By Samantha Rosenblum
It was a first for Las Vegas physical therapist Edward Dolegowski, PT: An amputee reported that her prosthesis felt like her leg.
“She smiled because she was surprised. And I was too,” said Dolegowski, who practices at Matt Smith Physical Therapy. “We had thought she’d be more at one with her prosthesis since it’s linked to her skeletal system, but this report stood out. No one’s ever said that.”
Dolegowski’s patient was the first in the US to undergo osseointegration, an alternative to typical traditional socket-type prosthetic limbs in which the prosthetic limb is attached directly to the bone of the residual limb through the skin. Though the procedure is new to the US, it dates back to the 1990s in Sweden.
While practicing in Germany for seven years, Nevada Orthopedic & Spine Center orthopedic surgeon Ronald W. Hillock, MD, observed patients who had undergone osseointegration and he became adamant about bringing the technology to the US. More than a decade after returning to the US, Hillock conducted the procedure on a nurse who had lost her leg to cancer.
After the initial amputation, osseointegration requires two surgical procedures followed by physical therapy. The first procedure, which in this case was done in August 2013, involves implantation of the endoprosthesis, a titanium rod fixed securely into the medullary canal of the distal residual femur.
Next, a stoma is created through which the coupling device passes from the skin to the stem. This typically happens six to eight weeks later, but in the US case, setbacks pushed the second procedure to December 2013, Hillock said.
“We ran into things that we had not anticipated as far as the fabrication of the components and the regulatory requirements involved,” he said.
On the other hand, aspects of the rehabilitation process have been faster than for typical amputees, Dolegowski said.
“I don’t have to worry about things like skin and socket suspension,” he said. “When we introduce new things to her, the transition is quick. There are no delays.”
One of the biggest challenges was psychological distress.
“She understood exactly what she was getting into, but the reality of having a piece of metal come through her skin caused a bigger psychological impact than we had anticipated,” Hillock said.
The patient was put in touch with another individual who had undergone an osseointegration implant in Australia, from whom she received advice and encouragement about the process.
Additionally, the patient complained about back pain during gait training, an issue that demonstrated the crucial difference between osseointegration and typical socket-type prosthetic limbs.
“I’ve never had a patient with an above-knee amputation with back pain after gait training,” Dolegowski said. “When she puts weight on that leg, she feels it throughout what we call ‘the chain,’ through her thigh, her hip and her back. It means she’ll have better control.”
Despite the encouraging results in this first case, osseointegration is not likely to replace typical prostheses any time soon. The inclusion criteria limit the procedure to individuals who have had transfemoral amputations for tumors, trauma, or general malformations that leave a large enough bone to work with. Candidates must not have diabetes, ongoing infectious issues, or peripheral vascular disease. Hillock hopes to perform the procedure in 10 patients, with the next case possibly beginning in the next few weeks.
For this patient, things are continuing in the right direction. With plans to return to her job and resume activities such as hiking and biking, in late July she was transitioning from a crutch to a cane for community ambulation and starting to walk on stairs and uneven surfaces.
“As therapists, we want our patients to achieve the highest level of function that they want to achieve,” Dolegowski said. “So this is just a means through which the highest level of function can be attained. It’s really groundbreaking and provides such a means to a fulfilled life.” – SR
Hillock R, Keggi J, Kennon R, et al. A global collaboration – osseointegration implant (OI) for transfemoral amputation. JISRF Reconstructive Review 2013;3(2):50-54.
Hillock R, Keggi J, Kennon R, et al. Stage II osseointegration implant (OI) skin coupling procedure. JISRF Reconstructive Review 2013;3(4):62-66.
Hillock RW, Tatum DL, Dolegowski E. Osseointegration implant post coupling with external prosthetic limb: continuation of previous case reports “Stage III”. JISRF Reconstructive Review 2014;4(2):13-16.