Osseointegration

What is Osseointegration?

Osseointegration (OI), also known as direct skeletal fixation (DSF), is a surgical procedure that involves fitting a metal implant directly into the bone and allowing for a prosthesis to be connected to it. Surgery can be performed in one or two stages, depending on the type of implant system involved. Osseointegration aims to provide improved mobility and function and quality of life to individuals who have undergone amputation.

Osseointegration represents a significant change from the traditional method of fitting a prosthetic socket to a residual limb, which has been the traditional approach for hundreds of years. Once an option for only those with above knee amputees, the technique is now being increasingly used to treat below the knee as well as upper limb patients.

Types of Osseointegration Systems

The 2 types of commonly used osseointegration systems include:

• Screw shape prosthesis (OPRA): In this type of osseointegration system, the titanium prosthesis has a screw design and a relatively short length and is basically derived from dental implants. The titanium screws need a fairly long time for solid osseointegration, and the rehabilitation period until full weight-bearing is usually long, consisting of 6 to 12 months. Another drawback of this prosthesis is that the distal abutment is relatively weak and the implant may become loose resulting in breakage or bending during daily activities.
• Press fit prosthesis (ILP): The design and implantation technique of this type of osseointegration system was derived from orthopedic hip prostheses. This prosthesis is comprised of a 3D tripod surface structure with a chrome cobalt molybdenum alloy rod. The osseointegration capacity of this type of prosthesis is good and can bear more load than the screw shape prosthesis. The latest generation press-fit prostheses are made up of titanium alloy rods with a rough surface. This titanium prosthesis has similar qualities to current orthopedic implants; solid and strong. The osseointegration period is fast (6 weeks), and the rehabilitation period is brief.

Who is a Good Candidate for Osseointegration?

You are a good candidate for osseointegration if you:

• Are uncomfortable with the use of conventional socket prostheses due to pain, skin problems, and perspiration 
• Have difficulty with sitting, standing, or walking with the use of prosthetic socket
• Have fitting issues with the use of prosthetic sockets 
• Have obtained full skeletal maturity
• Have normal skeletal anatomy
• Are between 18 years old and  70 years old
• Have met the criteria for surgery based on your medical history and physical examination
• Are willing to comply with the treatment recommendation and subsequent follow-up

Who is Not a Good Candidate for Osseointegration?

You are not a good candidate for osseointegration if you:

• Are diabetic
• Have severe peripheral vascular disease
• Are pregnant
• Have exposed your legs to radiation
• Have osteoporosis
• Have a bodyweight of more than 100 kg
• Are a smoker
• Have skin disorders involving the amputated leg
• Have mental illness or psychotic disorder
• Are satisfied with conventional prosthetic sockets

Procedure for Osseointegration

Osseointegration is performed under anesthesia and involves the following steps:

• After selecting the correct implant size, the titanium implant is inserted into the bone of your stump.
• Any adjustments that need to be made to the bone length and soft tissue is addressed. 
• The wound is closed after implantation.
• A small surgical cut is then made and a connecting adapter of the osseointegration prosthesis is placed through this incision into the implant. 
• This point of penetration is known as the stoma.
• The skin is then closed with sutures.

Postoperative Care and Instructions

Post surgery, you will be transferred to the recovery area where you will be observed for 3 to 5 days and discharged. In the meantime, your doctor will provide you with instructions on how to clean the stoma site. The prosthesis will be arranged for the connection with the osseointegrated implant by your prosthetist. One week after surgery a rehabilitation protocol is started daily in the rehab department. You will be taught how to load the prosthesis and how to walk with the crutches. The rehabilitation protocol will last anywhere from 3 to 5 weeks based on whether the individual is a below knee or above knee amputee. You need to continue doing exercises daily at home before you can fully bear weight on the osseointegration prosthesis without crutches.

Benefits of Osseointegration

Some of the potential benefits of osseointegration include:

• Eliminates the need for prosthetic sockets
• Reduced pain or irritation experienced with prosthetic sockets
• Enhanced stability with standing or walking
• Able to walk long distances with enhanced sitting comfort
• Minimal skin complications
• Osseoperception - a more natural feeling with an ability to feel or sense the prosthesis
• Improved quality of life

Complications of Osseointegration

Some of the potential complications of osseointegration include:

• Skin irritation
• Muscle pain
• Skin infection
• Soft tissue impingement
• Periprosthetic fractures
• Failure of osseointegration, needing implant revision

Memorial Hermann Behind the Medicine

Dr. Doherty has recently been featured for his work with osseointegration surgery and for he and his teams’ efforts to improve the lives of amputees. Check out the cutting edge technique and watch as his patients get their lives back!