REVISION AMPUTATION WITH PRESS-FIT OSSEOINTEGRATION FOR TRANSFEMORAL AMPUTEES

Background: Press-fit transfemoral osseointegration is the technique of inserting an intramedullary metal implant into the residual femur of an amputee; the implant is passed transcutaneously to attach to a standard prosthesis that includes a knee, tibia, ankle, and foot. This allows the prosthesis to be skeletally anchored, eliminating socket-related problems such as tissue compression that can provoke neurogenic pain, skin abrasion, and fitting problems resulting from residual limb size fluctuation(1). Amputees with osseointegrated prostheses typically wear their prosthesis more and experience better mobility, quality of life, and extremity proprioception compared to those with socket prostheses(2-4). Description: We demonstrate the fundamentals of a single-stage procedure involving an impacted press-fit porous-coated titanium osseointegration implant. The preoperative evaluation is summarized and the specific surgical steps are described: exposure, osteotomy, canal preparation, implant insertion, (optional) targeted muscle reinnervation, muscle closure, soft-tissue contouring and stoma creation, and abutment insertion. Alternatives: Amputees who are dissatisfied with their quality of life or mobility when using a socket prosthesis can attempt to modify their socket or activity level or accept their situation. Non-osseointegration surgical options to try to improve socket fit include bone lengthening and/or soft-tissue contouring. An alternative design is a screw-type osseointegration implant(1). Rationale: Press-fit osseointegration can be provided for amputees having difficulty with socket wear(5). Press-fit osseointegration usually provides superior mobility and quality of life compared with nonoperative and other operative options for patients expressing dissatisfaction for reasons such as those mentioned above, including poor fit, compromised energy transfer, skin pinching, compression, and abrasions. Expected Outcomes: Review articles describing the clinical outcomes of osseointegration consistently suggest that patients have improved prosthesis wear time, mobility, and quality of life compared with patients with a socket prosthesis(3,4). In a recent study(2) of 18 femoral and 13 tibial amputees who had osseointegration, Reif et al. showed significant improvements in prosthesis wear time, mobility, and multiple quality-of-life surveys at a mean follow-up of nearly 2 years. The most common postoperative complication for this procedure is low-grade soft-tissue infection, which is usually managed by a short course of oral antibiotics. Much less often, soft-tissue debridement or implant removal maybe needed to manage infection. Periprosthetic fractures can nearly always be managed with familiar fracture fixation techniques and implant retention(6).