December 22, 2015
Lower leg prosthetics have evolved in intricacy from historical times to current modern day with plans to change in the future. A person who has sustained an amputation has had the option to use no prosthetic, use a wooden or iron leg, or now, microprocessor technology with advances and planning for commercial use of utilizing osseointegration!
The first record of a functioning prosthetic limb in history was found in the book of Vedas from Sanskrit, India. This book, believed to have been written between 3,500 and 1,800 B.C. was a historical record of the time period. One entry stated that during a battle with a neighboring territory Queen Vishpla, a warrior queen in ancient India, received a blow that amputated one of her legs. After a time, having healed, she was fitted with an iron leg in order to be able to return to the battle field in defense of her kingdom once more.1
In the 16th century, a French surgeon named Ambroise Paré contributed major advances in prosthetics such as mechanical, hinged hands, and locking knee joints.2 A century later, a Dutch surgeon by the name of Pieter Verduyn created a lower-leg prosthesis that involved “specialized hinges and a leather cuff for improved attachment to the body.” 3 By the 1700’s, metal hooks and wooden legs attached with leather straps had become commonplace for individuals with amputations.4
Current prosthetic technology utilizes a socket interface with different materials used for suspending the prosthetic to a person’s amputated limb. Selection of prosthetic parts is performed by a team of medical professionals in collaboration with the patient based on functional potential, anticipated complications, taking into consideration insurance and financial concerns. Typically, patients will rate that in order of importance, comfort, avoidance of mechanical skin injury, and enhancement of ability to walk are the most import considerations to them in selecting a prosthesis.5
Despite advancements in technology for prosthetic parts, there still seems to be a disconnect between how some patients rate their approval of their prosthesis. How bad is this disconnect? A study by Dillingham et al6 in 2001 reported that of 78 amputees admitted to a trauma center, 43% were satisfied with comfort, 25% reported being very/extremely bothered by mechanical skin injury, and 25% very/extremely bothered by perspiration and heat which lead to difficulty walking. Therefore, it is clear that alternatives and further research is needed to advance the current state of prosthetics.
Cue in: osseointegration! This surgical procedure has been modified over time, but involves the insertion of an abutment implant into the residual bone. Following surgery, progressive limb loading is accomplished and progressed to prosthetic weight bearing where the patient directly connects to the prosthetic without a socket or any interface materials! Research was initially performed in animals since the early 1960’s and the procedure has been performed in humans internationally in such places like Germany, Britain, and Australia.
Recently, a group out of the University of Utah, led by principal investigators Kent Bachus and Roy Bloebaum, were approved for a grant to design and develop state of the art bone anchored implants and insert them into soldiers who sustained amputations following orthopedic trauma. This is the first known research of its kind in the United States. Although not a currently approved procedure by the Food and Drug Administration, citizens have travelled overseas to be implanted and have returned for rehabilitation. Current estimates in the Houston area include about 4-6 people living with osseointegration, with that number expected to rise.
Recently, I attended a lecture by Dr Munjed Al Muderis on osseointegration. I initially was skeptical because all of the previous research I had seen demonstrated negative outcomes such as infection, failure of the implant, etc. Since the procedure is not mainstream here in the US, it just isn’t accepted in day to day life. We just don’t see amputees with metal protruding from their lower legs. However, I will say that my thought process was completely changed after being educated on the advancements in the technology, implantation, and rehabilitation of patients who have undergone the procedure. Failure rate with this group in Australia is almost nonexistent, infection has not spread to the bone, and functional mobility of patients has drastically changed pre/post-surgery. I am very impressed with the focus on multi-disciplinary care from surgeon, to rehabilitation, to psychology, prosthetists, and nutritionists. There is a very set and rigorous protocol from pre surgery to post. Patients are reporting possibilities of decreased phantom limb pain and even improved position sense of the prosthesis (termed “proprioception” in the rehab world)!
Here at AMPT rehab, we treat patients in our “Amputee Mobility and Prosthetic Training” program and we recently received our first patient who has elected to undergo osseointegration in Australia. Currently, we are working with the patient’s physician in implementing a pre-operative conditioning program focusing on core/pelvic control, hip joint flexibility, upper limb strength, exercise tolerance, weight loss consultation with nutrition, and single limb balance. She will travel in early 2016 to Australia and undergo a very precise protocol and return after about 5 weeks to continue her rehabilitation needs.
Since this is a blog, we should give our opinion on the matter, right? Honestly, I don’t have an opinion because this concept is so new to us. Previous implants have been unsuccessful and only recently has success been documented and demonstrated, especially in the Australia group who have implanted about 200 people with documentation of very good outcomes. Since we have very few people living in the United States with osseointegration, it will be interesting to see how the procedure is advertised and when/if we receive approval to perform it. The most important thing to remember will be that not everyone will be an ideal candidate for osseointegration! Many people do well with traditional socket interfacing and componentry already and there may be issues with cosmesis (there will be an abutment protruding from the skin) and cost. It will be important for patients to consult physicians and physical therapists with experience with this procedure before making the decision to undergo it.
We are excited to participate in the management and rehabilitation of such a revolutionary procedure! Personally, I have treated this patient population for 11 years, have spoken on this topic nationally, and teach entry level doctorate physical therapy students and could not be more excited about being a part of the future of this type of rehabilitation. We promise to use this opportunity to educate consumers and professionals alike and to produce research that can benefit all. There are other groups performing this procedure in Europe as well, so if you are interested, it is important to do your research to pick the best fit for you. Here is a link to a video of someone performing walking, stairs, and ramp tasks 11 months post surgery7: https://www.osseointegrationaustralia.com.au/videos/91-ogap-opl-prosthesis-11-months-post-surgery
Here’s to an exciting new year in 2016!
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- Vanderwerker Jr. EE. A Brief Review of the History of Amputations and Prostheses. Inter-Clinic Information Bulletin. 1976;15(5):15-16.
- Douglas A. The Advancement of Prostheses Throughout History. Available at: https://www.pelinks4u.org/articles/douglas1109.htm . Accessed December 21, 2015.
- Clements IP. How Prosthetic Limbs Work Available at: https://health.howstuffworks.com/prosthetic-limb.htm. Accessed March 29, 2009.
- Science Clarified. Prosthetics. Available at: https://www.scienceclarified.com/Ph-Py/Prosthetics.html. Accessed March 29, 2009.
- Legro MW, Reiber G, del Aguila M, et al. Issues of importance reported by persons with lower limb amputations and prostheses. JRRD. 1999;36(3):155-63.
- Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction with prosthetic devices among persons with trauma related amputations: a long term outcome study. Am J Phys Med Rehabil 2001; 80(8):563.
- Osseointegration: Group of Australia. https://www.osseointegrationaustralia.com.au/videos/91-ogap-opl-prosthesis-11-months-post-surgery Accessed 12/21/15.