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Stand Up to Complications: Predicting Outcomes in Patients with Lower Limb Osseointegrated Prostheses
Grant G Black, BA1; Nicholas Andrew Vernice, AB1; Yunchan Chen, BS1; Albert Y Truong, MD1; Taylor Reif, MD2; S. Robert Rozbruch, MD3; David M Otterburn, MD1
1Weill Cornell Medicine, New York, NY; 2Hospital for Special Surgery, New York, NY; 3Hospital for Special Surgery, New York, CA

Purpose: Lower-limb osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses, which are associated with poor fit, soft tissue damage, and pain. Osseointegration, performed by a joint orthopedic and plastic surgery team, eliminates the socket-skin interface and allows for weight-bearing directly on the skeletal system. However, these prostheses can also be complicated by post-operative issues that plastic surgeons must manage. Little is known about the incidence of or risk factors for these complications as few centers currently perform the procedure.
Methods: An IRB-approved retrospective analysis was performed on all patients who received single-stage lower-limb osseointegration at our institution between 2017 and 2021. Patient demographics, medical history, operative data, and postoperative complications were reviewed. Complications include soft tissue infection, osteomyelitis, symptomatic neuroma, limb fracture, soft tissue revision, and hardware failure. Fisher’s exact test and unpaired t-tests were performed with an alpha of 0.05.
Results: 60 patients met our study criteria. This cohort included 42 males and 18 females with 35 transfemoral and 25 transtibial amputations. The cohort had an average age of 48 years (range 25-70) and follow-up period of 22 months (range 6-47). Indications for amputation were trauma (50), prior surgical complication (5), cancer (4) and limb infection (1). 54 postoperative complications were observed: 29 soft tissue infections treated with topical or oral antibiotics, 5 cases of osteomyelitis treated with IV antibiotics and/or operative washout, 7 symptomatic neuromas, 4 residual limb fractures, 7 soft tissue revisions, and 2 cases of hardware failure that necessitated implant removal. Unpaired t-tests showed statistically significant correlations between increased age at implantation and neuroma development (p<0.04), and decreased time since initial amputation and limb fracture (p<0.01). Fisher’s exact test revealed statistically significant associations between obesity (BMI>30 kg/m2) and soft tissue infection (RR 1.90; 95% CI [1.34, 2.46]; p<0.04) and female gender and soft tissue infection (RR 2.15; 95% CI [1.59, 2.71]; p<0.02). Subgroup analysis by amputation indication did not show significant differences in outcomes. Notably, hypertension (15), tobacco use (27), and prior infection (23) did not correlate with worse outcomes.
Conclusions: These data provide preliminary insight into risk factors for postoperative complications arising from osseointegration of the lower extremity, several of which are modifiable. As this promising procedure continues to expand in popularity, such results are necessary to inform best-practice guidelines and optimize outcomes. Further randomized, controlled trials are needed to confirm the above trends.


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