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The Transfemoral and Transhumeral OPRA (Osseoanchored Prostheses for the
Rehabilitation of Amputees) Osseointegration Technique
#MMPMID41262915
Bozzay AB
; Potter BK
; Forsberg JA
JBJS Essent Surg Tech
2025[Oct]; 15
(4
): ? PMID41262915
show ga
BACKGROUND: The transfemoral or transhumeral Osseoanchored Prostheses for the
Rehabilitation of Amputees (OPRA) osseointegration technique is indicated in
patients with transfemoral or transhumeral amputations who have difficulty with
use of a conventional socket and traditional prosthesis. Augmentations to the
procedure, such as targeted muscle reinnervation (TMR) and/or a regenerative
peripheral nerve interface (RPNI), serve to enhance function (in the case of TMR)
and/or improve residual-limb neuropathic pain (in the case of combined TMR and
RPNI) in the same patient population. DESCRIPTION: This surgical technique is
typically performed as a 2-stage procedure with approximately 6 weeks to 3 months
between stages to allow for adequate bone graft healing and osseointegration of
the fixture to the surrounding bone. Stage 1: Position the fluoroscopy machine on
the opposite side of the patient. Because all transfemoral amputations rest in
slight external rotation, obtain a true anteroposterior view of the hip, note the
rotation of the C-arm, and subtract 90° to obtain a true lateral radiograph.
Utilizing the prior incision, develop cutaneous flaps and distally approach the
bone of the residual limb. Most patients will require a thighplasty procedure to
manage excess soft tissues. Thighplasty may be performed during stage 1 and/or
stage 2. The previous muscle platform is encountered, and an osteotomy is
performed perpendicular to the long axis of the bone. A bone graft (5 to 10 cc)
is harvested from the proximal humerus or femur with use of a curved curet. Next,
the bone is progressively reamed under fluoroscopic guidance until the cortex is
encountered. Reaming is done by hand in order to avoid thermal necrosis. Care is
taken to avoid reaming too much of the anterior cortex proximally. A tap is
selected that is 1.5 mm thicker than the final reamer, and the bone is tapped
with use of the line-to-line technique to the size of the fixture. In cases of
soft bone, we choose to under-tap by 0.5 mm prior to inserting the fixture. The
final OPRA implant is inserted into the bone. The central screw is inserted and
tightened to 80 N-cm. The healing cylinder is placed, which serves as a mold for
the bone graft, and the previously harvested bone graft is packed around it. The
graft screw and large washer are placed to compress the bone graft. Placement of
the implant and healing components is confirmed on biplanar fluoroscopy. Stage 2:
Through a limited incision, the graft screw and components are removed. The bone
graft is inspected for proper integration around the distal fixture. The purpose
of the bone graft is to provide a broad, vascular base onto which the
full-thickness skin graft heals. Then, cutaneous flaps are elevated and
fasciotomies are made. A medial or lateral-based thighplasty can be performed to
address any soft-tissue redundancies that may prevent a tight soft-tissue
platform at closure. The fascia from the muscle is attached to the bone
approximately 1.5 cm proximal to the distal bone with use of 0 Vicryl (Ethicon)
suture. A purse-string stitch is utilized to further reinforce the myoplasty. If
there is muscle herniation, utilize 0 Vicryl suture to perform side-to-side
closure of the fascia over the underlying muscle. The cutaneous flap is thinned,
and a suitable position for the aperture is identified on the superior flap. A
9-mm (for transfemoral) or 6-mm (for transhumeral) punch-biopsy tool is utilized
to create the skin penetration site or aperture. With use of the abutment as a
guide, the fat layer is removed to expose the undersurface of the dermis. The
flap is then rotated into position atop the distal femur and bone graft with use
of a series of 2-0 Vicryl sutures. The abutment is then inserted, and the
internal threads are cleaned with an angiocatheter and saline solution. The
threads are dried with use of cotton-tip applicators, and the abutment screw is
tightened by hand (it is further tightened to 12 Nm at the first follow-up
visit). The incision is closed with 2-0 Monocryl (Ethicon), 3-0 Monocryl, and a
self-adhering mesh with 2-octylcyanoacrylate liquid adhesive. Topical
nitroglycerin is placed around the aperture and sealed with an antimicrobial foam
dressing bolster. The bolster dressing is held in place with use of a bolster
that is shaped like a skateboard wheel. The patient avoids range of motion of the
limb for 5 days to allow for healing of the aperture. Peripheral nerve
management: Terminal neuromas are identified. Mixed sensory and motor nerve
branches to neighboring muscle targets are identified with use of a handheld
nerve stimulator and then are preserved. The terminal neuroma is transected to
freshly bleeding fascicles, and the newly freshened nerve end is coapted to a
newly divided nearby motor nerve of a deliberately de-innervated muscle motor
branch for TMR. This step is performed with a single centralizing 8-0 suture and
several 6-0 epineurial to epimysial sutures. For RPNI, the transected nerve is
sutured to the harvested segments of muscle from the distal lower leg with use of
8-0 epineurial-to-epimysial sutures that are then reinforced with 4-0 Vicryl
sutures. Vascularized RPNI is an alternative technique performed by tunneling the
nerve through and embedding its ending in a neighboring muscle belly. Fibrin glue
may also be utilized to reinforce the suture fixation. Closure: At the end of the
above procedures, meticulous hemostasis is obtained with electrocautery and
thrombin spray. The wound is copiously irrigated. One gram of vancomycin powder
is placed into the wounds to decrease infection risk and the severity of
heterotopic ossification. The residual limb is irrigated, a drain is placed
laterally, and the soft tissues are closed sequentially in a standard layered
fashion to prevent bursa formation. ALTERNATIVES: Alternative treatments include
local soft-tissue rearrangement, such as thighplasty that allows for improvement
in socket use. Additionally, multiple percutaneous implant systems exist for
clinical use internationally. Each of these implants utilizes osseointegration
biology to create a stable bone-implant interface for direct skeletal attachment
while attempting to avoid complications such as infection and loosening.
RATIONALE: Direct skeletal attachment of a terminal prosthesis to a bone-anchored
implant allows amputees who have previously had trouble with socket wear to
experience improved function, mobility, and quality of life. EXPECTED OUTCOMES: A
prospective 5-year follow-up of patients undergoing the transfemoral OPRA
osseointegration technique demonstrated significant improvements in
patient-reported outcome measures. However, increases in deep infections and
mechanical complications remained a concern (11 patients had 14 deep infections,
15 patients had mechanical complications, and 4 fixtures were removed)(3). With
transhumeral osseointegration, the 2-year implant survival rate was 100%, with no
infection-related complications. Cellulitis related to skin penetration was
easily managed with nonoperative aperture hygiene and/or oral antibiotic therapy.
IMPORTANT TIPS: Appropriate soft-tissue management is the most important part of
any osseointegration procedure.A 2-stage procedure ensures a well-vascularized
bone surface to accept a full-thickness skin graft and ensures that there is no
relative motion at the skin-implant interface.The goal is to produce a stable
soft tissue platform with minimal tissue movement at the skin penetration site
(also called aperture or stoma). ACRONYMS AND ABBREVIATIONS: TMR = targeted
muscle reinnervationRPNI = regenerative peripheral nerve interfaceRLP =
residual-limb pain.
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