Enhancing transfemoral prosthetics: investigating the impact of surgery and implant modifications on soft tissue complications

Despite the initial fear of catastrophic implant infection, the bone-anchored prosthesis treatment for individuals with a lower extremity amputation has proven comparatively safe. The technique requires a metal implant to be implanted in the bone, protruding through the skin, to which an artificial limb can be attached. Research has shown treatment to result in advantages in prosthesis use and quality of life, at the expense of frequent soft tissue complications at the skin-implant interface (stoma).

Researchers Robin Atallah, David Reetz, Jan Paul Frölke and Ruud Leijendekkers set out to investigate if modifications to surgical technique and implant design could reduce soft tissue complication rates, aiming to further develop and improve the bone-anchored prosthesis treatment of individuals with a above-knee amputation. The research group, led by Marinus de Kleuver and Nico Verdonschot from the orthopaedics department published the results in the Clinical Orthopaedics and Related Research on 1 july 2023 (epub 6 jan’23).

Earlier performed research from Germany showed the potential influence of implant design and surgical technique on the occurrence of soft tissue complications, mostly stoma infections. In our comparative cohort study we investigated adverse events rates in individuals treated with 1) the former surgical technique and cobaltchrome implant, or 2) a modern surgical technique and titanium implant. It was hypothesized that aiming for a shorter stoma (by additional removal of soft tissues) and using a titanium implant with a polished coating of the part protruding through the skin, would result in a decrease of soft tissue complications. Treatment modifications resulted in a 6-fold decrease in stoma infection, although increasing the risk of wound infections directly postoperative. These results reveal the potential improvements that can still be achieved, optimizing such a novel treatment. New studies have already been set up, investigating if the sudden rise of wound infections can be counteracted.  

Fig 1. (A) The conventional surgical technique is shown; a myoplasty was formed by suturing the fascia over the implant. (B) In the conventional surgical technique, the fascia was sutured over the implant. (C) In the adapted surgical technique, soft tissue surplus was removed and a myodesis was formed; fascia sutures were passed through the distal femur. (D) In the adapted surgical technique, the fascia was sutured onto the distal femur.

Read the study here

Atallah R, Reetz D, Verdonschot N, De Kleuver M, Frölke JP, Leijendekkers R. Have surgery and implant modifications been associated with reduction in soft tissue complications in transfemoral bone-anchored prostheses? Clinical Orthopaedics and Related Research. 2023 Jul 1;481(7):1373-1384. Doi: 10.1097/CORR.0000000000002535. Epub 2023 jan 6. PMID: 36607733; PMCID: PMC10263214