Osseointegration is a form of surgery which replaces the need for an amputee to wear a socket upon which he or she would traditionally attach their prosthesis. The surgery involves inserting a titanium implant directly into the residual bone of an arm or a leg, upon which an external prosthesis can anchor, removing the need for a traditional socket to be used.
Since 2018, osseointegration has been performed on amputees on a private basis by Mr Kang and Mr Woollard at Relimb who provide amputee reconstruction services for patients based in the UK and abroad at the Royal Free London NHS Foundation Trust. They work in close partnership with Professor Munjed Al-Muderis who is based in Australia and who pioneered OPL Osseointegration surgery. It remains a relatively uncommon procedure outside of the military but is gaining traction due to the perceived benefits to function and mobility over the use of traditional socket-based systems. Residuum shrinkage which occurs over a couple of years post amputation significantly impacts socket fit and can lead to the need for frequent refitting of sockets which is itself costly. The socket can frequently be responsible for sweating, skin irritation, sores, ulcers and infection which can potentially lead to revision surgery being required, pain and issues with comfort all of which impact how long a prosthetic is worn and ultimately function and mobility.
The vast majority of lower limb amputations undertaken on the NHS are conducted in the elderly population due to vascular disease and diabetes rather than as a result of trauma. In 2019 the NHS issued a Clinical Commissioning Policy Statement on the provision of osseointegration for transfemoral adult amputees. At that point, NHS England determined that osseointegration was not recommended as a treatment option given, at that time, the body of evidence regarding the effectiveness and safety of osseointegration remained small.
However, the first NHS funded osseointegration surgery has now reportedly taken place in England on a public patient in November 2022 by Mr Alex Trompeter, an orthopaedic surgeon and limb reconstruction specialist at St George’s Hospital, partnered with Professor Al-Muderis. As yet, it is unknown whether this was femoral or humeral surgery (although presumably the former), whether this was a one off surgery or whether this is the start of a general policy shift by NHS England.
If the NHS are now showing an interest in publicly funding osseointegration then that can only be a good thing. However, there is little doubt that they will apply strict criteria to qualifying participants to minimise the potential costs caused by possible complications including deep infection necessitating further surgery to remove and re-implant the implant and structural failure including bending or fracture of the abutment. A cost:benefit analysis will continue to be the paramount consideration for the NHS in agreeing to undertake publicly funded osseointegration. Whether the overall benefits of osseointegration are now beginning to take precedence over the cost remains to be seen.
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