Percutaneous exposure for tibia osseointegration: reduced antibiotics, improved perioperative metrics, and greater pain reduction versus open exposure

Abstract

Introduction: This article compared outcomes of patients who received transtibial osseointegration through percutaneous incision (Perc and existing amputation by definition), open exposure (Open) of an existing amputation, or simultaneous transtibial amputation and osseointegration (Amp).

Methods: Retrospective chart review evaluated the aims. Adverse events: subsequent antibiotic administration and additional relevant surgery. Perioperative care: length of operation, estimated blood loss, infusion volume, and length of hospital stay. Patient-reported outcomes: preoperative versus postoperative scores of the Limb Deformity-Modified Scoliosis Research Society (LD-SRS) and PROMIS patient-reported outcome measures. Comparisons were made at short term (first 6 months) and longer term (6 months and beyond).

Results: The demographics of the 7 Amp, 15 Open, and 14 Perc patients were similar with the exception of time between amputation and osseointegration, etiology of amputation, and laterality. Perc patients had significantly lower antibiotic prescription versus Amp patients in the first 6 months (21% vs. 100%, P = 0.001) and versus Open beyond 6 months (21% vs. 66%, P = 0.025). Additional surgery for debridement or removal was minimal and similar among the 3 groups. Operative time was significantly shorter for Perc versus Amp (66.9 vs. 173.6 minutes, P < 0.001) and Perc versus Open (66.9 vs. 166.7 minutes, P < 0.001). Estimated blood loss was significantly less for Open versus Amp (87.1 vs. 257.1 mL, P = 0.001) and Perc versus Open (40.0 vs. 257.1 mL, P < 0.001). Inpatient stay was significantly shorter for Perc versus Open (2.5 vs. 3.5 days, P = 0.022). Perc patients also had significantly better improvement versus Open group for LD-SRS pain subscore (1.5 vs. 0.6, P = 0.010), PROMIS pain intensity score (-14.7 vs. -4.3, P = 0.005), and PROMIS pain interference score (-17.1 vs. -4.8, P = 0.007). Interestingly, the Amp group had a significantly better improvement in PROMIS pain intensity score versus the Open group (-21.1 vs. -4.3, P = 0.009).

Conclusions: Although a percutaneous approach may not always be possible, surgeons may want to actively consider whether their patients can have a smaller surgical approach that may confer measurable benefits.

Keywords: amputation reconstruction; below-knee amputation; osseointegration; percutaneous.

Figure 1.

Implant and radiographs. Overview of transcutaneous osseointegration. (A) Exploded view of an OPL implant, with the components arranged at approximately the proximal-distal levels in which they would be once assembled and implanted in a patient with a femoral amputation. (1) proximal cap screw, (2) OPL body, (3) safety screw, (4) dual-cone abutment adapter, (5) permanent locking screw, (6) proximal connector, and (7) prosthetic connector. (B) Anterior-posterior radiograph. (C) Lateral radiograph. The implants shown in the subsequent figures' radiographs do not have the proximal flutes and taper portion of the implant shown in (A) because they are of a shorter design without these portions.

Figure 2.

Percutaneous experience. (A) Preoperative clinical photograph of patient from front and (B) lateral side with tight soft tissue envelope around the tibia amputation. C, Preoperative anterior-posterior and (D) lateral radiograph showing the residual tibia. E, Intraoperative photograph of a different patient showing the technique in which the tibia is first percutaneously cannulated and then (F) a small circle exposure that is only the diameter of the implant is made to access the tibia. (G) A different patient is shown having percutaneous insertion of the implant. (H) Full length standing radiograph showing the implant 1 year after implantation in the tibia with a perfectly aligned hip-knee-ankle. (I) Lateral knee radiograph 1 year after implantation. (J) One year after the implantation, the patient can walk well balanced without assistive devices and (K) can even dance easily.

Figure 3.

Open experience. (A) Preoperative clinical photograph of the patient from front and (B) lateral side demonstrating the patient presented with a full limb but wanted amputation due to pain and difficulty walking related to his fibular deficiency and fractures and general deformities which are portrayed in his preoperative (C) standing anterior-posterior and (D) lateral radiograph. (E) An open exposure of a different patient but representative of an open surgical exposure for osseointegration. One year after surgery, the patient's standing (F) and lateral (G) radiographs show good alignment following a distal femur osteotomy; the patient did not want his prosthetic leg to be longer and level his pelvis because he had lived his whole life with a leg length difference and felt better with maintaining that difference rather than equalizing. (H) His skin portal is clean and healthy. (I) He was able to return to working heavy labor.