Rehabilitation of Patients with Osseointegrated Prosthesis after Transfemoral Amputation – Literature-based Recommendation for Postoperative Rehabilitative Procedure

Abstract

Background Osseointegrative implantation after amputation of the lower extremity is a special treatment option. Physiotherapeutic treatment is important for the functional outcome. This study systematically evaluated existing follow-up treatment protocols to establish a literature-based recommendation for postoperative rehabilitation procedures.

Methodology A PubMed literature search was conducted on December 10, 2020, using the following search terms: (osseo-integrat* OR endo-exo OR boneanchored OR bone anchored) AND (prosthe*) AND (leg OR lower limb* OR lower extremit* OR transfem* OR transtib*) AND (rehabilitation). 113 publications were found in this context. 10 of them met inclusion criteria. The Cochrane risk of bias tool was used to determine the publicationsʼ quality.

Results Three systematic rehabilitation protocols have been described: Osseointegrated Prostheses for the Rehabilitation of Amputees protocol, Osseointegration Group of Australia Accelerated protocol and Radboud Amputation: rehabilitation protocol for endo-exo femoral prosthesis. There are clear differences in the duration of the rehabilitation protocols. The quality of published studies is limited due to the high risk of bias and low evidence levels (mainly III – V). A concept for long-term rehabilitation has not been described yet.

Conclusions There are various protocols for rehabilitation after treatment with osseointegrative prosthesis. Gradually increasing axial weight bearing started shortly after surgery; step-by-step gait training, adaptation of the prosthesis to the new biomechanics and critical patient selection and pre-operative training have been proven useful for successful rehabilitation. Controlled comparative studies, standardised outcome measurements or comparative studies between different protocols are not available. Models for multi-level long-term care have not been described in the literature so far.

Key words

transfemoral amputation - transcutaneous osseointegrated prosthesis - OPRA-protocol - OGAAP - RAp-EEFP

Publication History

Article published online:
23 September 2021

• References/Literatur

• 1 Hagberg K, Brånemark R. One hundred patients treated with osseointegrated transfemoral amputation prostheses – rehabilitation perspective. J Rehabil Res Dev 2009; 46: 331-344
• 2 Juhnke DL, Aschoff HH. Endo-Exo-Prothesen nach Gliedmaßenamputation. Orthopäde 2015; 44: 419-425
• 3 Hebert JS, Rehani M, Stiegelmar R. Osseointegration for Lower-Limb Amputation: A Systematic Review of Clinical Outcomes. JBJS Rev 2017; 5: e10
• 4 Hoffmeister T, Schwarze F, Aschoff HH. Das Endo-Exo-Prothesen-Versorgungskonzept: Verbesserung der Lebensqualität nach Extremitätenamputation. Unfallchirurg 2017; 120: 371-377
• 5 Ranker A, Örgel M, Beck JP. et al. Transkutane osseointegrierte Prothesensysteme (TOPS) zur Versorgung Oberschenkelamputierter – Eine sechsjährige retrospektive Analyse des aktuellen Prothesendesigns in Deutschland. Rehabilitation 2020; 59: 357-365
• 6 Wetz HH. Bericht der Klinischen Prüfstelle für orthopädische Hilfsmittel zum Prüfauftrag „Klassifikation von Schaftsystemen und Stumpfbettungen“ an das Bundesministerium für Arbeit und Soziales. Universitätsklinik Münster; 2008. Im Internet (Stand: 30.06.2021): https://www.ukm.de/fileadmin/ukminternet/daten/kliniken/techortho/Klassifikation_von_Schaftsystemen.pdf
• 7 Aschoff HH, Juhnke DL. Endo-Exo-Prothesen: Osseointegrierte, perkutan ausgeleitete Implantate zur Rehabilitation nach Gliedmaßenamputation. Unfallchirurg 2016; 119: 421-427
• 8 Hagberg K, Brånemark R, Gunterberg B. et al. Osseointegrated trans-femoral amputation prostheses: prospective results of general and condition-specific quality of life in 18 patients at 2-year follow-up. Prosthet Orthot Int 2008; 32: 29-41
• 9 Lundberg M, Hagberg K, Bullington J. My prosthesis as a part of me: a qualitative analysis of living with an osseointegrated prosthetic limb. Prosthet Orthot Int 2011; 35: 207-214
• 10 Haket LM, Frölke JPM, Verdonschot N. et al. Periprosthetic cortical bone remodeling in patients with an osseointegrated leg prosthesis. J Orthop Res 2017; 35: 1237-1241
• 11 Hansen RL, Langdahl BL, Jørgensen PH. et al. Changes in periprosthetic bone mineral density and bone turnover markers after osseointegrated implant surgery: A cohort study of 20 transfemoral amputees with 30-month follow-up. Prosthet Orthot Int 2019; 43: 508-518
• 12 Hoellwarth JS, Tetsworth K, Kendrew J. et al. Periprosthetic osseointegration fractures are infrequent and management is familiar. Bone Joint J 2020; 102-B: 162-169
• 13 Tillander J, Hagberg K, Berlin Ö. et al. Osteomyelitis Risk in Patients With Transfemoral Amputations Treated With Osseointegration Prostheses. Clin Orthop Relat Res 2017; 475: 3100-3108
• 14 Örgel M, Ranker A, Harb A. et al. Transkutane osseointegrierte Prothesensysteme (TOPS) nach Majoramputation der unteren Extremität: Eine retrospektive 3-Jahres-Analyse. Orthopäde 2021; 50: 4-13
• 15 Grundei H, Timmermann A. Anschlussadapter zur Ankopplung der Exoprothese an den Endostiel: Anforderungen an den Orthopädietechniker hinsichtlich Planung und Anwendung. Unfallchirurg 2017; 120: 378-384
• 16 Baumgartner R. Oberschenkelamputation. Transfemorale Amputation. Oper Orthop Traumatol 2011; 23: 296-305
• 17 Simmel S, Müller WD, Reimertz C. et al. Phasenmodell der Traumarehabilitation: Wie können wir das „Rehaloch“ vermeiden?. Unfallchirurg 2017; 120: 804-812
• 18 Tricco AC, Lillie E, Zarin W. et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169: 467-473
• 19 Higgins J, Green S. Cochrane Handbook for systematic Reviews of Interventions. Chichester (West Sussex): John Wiley & Sons Ltd; 2008
• 20 Hagberg K. Bone-anchored prostheses in patients with traumatic bilateral transfemoral amputations: rehabilitation description and outcome in 12 cases treated with the OPRA implant system. Disabil Rehabil Assist Technol 2019; 14: 346-353
• 21 Hagberg K, Brånemark R, Hägg O. Questionnaire for Persons with a Transfemoral Amputation (Q-TFA): initial validity and reliability of a new outcome measure. J Rehabil Res Dev 2004; 41: 695-706
• 22 Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158: 1384-1387
• 23 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39: 142-148
• 24 Van de Meent H, Hopman MT, Frölke JP. Walking ability and quality of life in subjects with transfemoral amputation: a comparison of osseointegration with socket prostheses. Arch Phys Med Rehabil 2013; 94: 2174-2178
• 25 Leijendekkers RA, van Hinte G, Nijhuis-van der Sanden MW. et al. Gait rehabilitation for a patient with an osseointegrated prosthesis following transfemoral amputation. Physiother Theory Pract 2017; 33: 147-161
• 26 Reetz D, Atallah R, Mohamed J. et al. Safety and Performance of Bone-Anchored Prostheses in Persons with a Transfemoral Amputation: A 5-Year Follow-up Study. J Bone Joint Surg Am 2020; 102: 1329-1335
• 27 Atallah R, van de Meent H, Verhamme L. et al. Safety, prosthesis wearing time and health-related quality of life of lower extremity bone-anchored prostheses using a press-fit titanium osseointegration implant: A prospective one-year follow-up cohort study. PLoS One 2020; 15: e0230027
• 28 Ellert U, Bellach BM. Der SF-36 im Bundes-Gesundheitssurvey – Beschreibung einer aktuellen Normstichprobe. Gesundheitswesen 1999; 61 (Sonderheft 2): S184-S190
• 29 Gailey RS, Roach KE, Applegate EB. et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputeeʼs ability to ambulate. Arch Phys Med Rehabil 2002; 83: 613-627
• 30 Muderis MA, Tetsworth K, Khemka A. et al. The Osseointegration Group of Australia Accelerated Protocol (OGAAP-1) for two-stage osseointegrated reconstruction of amputated limbs. Bone Joint J 2016; 98-B: 952-960
• 31 Muderis M, Lu W, Tetsworth K. et al. Single-stage osseointegrated reconstruction and rehabilitation of lower limb amputees: the Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2) for a prospective cohort study. BMJ Open 2017; 7: e013508
• 32 McMenemy L, Ramasamy A, Sherman K. et al. Direct Skeletal Fixation in bilateral above knee amputees following blast: 2 year follow up results from the initial cohort of UK service personnel. Injury 2020; 51: 735-743
• 33 Sullivan J, Uden M, Robinson KP. et al. Rehabilitation of the trans-femoral amputee with an osseointegrated prosthesis: the United Kingdom experience. Prosthet Orthot Int 2003; 27: 114-120
• 34 Schalk SA, Jonkergouw N, van der Meer F. et al. The Evaluation of Daily Life Activities after Application of an Osseointegrated Prosthesis Fixation in a Bilateral Transfemoral Amputee: A Case Study. Medicine (Baltimore) 2015; 94: e1416
• 35 Noreau L, Fougeyrollas P, Vincent C. The LIFE-H: Assessment of the quality of social participation. Technologys and Disability 2002; 14: 113-118
• 36 Dingemans SA, Kleipool SC, Mulders MAM. et al. Normative data for the lower extremity functional scale (LEFS). Acta Orthop 2017; 88: 422-426
• 37 Ryall NH, Eyres SB, Neumann VC. et al. The SIGAM mobility grades: a new population-specific measure for lower limb amputees. Disabil Rehabil 2003; 25: 833-844
• 38 Hanspal RS, Fisher K, Nieveen R. Prosthetic socket fit comfort score. Disabil Rehabil 2003; 25: 1278-1280
• 39 Atallah R, Li JJ, Lu W. et al. Osseointegrated Transtibial Implants in Patients with Peripheral Vascular Disease: A Multicenter Case Series of 5 Patients with 1-Year Follow-up. J Bone Joint Surg Am 2017; 99: 1516-1523