Clinical specialties in orthotics and prosthetics Osseointegration for people with limb loss

What is osseointegration? Osseointegration is a broad term that describes the bio-chemical union between a man-made implant and a bone in the human body. For people with limb loss, osseointegration involves a surgical procedure that enables connection of a prosthesis (artificial limb) directly into the end of a residual limb. This is commonly referred to as a ‘bone-anchored prosthesis’. Osseointegration has been used in other prosthetic applications including dental care, facial reconstructions, hearing aids and more recently, bionics. How is a bone-anchored prosthesis different to a conventional prosthesis? The conventional way to suspend a prosthesis is by using a socket fitted around the residual limb. A bone-anchored prosthesis is different because there is no need for a prosthetic socket. Osseointegration allows an implant to be surgically inserted into the residual skeleton (the remaining bone of the Australia Images courtesy of the Osseointegration Group of A tibial implant A transfemoral prosthesis and abutment amputated limb) and the prosthesis is then attached directly to the implant via a specially designed connector. with the rest of the prosthesis. Since 2014 a single stage It is not uncommon for people with limb loss – particularly operation has been developed which allows both the fixture and transfemoral (above-knee) amputees – to experience socket- abutment to be inserted at the same time, which may result in related problems due to sweating and friction between the socket shorter treatment time. and skin. This can lead to soft tissue damage, difficulty with suspension, discomfort and reduced range of motion. Some What are the benefits of a bone-anchored of these problems are worse for people with short or unusually prosthesis? shaped residual limbs, or for bilateral amputees. Sometimes these Osseointegration offers a relatively new method of prosthetic problems are challenging to overcome and alternatives to traditional attachment for people with limb loss and scientific research prosthesis designs are sought. Osseointegration negates the need continues to reveal benefits and risks of the procedure. Reported for a socket and thereby alleviates these socket-related problems. benefits are largely due to elimination of the prosthetic socket. Research has focused mainly on transfemoral amputees and What does osseointegration involve? has found that bone-anchored prostheses improve hip range of If assessed as a suitable candidate for osseointegration, surgery motion and sitting comfort, improved hip and pelvic motion during is performed in either one or two stages depending on the clients walking, improve the perception of vibration, increase prosthesis existing conditions, suitability and surgical method. The first stage use and result in a higher functional level. Unfortunately, of the surgical procedure involves inserting the implant (called osseointegration does not reduce phantom limb pain. Recent a fixture) into the bone. A healing period might be required to studies also suggest that clients with bone-anchored prostheses facilitate integration with the bone. The second stage involves require fewer prosthetic review appointments than with standard inserting the external part (called an abutment) that connects to prostheses, and experience improved quality of life (compared the implant and penetrates through the skin to enable attachment with pre-osseointegration). www.aopa.org.au 1 of 2 Orthotist/prosthetists – supporting the Australian community

It is important to note that amputees with a bone-anchored suitable for osseointegration, as well as upper limb amputees. prosthesis are often limited prosthetic users prior to Osseointegration is not generally suitable for people who smoke, osseointegration and experience increased prosthetic use have diabetes, poor fitness or who cannot commit to the afterwards. For example, 30% of patients included in one study rehabilitation process. were wheelchair bound before receiving osseointegration implants. Therefore, some of the benefits of bone-anchored Who provides bone-anchored prostheses are due to increased prosthetic use, rather than the prostheses? bone-anchored prosthesis itself. Prosthetists (pron. pros-tho-tists) are tertiary qualified allied health Cost practitioners who specialize in the clinical assessment, provision and ongoing review of prostheses, including education, therapy The financing of osseointegration is complex as it involves both and device maintenance. This includes conventional and bone- the health and disability sector. In Australia, the surgical procedure anchored prostheses. Prosthetists work autonomously and to insert the implant is generally not covered by the Medicare within the multidisciplinary team. The role of the prosthetist in the system and is instead paid for through self-funding and/or an provision of bone-anchored prostheses is critical as the alignment individual’s Private Health Insurance. The related costs of the of the prosthesis must ensure loading is minimized, which may prosthetic hardware, such as the knee unit and the prosthetists also help to prevent infection. clinical services are partially covered through state artificial limb schemes or the National Disability Insurance Scheme. An out of How do I access more information on pocket expense is not uncommon and should be investigated thoroughly by potential clients. osseointegration? If you are interested in osseointegration and bone-anchored Risks of osseointegration prostheses please speak with your prosthetist, medical and/ Commonly acknowledged risks of osseointegration include or rehabilitation specialist. They will support you to determine irritation of the soft tissue in the skin-penetration area, infection your goals, the most suitable prosthetic treatment plan for that might require antibiotics, breakage of internal and external your situation and will outline any associated costs. Certified parts and pain due to loading. The most severe failure of the Orthotist/Prosthetists (c-OP AOPA) can be located using the treatment might result in re-amputation at a higher level or ‘Find a practitioner’ search function on the AOPA website reverting to a conventional prosthesis. (www.aopa.org.au). Can anyone with limb loss benefit from a bone-anchored prosthesis? Globally, osseointegration is still considered a relatively novel attachment technique for people with limb loss. The majority of clients who use a bone-anchored prosthesis have experienced limb loss due to cancer, infection or trauma; have a short residual limb and have experienced difficulty with conventional socket suspension. Both unilateral and bilateral Disclaimer – This fact sheet does not replace clinical advice. If you require orthotic/prosthetic services AOPA transfemoral and transtibial (below-knee) amputees may be recommend speaking to your practitioner. www.aopa.org.au 2 of 2