.1%; p = 0.021). Pediatric age, early loading, or comorbidities did not significantly influence implant survival. At least 592 implants (73.4%) were used for bone conduction hearing, of which 65.4% were used daily.

CONCLUSION

Both children and ID patients are more prone to (adverse) soft tissue reactions, ID patients only have a higher risk of implant loss. The rate of implant loss in children seemed to be reduced compared to previous studies and thus more comparable to adults since using wide-diameter implants.

Complications and audiological results of percutaneous bone-anchored hearing devices

OBJECTIVE

To describe the post-operative complications and audiological results related to percutaneous bone-anchored hearing devices.

METHODS

A retrospective review was conducted of 44 patients with bilateral conductive or mixed hearing loss who were implanted with unilateral Baha Connect or Ponto devices. A generalised linear model for repeated measurements was used.

RESULTS

Twenty patients were Baha Connect users, and 24 were implanted with Ponto devices. Twenty-seven patients experienced complications. No fewer complications were found in the group of patients using longer abutments. When we compared the frequency of complications between Ponto and Baha Connect users, there was no statistically significant difference (p = 0.90). Free-field hearing thresholds were statistically significantly improved when we compared pre- and post-operative results (p < 0.001). Average speech perception also improved (p < 0.001).

CONCLUSION

Despite percutaneous bone-anchored hearing devices having a high rate of complications, they provide significant audiological benefits.

Long-Term Results of the Linear Incision Technique With Tissue Reduction Versus Tissue Preservation for Inserting Bone-Anchored Hearing Implants: The Ongoing Optimization in Bone Implant Surgery

OBJECTIVE

To compare the long-term outcomes of the linear incision technique with tissue reduction (LIT-TR) and the linear incision technique with tissue preservation (LIT-TP) for inserting bone-anchored hearing implants (BAHIs).

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Large general teaching hospital.

PATIENTS

A total of 231 adult patients were included between August 2005 and October 2020, with a minimum follow-up time of 6 months.

INTERVENTION

The test group received a BAHI using the LIT-TP (N = 147). The control group underwent surgery using the LIT-TR (N = 84).

MAIN OUTCOME MEASURES

Soft tissue reactions, skin thickening, postoperative complications (e.g., wound dehiscence), and implant loss were compared between the test and control group. Furthermore, Cochlear Bone Anchored Solutions AB (Mölnlycke, Sweden) and Oticon Medical AB (Askim, Sweden) implants/abutments within the LIT-TP cohort were compared. Validated questionnaires were used to quantify patients' health-related quality of life (HRQoL).

RESULTS

Significantly more cases with wound dehiscence and adverse soft tissue reactions (Holgers ≥2) were observed in the LIT-TR cohort (p < 0.001). However, the LIT-TP cohort showed significantly more cases with skin thickening (requiring treatment) within the first 2 years after implantation. There were no differences in implant loss rates, overall soft tissue reactions (Holgers >1), and overall HRQoL between the two patient groups. Significant improvement in the patients' HRQoL after implementation of a BAHI was found in both techniques. The Ponto Wide implant/abutment showed less frequent skin thickening (requiring treatment) and fewer soft tissue reactions compared with the BIA400 implant/abutment.

CONCLUSION

This large-scale study demonstrates that the LIT-TP shows excellent long-term outcomes, including a low incidence of implant failure.

Long-term osseointegration of laser-ablated hearing implants in sheep cranial bone

Osseointegration, the ability for an implant to be anchored in bone tissue with direct bone-implant contact and allowing for continuous adaptive remodelling, is clinically used in different reconstructive fields, such as dentistry, orthopedics and otology. The latter uses a bone conducting sound processor connected to a skin-penetrating abutment that is mounted on a titanium implant placed in the temporal bone, thereby acting as a path for transmission of the vibrations generated by the sound processor. The success of the treatment relies on bone healing and osseointegration, which could be improved by surface modifications. The aim of this study was to evaluate the long-term osseointegration in a sheep skull model and compare a laser-ablated implant surface with a machined implant. Commercially available 4 mm titanium implants, either with a machined (Wide Ponto) or a laser-ablated surface (Ponto BHX, Oticon Medical, Sweden), were used in the current study. The surfaces were evaluated by scanning electron microscopy. The implantation was performed with a full soft tissue flap and the osteotomy was prepared using the MIPS drill kit (Oticon Medical, Sweden) prior to installation of the implants in the frontal bone of eight female sheep. After five months, biopsies including the implant and surrounding bone tissue obtained, processed and analysed using histology, histomorphometry, scanning electron microscopy and Raman spectroscopy. The animals healed well, without signs of adverse events. Histomorphometry showed a large amount of bone tissue around both implant types, with 75% of the threaded area occupied by bone for both implant types. A large amount of bone-implant contact was observed for both implant types, with 67%–71% of the surface covered by bone. Both implant types were surrounded by mature remodelled lamellar bone with high mineral content, corroborating the histological observations. The current results show that the laser-ablated surface induces healing similar to the well-known clinically used machined surface in ovine cranial bone. In conclusion, the present long-term experimental results indicate that a laser-ablated implant performs equally well as a clinically used implant with a machined surface. This, together with previously reported, improved early biomechanical anchorage, suggests future, safe and efficient clinical potential.

Hearing-Related Quality of Life in 75 Patients With a Percutaneous Bone Conduction Device

OBJECTIVE

To evaluate long-term hearing-related quality of life (HRQoL) and device use in bone conduction (BCD) users. Furthermore, to assess differences between indications and changes in HRQoL over time.

STUDY DESIGN

Prospective questionnaire survey.

SETTING

Tertiary referral center.

PATIENTS

Seventy-five patients with a percutaneous BCD.

MAIN OUTCOME MEASURES

Glasgow Benefit Inventory (GBI) at 3 and 12 months postoperatively, Glasgow Health Status Inventory (GHSI) preoperatively, and 6 and 36 months postoperatively, device use at 6, 12, and 36 months. Changes over time were assessed and outcomes were compared between indications.

RESULTS

After implantation, 97% of all patients reported a positive benefit on the GBI total. The GHSI total had improved with median 15 points (Interquartile range [IQR] 12). At 36 months, median device use was 15 hours/day (IQR 10) and one nonuser was reported. Patients with bilateral hearing loss (BHL) showed greater improvement on the GHSI total (median 18 vs 14, p < 0.0001) and used their devices more frequently (median 16 vs 8 h/day, p < 0.0001) than patients with unilateral HL (UHL). Postoperative GHSI and GBI scores were consistent over time, in the entire patient population and for every indication. Between 6 and 36 months, device use was stable over time, except for patients with single-sided deafness (SSD; median -6.4 h/day, p = 0.009).

CONCLUSION

The BCD improves HRQoL in patients with BHL, in patients with unilateral conductive/mixed hearing loss and in patients with SSD. Patients with BHL experienced a greater improvement in hearing status compared to patients with UHL. Although use decreased over time in SSD patients, device use was high for every indication.

Clinical Evaluation of a Novel Laser-Ablated Titanium Implant System for Bone Anchored Hearing Systems in a Pediatric Population and the Relationship of Resonance Frequency Analysis With Implant Survival

OBJECTIVE

To evaluate the clinical outcomes of pediatric patients implanted a novel 4.5 mm wide laser ablated titanium bone anchored implant system and to evaluate the implant stability over the first 12-month period.

STUDY DESIGN

A prospective, single-subject, repeated measure, cohort study. Participants served as their own controls.

SETTING

Community and tertiary referral hospital pediatric assessment center.

PATIENTS

A total of 115 consecutive pediatric patients aged 4 to 15 years were implanted with 176 laser ablated titanium bone anchored implants from January 2016 to January 2019.

MAIN OUTCOME MEASURE

Clinical outcomes, implant failure rates, and post implantation implant stability quotient (ISQ) scores were studied over the first 12-month period. Data were analyzed for statistical significance through mixed effect modeling, with the significance level p = 0.01.

RESULTS

A median 12-month survival of 96.6% was observed. Six implants (3.5%) were lost in total, one of these (0.6%) was lost due to trauma. Adverse skin reactions (Holgers grade 2-4) were observed in 4.4% of all postoperative visits, occurring in 22 individuals (19.1%). Neither the ISQ high (ISQH) nor ISQ low (ISQL) values increased significantly between the stage 1 and 2 surgeries. In contrast, the ISQ results, irrespective of abutment size, demonstrated an increasing trend from 49.1 to 57 over the 12 months review period. A statistically significant change was only demonstrated from the 3 months follow up onwards.

CONCLUSION

The use of 4.5 mm wide laser-ablated titanium bone anchored hearing implants resulted in superior survival rates and excellent clinical outcomes compared with previous implant systems.

Interaction of KRSR Peptide with Titanium Dioxide Anatase (100) Surface: A Molecular Dynamics Simulation Study

Due to its tensile strength and excellent biocompatibility, titanium (Ti) is commonly used as an implant material in medicine and dentistry. The success of dental implants depends on the formation of a contact between the oxidized surface of Ti implant and the surrounding bone tissue. The adsorption of proteins and peptides to the implant surface allows the bone-forming osteoblast cells to adhere to such modified surfaces. Recently, it has been observed that tetrapeptide KRSR (Lys-Arg-Ser-Arg) functionalization could promote osteoblast adhesion to implant surfaces. This may facilitate the establishment of an efficient bone-to implant contact and improve implant stability during the healing process. GROMACS, a molecular dynamics software package was used to perform a 200 ns simulation of adsorption of the KRSR peptide to the TiO₂ (anatase) surface in an aqueous environment. The molecule conformations were mapped with Replica Exchange Molecular Dynamics (REMD) simulations to assess the possible peptide conformations on the anatase surface, and the umbrella sampling method was used to calculate the binding energy of the most common conformation. The simulations have shown that the KRSR peptide migrates and attaches to the surface in a stable position. The dominant amino acid residue interacting with the TiO₂ surface was the N-terminal charged lysine (K) residue. REMD indicated that there is a distinct conformation that is taken by the KRSR peptide. In this conformation the surface interacts only with the lysine residue while the ser (S) and arg (R) residues interact with water molecules farther from the surface. The binding free energy of the most common conformation of KRSR peptide to the anatase (100) surface was ΔG = −8.817 kcal/mol. Our result suggests that the N-terminal lysine residue plays an important role in the adhesion of KRSR to the TiO₂ surface and may influence the osseointegration of dental implants.

Clinical evaluation and resonance frequency analysis of laser-ablated titanium bone-anchored hearing implant system in children with Down Syndrome

OBJECTIVES

To evaluate complication rates and resonance frequency analysis (RFA) of the stability of a new laser-ablated titanium Bone Anchored hearing Implant system in children with Down syndrome.

METHODS

A prospective, single-subject, repeat measure, cohort study in which each participant served as their own control. Consecutive paediatric patients 4yrs- 15 years old, with a primary diagnosis of Down syndrome (trisomy 21) were implanted between January 2015-January 2020 with BHX Oticon wide implants. Evaluation of soft tissue reactions, fixture failure rates and post implantation Implant stability Quotient (ISQ) at both fixtures and abutment levels were studied over a 12-month period. Data was analysed for statistical significance through mixed effect modelling with significance set at p = 0.01.

RESULTS

31 consecutive paediatric patients with a diagnosis of Down syndrome were implanted with 43 Ponto BHX Oticon™ implant system. Twelve children had bilateral implants and nineteen were unilateral. Over the 12 month follow up 2 fixtures (4.6%) were lost, and adverse skin reactions (Holgers >2) were recorded in 3.2% of all clinical reviews. Implant level stability quotient showed no statically significant change between first and second stage 71.1-71.7. Abutment level ISQ increased from 46.2 to 56.7 p = 0.0001 at the 12-month review point as compared to that recorded at loading.

CONCLUSION

Implant survival and adverse skin reactions were found to be in keeping with those in published literature and much improved compared to previous implant systems placed at this centre. Although abutment level ISQ showed an increase over the review period no correlation between this and implant loss can be concluded.

A Clinical Evaluation of Minimally Invasive Ponto Surgery With a Modified Drill System for Inserting Bone-Anchored Hearing Implants

OBJECTIVE

To compare 6-months outcomes of the modified minimally invasive Ponto surgery (m-MIPS) to both the linear incision technique with soft tissue preservation (LIT-TP), and original MIPS (o-MIPS) for inserting bone-anchored hearing implants (BAHIs).

STUDY DESIGN

Exploratory pilot study with one test group and two historical control groups.

SETTING

Tertiary referral center.

PATIENTS

In the test group, 24 patients (25 implants) were prospectively included. Each control group comprised 25 patients (25 implants) who participated in previously conducted clinical trials.

INTERVENTIONS

The test group received a BAHI using m-MIPS. The two control groups underwent surgery using the LIT-TP and o-MIPS, respectively.

MAIN OUTCOME MEASURES

Implant survival, implant stability, and surgery-related variables were compared between the test and control groups. Soft tissue status, skin sensibility, and subjective numbness were compared between m-MIPS and LIT-TP only.

RESULTS

Implant survival was comparable between m-MIPS and LIT-TP, whereas implant stability measurements were slightly lower for m-MIPS. M-MIPS resulted in comparable adverse skin reactions and skin sensibility, significantly reduced surgical time and slightly improved subjective numbness, compared with LIT-TP. Between m-MIPS and o-MIPS, no statistically significant differences in implant survival, implant stability and surgical time were observed.

CONCLUSIONS

A trend toward lower implant loss rates after m-MIPS was observed, when compared with o-MIPS. M-MIPS seems to be a good alternative to LIT-TP for inserting BAHIs, since most clinical outcomes were either comparable or slightly better for m-MIPS. Upon deciding on which technique to use, larger studies on implant survival should be performed. Furthermore, other aspects such as costs, training aspects and surgical experience should be evaluated.

Review of Bone Conduction Hearing Devices

Bone conduction is an efficient pathway of sound transmission which can be harnessed to provide hearing amplification. Bone conduction hearing devices may be indicated when ear canal pathology precludes the use of a conventional hearing aid, as well as in cases of single-sided deafness. Several different technologies exist which transmit sound via bone conduction. Here, we will review the physiology of bone conduction, the indications for bone conduction amplification, and the specifics of currently available devices.

Economic Evaluation of Percutaneous Titanium Implants for Bone Conduction Hearing: A Cost-benefit Analysis

INTRODUCTION

Developments in bone-anchored hearing implants have resulted in fewer complications, and, thus, lower complication-related costs. However, a weighing of the potential clinical benefits with higher implant purchase price is lacking.

METHODS

A mathematical Markov model was used to evaluate the total costs (complication costs, implant purchase price, and standard costs) of three widely used current generation implants with expected similar outcomes, compared to a previous generation implant in adult patients over a 10-year time horizon from a healthcare perspective. Parameter estimates were derived from published clinical literature. Missing parameter estimates were based on expert opinion. Implant costs were derived from manufacturer catalogues, while standard and complication costs related to the BAHI were derived from a Dutch University Hospital and Dutch guideline for cost-effectiveness research.

RESULTS

The average total costs of the treatment with a previous generation implant was &OV0556;4.967 (SD ± &OV0556;134) per patient over a 10-year time horizon, compared to &OV0556;4.678 (SD ± &OV0556;83) with a current generation implant. This implant type is potentially up to &OV0556;506 more beneficial per patient over a 10-year horizon. By further improving implant survival, an additional &OV0556;645 (SD ± &OV0556;86) per patient could be saved over 10 years.

CONCLUSION

Despite a higher initial purchase price, the current generation implants are potentially cost-beneficial compared with previous generation implants. More data on current generation implants is needed to be able to determine which of the newer implants is most cost-beneficial. Focussing future developments on improving implant survival is likely to have more impact on costs compared with developments on improving soft tissue tolerability.

Six-Month Clinical Outcomes for Bone-Anchored Hearing Implants: Comparison Between Minimally Invasive Ponto Surgery and the Linear Incision Technique With Tissue Preservation

OBJECTIVES

The aim of this study is to investigate and compare the clinical outcomes of minimally invasive ponto surgery (MIPS) to the linear incision technique with soft tissue preservation (LIT-TP) for percutaneous bone-anchored hearing implants (BAHI).

STUDY DESIGN

Prospective cohort study with a historical control group.

SETTING

Tertiary referral center.

PATIENTS

Twenty-five patients were prospectively included in the test group. The control group consisted of 25 patients who previously participated in another clinical trial and already underwent BAHI surgery.

INTERVENTION

All patients were implanted with a 4.5-mm-wide implant, using MIPS in the test group and the LIT-TP in the control group. Follow-up visits were scheduled 7 days, 21 days (sound processor fitting), 12 weeks and 6 months after surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was skin sensibility around the abutment 6 months after surgery. Secondary outcomes were subjective numbness, surgery time, wound healing, adverse soft tissue reactions, cosmetic outcomes, implant stability quotient (ISQ), implant survival, and sound processor use.

RESULTS

Skin sensibility, adverse soft tissue reactions, and sound processor use were comparable between groups. The test group had a shorter surgery time and better cosmetic outcomes. More skin dehiscences and a statistically nonsignificant higher implant loss rate (12% vs 0%, p = 0.079) were observed in the test group.

CONCLUSION

MIPS is comparable to the LIT-TP regarding skin sensibility at 6 months and soft tissue tolerability. With MIPS, surgery time is further reduced and better cosmetic outcomes are reported. More research into MIPS, exact drill protocol, used instruments, and associated implant loss is warranted.

Patient Preferences in Sound Processor Loading Time After BAHI Surgery

OBJECTIVE

Sound processor loading times after bone-anchored hearing implant (BAHI) surgery have gradually decreased over time. This study assessed patient preferences in loading time.

STUDY DESIGN

Prospective patient questionnaire study.

SETTING

Tertiary referral center.

PATIENTS

Patients indicated for BAHI surgery received two questionnaires preoperatively: the validated Glasgow Health Status Inventory (GHSI) and a nonvalidated questionnaire that assessed patient preference for loading time and the rationale behind it. This preference questionnaire was also provided immediately, 7 days and 3 weeks (moment of sound processor loading at our center) postoperatively.

MAIN OUTCOME MEASURES

The preoperative and postoperative preferred loading time and the postoperative changes in preference were determined. Correlations between preference and patient-specific variables were assessed.

RESULTS

Sixty patients were included. Preoperatively, 70% preferred loading within 1 week after surgery. Of all patients, 43% preferred loading on the day of surgery, mainly motivated by the fast hearing rehabilitation and practical considerations. These preferences were not correlated with the total GHSI score or duration of hearing loss. Directly postoperatively, no change in preference was observed. However, 7 days and 3 weeks after surgery, significantly more patients preferred loading at a later moment. At 7 days and at 3 weeks, 50 and 40% preferred loading within 1 week, and 12.5 and 7.5% preferred loading on the day of surgery, respectively.

CONCLUSION

The preference for the timing of sound processor loading varied among patients and differed pre- and postoperatively. Despite the postoperative decline in patients preferring earlier loading, approximately half of all patients preferred sound processor loading within 1 week after BAHI surgery.

Results of a 2-Year Prospective Multicenter Study Evaluating Long-term Audiological and Clinical Outcomes of a Transcutaneous Implant for Bone Conduction Hearing

To evaluate 2-year audiological and clinical outcomes of a transcutaneous implant for bone conduction hearing of a previously published 6-month evaluation.

Long-Term Outcomes of the Minimally Invasive Ponto Surgery vs. Linear Incision Technique With Soft Tissue Preservation for Installation of Percutaneous Bone Conduction Devices

Objective: Comparing the surgical outcomes of the Minimally Invasive Ponto Surgery (MIPS) technique with the linear incision technique with soft tissue preservation (LITT-P) for bone conduction devices after a follow-up of 22 months.

Methods: In this multicenter randomized controlled trial, there was the inclusion of 64 adult patients eligible for unilateral surgery. There was 1:1 randomization to the MIPS (test) or the LITT-P (control) group. The primary outcome was an (adverse) soft tissue reaction. Secondary outcomes were pain, loss of sensibility, soft tissue height/overgrowth, skin sagging, implant loss, Implant Stability Quotient measurements, cosmetic scores, and quality of life questionnaires.

Results: Sixty-three subjects were analyzed in the intention-to-treat population. No differences were found in the presence of (adverse) soft tissue reactions during complete follow-up. Also, there were no differences in pain, wound dehiscence, skin level, soft tissue overgrowth, and overall quality of life. Loss of sensibility (until 3-month post-surgery), cosmetic scores, and skin sagging outcomes were better in the MIPS group. The Implant Stability Quotient was higher after the LITT-P for different abutment lengths at various points of follow-up. Implant extrusion was nonsignificantly higher after the MIPS (15.2%) compared with LITT-P (3.3%).

Conclusion: The long-term results show favorable outcomes for both techniques. The MIPS is a promising technique with some benefits over the LITT-P. Concerns regarding nonsignificantly higher implant loss may be overcome with future developments and research.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02438618.

Five year clinical outcomes and evaluation following implantation of the Oticon™ wide bone anchored hearing system in 47 children

OBJECTIVES

The Oticon™ wide implant system was launched in 2009 and used at Birmingham Children's Hospital from 2014. To evaluate clinical outcomes of the Oticon™ wide implant (Oticon Medical), with a focus on skin complication rates and fixture loss over a 5-year period in a tertiary paediatric hospital in the UK.

METHODS

Retrospective 5-year longitudinal case record review of 47 children who were implanted with the Oticon™ wide implant system at Birmingham Children's Hospital (BCH) between January 2014 and January 2016.

RESULTS

47 children (27 M:20F) were implanted with 70 Oticon wide implants 23 bilateral, 27 unilateral. Mean age at the time of implantation was 9y 6 m. The follow up was for a mean of 5.4 years. Significant soft tissue complications requiring treatment was found in 11% (n = 8) of loaded fixtures, abutment tightening on two patients, abutment exchange 6% (n = 4) and a 10% (n = 7) fixture failure.

CONCLUSION

The Oticon™ wide implant system produces favourable results with regards to peri-abutment skin complications, fixture stability and revision surgery rates when compared to similar cohorts of children studied at Birmingham Children's Hospital.

Orthopaedic osseointegration: Implantology and future directions

Osseointegration (OI) is the direct anchorage of a metal implant into bone, allowing for the connection of an external prosthesis to the skeleton. Osseointegration was first discovered in the 1960s based on the microscopic analysis of titanium implant placed into host bone. New bone was observed to attach directly to the metal surface. Following clinical investigations into dentistry applications, OI was adapted to treat extremity amputations. These bone anchored implants, which penetrate the skin and soft tissues, eliminate many of the challenges of conventional prosthetic sockets, such as poor fit and suspension, skin breakdown, and pain. Osseointegrated implants show promise to improve prosthesis use, pain, and function for amputees. The successful process of transcutaneous metal integration into host bone requires three synergistic systems: the host bone, the metal implant, and the skin-implant interface. All three systems must be optimized for successful incorporation and longevity of the implant. Osseointegration begins during surgical implantation of the metal components through a complex interplay of cellular mechanisms. While implants can vary in design-including the original screw, press fit implants, and compressive osseointegration-they face common challenges to successful integration and maintenance of fixation within the host bone. Overcoming these challenges requires the understanding of the complex interactions between each element of OI. This review outlines (a) the basic components of OI, (b) the science behind both the bone-implant and the skin-implant interfaces, (c) the current challenges of OI, and (d) future opportunities within the field.

Clinical Presentation, Management, and Outcomes of Idiopathic Pain in Percutaneous Bone-anchored Hearing Implants

OBJECTIVE

To identify clinical features and investigate treatment outcomes of patients with idiopathic pain related to a percutaneous bone-anchored hearing implant (BAHI) and to propose management recommendations.

STUDY DESIGN

Retrospective chart analysis.

SETTING

Tertiary referral center.

PATIENTS

The clinical data of 14 patients who were treated for idiopathic pain around their percutaneous BAHI between May 2007 and February 2018 at our tertiary referral center were reviewed.

MAIN OUTCOME MEASURES

Pain after treatment and implant loss.

RESULTS

All 14 patients received treatment with oral antibiotics. Nine patients received oral antibiotic combination therapy for 4 weeks, whereafter pain resolved in 4. Out of the five other patients, receiving either antibiotic monotherapy or shortened antibiotic combination therapy, pain resolved in two. In case of persistent pain (57.1%) after initial treatment, other pain management therapies were attempted, however all with only limited effect. Six patients (42.8%) underwent elective removal of the implant. In two patients spontaneous implant loss occurred. In two of the four patients who underwent reimplantation, pain relapsed. In one of these, pain resolved after the removal of the new implant. In the other patient, pain persisted, despite abutment removal. With exception of this latter patient, all other 13 patients were pain free at the latest follow-up. Cone beam computed tomography did not offer additional information regarding diagnosis or treatment.

CONCLUSION

Idiopathic pain in BAHI is a rare but bothersome symptom which can result in implant removal. After oral antibiotic combination treatment, symptoms resolved in approximately 40% of patients. Therefore, we think conservative treatment with these antibiotics before implant removal surgery, is worth considering.

Ten years of experience with the Ponto bone-anchored hearing system-A systematic literature review

Background

Bone‐anchored hearing systems (BAHSs) are widely used for hearing rehabilitation and are indicated in cases of conductive and mixed hearing loss and in single‐sided deafness. The Ponto system, that is one available option, has been on the market since 2009.

Objective of review

The aim of this study is to systematically review the literature reporting on the Ponto system, with regard to audiological and surgical outcomes and patient's quality‐of‐life scores.

Type of review

A systematic literature search was performed in the PubMed database 2009‐July 2019.

Search strategy

Search term: ((osseointegrated hearing aid) OR (bone conduction implant) OR (bone anchored hearing) OR BAHA OR BAHS OR BAHI). Pre‐defined inclusion and exclusion criteria were applied.

Evaluation method

English‐language articles reporting original clinical data (audiological, surgical or quality‐of‐life outcomes) on the Ponto system were included.

Articles reporting on Ponto and another BAHS system where the results on Ponto constituted less than 50% of the patient population or including only results on testband or softband devices were excluded.

Results

Audiological outcomes were discussed in 20 publications. Improvement against the unaided thresholds was demonstrated. The functional improvement was on average 33.9 dB. The effective gain or remaining air‐bone gap was on average 6.7 dB. All evaluated data showed aided speech reception thresholds significantly below normal speech level. Twenty‐seven publications reported surgical and follow‐up data for the Ponto system. Implant survival was 97.7%, adverse skin reactions (Holgers ≥ 2) were 5% across visits and 15% across patients. No complications were life‐threatening, causing permanent disability/damage or requiring a hospitalisation. Five studies reported quality of life using the Glasgow benefit inventory, 98% reported an improvement when analysing the score on an individual level.

Conclusions

The outcomes of this systematic review confirm that percutaneous systems provide consistent audiological benefits and improved quality of life for patients. Further, the review demonstrates that the percutaneous systems are safe, with relatively low complication rates. Skin‐related complications are the most common complication type and are experienced by approximately one patient out of seven, or in less than one of 20 follow‐up visits.

The efficacy of bone-anchored hearing implant surgery in children: A systematic review

OBJECTIVE

To evaluate the efficacy of Bone-Anchored Hearing implants (BAHIs) in children and to elucidate the usage and outcomes of new surgical techniques and implants in this specific population.

DATA SOURCES

Embase and PubMed.

STUDY SELECTION

We identified studies evaluating surgical outcomes of BAHIs in children. Retrieved articles were screened using predefined inclusion and exclusion criteria. Critical appraisal included directness of evidence and risk of bias. Studies that successfully passed critical appraisal were included.

DATA EXTRACTION

Outcome measures included patient demographics, follow-up time, surgical technique (one-versus two-stage surgery), tissue handling technique (reduction versus preservation), type of implant used, and complications.

DATA SYNTHESIS

We selected 20 articles published between 2000 and 2017 for data extraction, encompassing 952 implanted BAHIs. The overall mean age at implantation was 8.6 years (range, 2-21 years). Adverse soft-tissue reactions occurred in 251 of the 952 implants (26.4%; range 0%-89% across studies). Revision surgery was performed in 16.8% (142 of the 845) of the implants. The total rate of implant loss, i.e. caused by OIF (n = 61), trauma (n = 33), recurrent infection (n = 15), elective removal due to insufficient benefit (n = 1), cosmetic reasons (n = 1), or unknown reason (n = 16), was 13.3% of the implants (127 out of 952; range 0%-40% across studies). Differences are seen in the type of implants used; wide-diameter implants seem to be superior in terms of implant survival, and similar in terms of adverse skin reactions, while one-stage surgery and soft-tissue preservation do not seem to result in higher implant loss rates or increased adverse skin reactions based upon limited amounts of literature.

CONCLUSION

In general, BAHIs are a safe method for hearing rehabilitation in children, although large differences between studies are observed. The outcomes of new surgical techniques and implant designs in the pediatric population seem promising, but more research is needed before definitive conclusions can be drawn.

Three-Year Clinical and Audiological Outcomes of Percutaneous Implants for Bone Conduction Devices: Comparison Between Tissue Preservation Technique and Tissue Reduction Technique

OBJECTIVES

To evaluate the three-year clinical and audiological outcomes of soft-tissue preservation compared to soft-tissue reduction in linear incision surgery for percutaneous implant for bone conduction (BC) devices.

METHODS

Twenty-five patients (25 implants) were enrolled in a prospective cohort for implant surgery with linear incision and tissue preservation. The control group consisted of 25 patients (25 implants) from a previous randomized controlled trial in which a linear incision with soft-tissue reduction was applied. Follow-up visits were scheduled at 7 and 21 days (fitting of sound processor); 12 weeks; 6 months; and at 1, 2, and 3 years after implantation. Main outcome measures were skin sensibility, soft-tissue status, Implant Stability Quotient (ISQ), skin height, implant survival, revision surgery, scar assessment, and hearing thresholds (BC in-situ between 250 Hz and 8 kHz with BC device on testband and abutment, and BC thresholds at 250Hz-4 kHz with a B71 bone conductor).

RESULTS

Tissue preservation resulted in superior sensibility (mean percentage correct responses 99.7% [SD 1.7] vs 92.0% [SD 9.2], p = 0.0001). No spontaneous implant loss occurred in either group. The abutment was removed in two tests and in one control patient. Two control patients needed skin revision surgery. Although not statistically significant, more adverse soft-tissue reactions (Holgers ≥2) were observed in the test-group (n = 9 [36%] vs n = 3 [12%], p = 0.095). ISQ increased significantly more in the test group compared to the control group (7.64 [SD 4.05] vs 4.29 [SD 3.93]). Skin thickening, scar assessment, and hearing outcomes were comparable.

CONCLUSION

Tissue preservation demonstrated superior skin sensibility compared to tissue reduction while other clinical outcomes were comparably excellent.

The state of the art of osseointegration for limb prosthesis

Osseointegration (OI) is the direct attachment of bone onto a titanium implant. Recently, the term is used to describe "transdermal" implants that allow an external prosthesis to be connected directly to the skeleton. This technology eliminates the challenges of conventional socket-based prostheses, such as skin breakdown and poor fit, which are common in patients with major extremity amputations. Osseointegration patients demonstrate encouraging improvements in quality of life and function. Patients report improvement in prosthetic use, prosthetic mobility, global health, and pain reduction on a variety of clinical assessment tools. Various implants have been developed for osseointegration for amputees. These implants use a variety of fixation strategies and surface augments to allow for successful integration into the host bone. Regardless of design, all OI implants face similar challenges, particularly infections. Other challenges include the inability to determine when integration has occurred and the inability to detect loss of integration. These challenges may be met by incorporating sensing systems into the implants. The percutaneous nature of the metal devices can be leveraged so that internal sensors need not be wireless, and can be interrogated by external monitoring systems, thus providing crucial, real-time information about the state of the implant. The purpose of this review is to (1) review the basic science behind osseointegration, (2) provide an overview of current implants, practice patterns, and clinical outcomes, and (3) preview sensor technologies which may prove useful in future generations of transdermal orthopaedic implants.