What is Osseointegration

What is Osseointegration?

Osseointegration was discovered in the 1950s by professor Per -Ingvar Branemark and is based on the ability of human bone cells (orange) to attach to a metal surface (green). To date, osseointegration is used for permanent anchorage of artificial limbs to the human skeleton. In a two step surgical procedure a metal (titanium) implant is inserted into the bone of the arm or leg and this implant penetrates through the skin. The artificial limb (prosthesis) is easily attached to this implant with a connector.

osseointegration scanning electron micrograph

Why Osseointegration?

For patients with extremity amputation, osseointegration offers many advantages in comparison to socket prostheses. The attachment of the osseointegrated prosthesis is much more stable and this allows for much improved walking and joint movement. An osseointegrated prosthesis does not cause skin breakdown. Because the prosthesis is directly attached into the bone, patients feel their prosthesis as part of their own body by natural osseoperception. This highly innovative technique contributes to the amputees’ quality of life.

Lange beenopname met valgushoek         Daglichtfotos klikprothese vooraanzicht 1

Xray TT osseointegartie     ILP onderbeen daglicht

X-humerus_AP postop     IAP met deel koppeling

Advantages of osseointegration

  • Increased prosthetic use
  • Longer walking distances
  • Better sitting comfort
  • No skin problems
  • Stable and safer standing and walking
  • Osseoperception
  • Quickly on and off
  • Better quality of life

 

Two osseointegration systems:

  • Screw shape prosthesis (OPRA): This prosthesis was developed by the osseointegration pioneers in Sweden and is the system with the longest and largest follow up. The titanium prosthesis is derived from the dental implants, has a screw design and a relatively short length. There is broad experience across Europe with this osseointegration system. However the titanium screw requires a relatively long time for solid osseointegration and therefore, the rehabilitation period until full weight bearing is long- typically 6 to 12 months. Another disadvantage is that the implant may become loose and the distal abutment is relatively weak. The abutment may bend or break at higher bending forces during daily activities.
  • Press fit prosthesis (ILP): The design and implantation technique was derived from orthopedic hip prostheses. This prosthesis  was developed in Germany and is a chrome cobalt molybdeen alloy rod with a 3D tripod surface structure. The osseointegration capacity of this prosthesis is huge, therefore the prosthesis can be load bearing much earlier than the OPRA system. The osseointegration period is 6 weeks and there are osseointegration clinics that allow full weight bearing on the osseointegration system immediatly after single stage surgery. A new generation press fit prostheses is made of titanium alloy rods with a rough surface. This titanium prosthesis has the same features as current orthopedic implants;  strong and solid. The osseointegration is quick and the rehabilitation period short.

 

Osseointegration study

In 2011, the Radboudumc Osseointegration Clinic in The Netherlands carried out a socket versus osseointegration study in the 22 patients. Gait and quality of life were assessed. In this study it was found that prosthesis use increased from 56 to 101 hours per week, walking speed increased with 32% and walking with an osseointegration prosthesis cost 18% less energy. With osseointegration, the prosthesis-related-quality of life improved from 39 to 62 on a 0 to 100 scale.

Lange beenopname met valgushoek                 X-lange benen met koker.JPG_6_1

Osseointegration                   Socket

Are there any disadvantages of osseointegration ?

Osseointegration is a safe treatment. Inflammation of the bone is rare. A disadvantage is that the area where the implant penetrates the skin (=stoma) needs to be cleaned with water and soap twice daily. This is comparable with brushing teeth. In some cases the skin at the penetration area may become irritated. In the first year after implantation you may have intensive muscle pain. This muscle pain disappears as soon as the stump muscles become fitter and stronger.

stoma heesakkers L 17 mrt 11   foto fraai stoma

Osseointegration stoma

What happens with the bone with an osseointegration prosthesis?

Most patients treated with osseointegration have weak bone because of disuse osteoporosis. In the socket prosthesis the bone is not loaded and the stump muscles are not active. This may result in decreased muscle volume and weaker bone. With osseointegration the natural load of the bone is restored and the stump muscles are reactivated to stabilize the bone.

In the Radboudumc Osseointegration Clinic in The Netherlands, bone remodeling processes have been evaluated and the data show that the bone around the osseointegration implant becomes thicker and stronger.

Bone remodeling study

figure4 - Copy

Post operative          1 year              2 years

Does my health insurance company pay for the osseointegration treatment?

In Europe most health insurance companies reimburse the osseointegration treatment. Before your first consultation with the osseointegration team you will have to get an agreement of your insurance company about the reimbursement.

Can I do everything with my osseointegration prosthesis?

With an osseointegration prosthesis you can do all daily life activities including taking a bath, swimming in the sea, river, lake, pool, going in the sauna, bicycling, sailing etc. Contact sports including; fighting, soccer and skiing are not recommended. You may do these sports without wearing your prosthesis.

Am I suitable for osseointegration?

 You are a good candidate for osseointegration when:

  • you experience problems with your socket (perspiration, skin problems, pain)
  • your walking distance is limited because of your socket
  • you can’t sit comfortably with your socket
  • you often lose your prosthesis during daily activities
  • you have back pain because you stand or sit not straight or limb while you walk

 

 The osseointegration treatment in summary

Intake: After agreement of your Insurance company you send us a request for an intake. The intake procedure is to evaluate whether you are a suitable candidate for osseointegration. The intake is to inform you about the osseointegration procedure this also includes a consultation with a patient with an osseointegration prosthesis. When you are a suitable candidate you will be prepared and scheduled for surgery.

Surgery 1: The metal implant(rod) will be inserted into the bone of your stump. If necessary the length of the bone will we adjusted and the soft tissue corrected. After the first operation you will be admitted in the hospital for a few days’ observation. The second operation is six to eight weeks after the first operation. In this period you can not wear your socket prosthesis. Your prosthesis stays in the hospital and will be prepared for the connection with the osseointegrated implant by our prosthetists.

Surgery 2: A small skin incision is made and a connecting part of the osseointegration prosthesis is put through this incision into the implant. This skin penetration point is called a stoma. The second operation is short. You may go home the same day or may stay for one night. In the hospital you will get instructions how to clean the stoma.

Rehabilitation: One week after the second operation the osseointegration rehabilitation starts. This takes place every day in a rehab department. You step-by-step learn how to load the prosthesis and how to walk with crutches. Below knee amputees will complete the rehabilitation in four weeks. Above knee amputees will have to do exercises at home and are able to walk without crutches in two to three months.