SLR - September 2022 - Shelby Busch, DPM PGY-3
Reference: Akhtar MA, Hoellwarth JS, Al-Jawazneh S, Lu W, Roberts C, Al Muderis M. Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up. JB JS Open Access. 2021 Jun 23;6(2):e20.00113.Level of Evidence: IV
Scientific Literature Review
Reviewed by: Shelby Busch, DPM PGY-3
Residency Program: Legacy Health PMSR/RRA, Portland OR
Podiatric Relevance: Complications secondary to peripheral vascular disease (PVD) are a common occurrence treated by podiatric surgeons. Unfortunately, proximal amputation is often indicated despite dedicated limb salvage efforts. Proximal amputations frequently result in poor mobility, diminished quality of life outcomes, and correlate with high rates of 1- and 5-year mortality. This study examines the outcomes of patients treated with transtibial osseointegrative prostheses who underwent amputations secondary to PVD, a condition which has previously been considered a contraindication to this technique.
Methods: The study is a prospective case series of 6 patients with preexisting PVD who underwent transtibial osseointegration (TTOI), in most instances following failed bypass surgeries. Patients were followed for a minimum of 3 years. Three patients had prior amputation and were revised to TTOI during the study period, while the remaining three underwent TTOI at time of amputation. Functional outcomes were assessed preoperatively, at 12 months, and at most recent follow-up using patient reported quality of life (QoL) measures with the Short Form 36 (SF-36), hours of daily prosthesis wear, 6-Minute Walk Test (6MWT), and Timed Up and Go test (TUG). Additionally, adverse events such as need for revision, fracture, infection, proximal amputation, and death were recorded.
Results: Six patients aged 36 to 84 (mean 64.1) years were included in the study. Three patients with previous amputation were wheelchair bound prior to TTOI. At 12 months post-op, all 6 patients were able to walk unaided using their integrative prostheses. The three ambulatory patients improved their TUG by 4 - 7.4 seconds and increased their 6MWT distance by a mean of 180 meters. The previously wheelchair-bound patients were able to complete both tests postoperatively, with a TUG of 8.6 - 26 seconds and a 6MWT distance of 145 - 300 meters. There was a mean improvement of 14 points on the SF-36 QoL scores. Three patients had superficial soft tissue infections which were successfully treated with oral antibiotics. One developed a deep infection at 2.8 years post-op which required above knee amputation, and unfortunately died two days later due to an MI.
Conclusions: The authors’ hypothesis was that a TTOI prosthesis would eliminate socket concerns as a barrier to prosthetic use and enable lower energy ambulation. They concluded that their data supported this and demonstrated that PVD is not necessarily an absolute contraindication to this technique. Decreased physical activity correlates with an increased rate of coronary events, overall physical deterioration, and earlier mortality. This technique represents an opportunity for certain patients to maintain mobility and quality of life, potentially indirectly improving overall survival rates. Although currently used most frequently for traumatic amputees, future studies may demonstrate a wider role for TTOI for patients undergoing amputation, including those commonly seen by the podiatric surgeon. In attempting limb salvage for patients, it is also our duty as providers to guide patients regarding the next steps when these attempts fail. Being aware of techniques such as this can allow us to provide information and potentially assist appropriately selected patients in exploring these options.