Surgical technique of minor revision of a transcutaneous osseointegration prosthetic system (TOPS) with implant retention.

Abstract

Objective: Transcutaneous osseointegration prosthetic systems (TOPS) offer a stable skeletal attachment for artificial limbs post-extremity amputation, serving as an alternative to socket attachment. Press-fit osseointegration implants (OI) utilized in TOPS consistently enhance quality of life and mobility for amputees, particularly those experiencing socket-related issues. Despite notable benefits, late complications such as infection and implant loosening pose challenges unique to TOPS due to their percutaneous nature. Recent studies indicate a low risk of implant failure but highlight the prevalence of minor soft tissue complications. Successful TOPS implementation is hypothesized to rely on early osseointegration and effective drainage of fluid discharge from the stoma. Factors influencing implant survival encompass implant characteristics, bone quality, and host factors. Longitudinal follow-up data reveal changes in periprosthetic bone and soft tissue conditions over time, necessitating ongoing clinical management. Distal bone resorption, evidenced by X‑ray, may result from stress shielding or local osteitis, leading to stoma-related complaints and jeopardizing implant survival. Understanding these dynamics is crucial for optimizing TOPS outcomes and addressing evolving patient needs.

Indications: Purulent and bloody discharge from the stoma with pain and radiographic evidence of distal cortical resorption.

Contraindications: Complaints attributed to other pathologies, signs of progressive bone resorption or implant loosening.

Surgical technique: We propose a unique innovative surgical approach to address symptomatic distal bone resorption in individuals undergoing treatment with press-fit transcutaneous osseointegration prosthetic systems (TOPS) following limb amputation. Distal bone resorption can lead to painful symptoms and compromise the effectiveness of TOPS, necessitating a stepwise intervention strategy. The protocol involves assessing cortical involvement through radiographs, followed by surgical debridement with assessment of potential implant loosening. The next step involves application of a two-part mirror-polished sleeve to mitigate local soft-tissue irritation and promote physiological drainage. Patient education is paramount, emphasizing the potential for limited pain relief and the risk of postoperative infectious complications. This protocol offers a structured approach to managing distal bone resorption in TOPS recipients, aiming to optimize treatment outcomes while ensuring informed patient consent.

Postoperative management: Following surgery, the cement used to fixate the sleeve must harden and after 24 h the leg prosthesis can be clicked on again. With regard to the surgical wound, no special measures are necessary other than standard orthopedic postoperative wound care. In view of this revision surgical procedure, we recommend to continue antibiotics for 6 weeks with preference for clindamycin 3 × 600 mg/day.

Results: Limited preliminary clinical data show promising results.