How Osseointegration Is Restoring Freedom to Amputees

Caitlin Whyte (Host): Advancing health.Personalizing care. At Memorial Hermann, this is our mission. This podcast shares the science and stories behind those efforts. Today we're interviewing Dr. David Doherty and Dr. Danielle Melton to discuss how osseointegration is restoring freedom to amputees by offering better outcomes.

Dr. David Doherty is an Assistant Professor in the Department of Orthopedic Surgery at McGovern Medical School at UTHealth Houston. Dr. Doherty is a Memorial Hermann-affiliated surgeon who specializes in hip and knee replacement surgery and performs partial and total joint arthroplasty. His clinical interests include both primary and revision hip and knee replacement.

Dr. Danielle H. Melton is an Associate  Professor in the Department of Orthopedic Surgery at McGovern Medical School at UTHealth Houston. She is affiliated with and Director of the Amputee and Orthotics and Prosthetics Program at TIRR Memorial Hermann, where she specializes in the care of people with amputations, encompassing pre-prosthetic management, prosthetic design and prescription, and rehabilitation.

Together, both physicians lead the osseointegration program, which offers multidisciplinary care for amputees. With coordinated care from a comprehensive team of other surgeons, psychologists, pain medicine and rehabilitation physiatrists, pain management specialists, physical therapists and prosthetists, patients at Memorial Hermann are able to take advantage of leading-edge technology and proven rehabilitation techniques.

Dr. Melton, start us off here. Just what is osteointegration or OI?

Dr. Melton: That's a great question. So, osseointegration was a term that actually has been around for about 30 years and it started more in the dental implant realm, but it's really moved more into amputation and limb loss. Another term that we use is direct skeletal attachment. And the idea is that using an implant that goes directly into a long bone and then having a trans- continuous connector allows amputees the ability to have a prosthesis without a socket. And a socket is really the most challenging interface or fit or difficulty that people have with wearing a prosthesis. So, for many people, osseointegration allows them to be able to use the prosthesis, whereas before they may not have been able to do so.

Host: And Dr. Doherty, is OI a common procedure for amputees? I mean just how many health care systems offer OI procedures?

Dr. Doherty: So, OI is not a common procedure for amputees. It's becoming more popular and becoming more visible in the orthopedic and limb loss community. However, the first procedure for an amputee was performed in 1990 by Dr. Rickard Brånemark. And since that time, he has been perfecting his technique and implant system and making the improvements that were necessary and became evident as he started to hone the procedure down. And now we finally entered into the phase of this procedure where we have an implant system that is FDA-approved for this indication. So, I think that in the future, osseointegration will become a much more approachable and much more mainstream treatment for these patients. As we’re talking right now, there's only a handful of centers in the country and I'm being a little vague about that because it's tough to nail down exactly how many centers are doing this. There are some surgeons that have done one and really have a plan to continue the program, but in terms of main centers where the focus is on osseointegration and providing osseointegration for amputees, I think that  Memorial Hermann is, is unique in it, in the sense that we have our University of Texas physicians who are focused on both the rehab and the surgical procedure.

And so, we are able to offer them a comprehensive care package for their amputee osseointegration needs. Not only is the surgery incredibly important to complex and unique, but the rehabilitation needs for these patients are incredibly unique as well. And so, one doesn't work without the other and that's sometimes the barrier for places in the country that do not have as robust of a system, that has the expertise in the physicians and also in the hospital system to provide this level of care for patients. So, it's so unique and complex. So, not many people are performing the procedure at this time, but part of our goal is to demonstrate its effectiveness and to demonstrate the improvements in patient and quality of life that they experienced. So, we can bring this more to the forefront and,  hopefully, continue to improve the procedure.

Host: Now what type of patient makes a good OI candidate? We'll go back to you, Dr. Melton.

Dr. Melton: There's lots of people that have limb loss and,  we really do need to be fairly selective in who is appropriate for osseointegration. There are some risks involved with a procedure like this. One of the significant ones that has been a concern for a delay perhaps in ensuring that this goes through the proper FDA-approval channels, is the risk for infection. And so, in selecting the right patient. You want to make sure that they meet certain criteria when selecting a patient that we want to make sure that they're skeletally mature.

So usually it's someone of adult age, at least skeletally. And then to make sure that they don't have other significant comorbidities or risk factors that might prevent them from being a good candidate for this. As Dr. Doherty mentioned, one of the things that we really strive to do in our team approach is to be able to screen patients appropriately.

We have an osseointegration clinic once a month. During that process, we evaluate patients who might be good candidates. Typically that starts with people who are currently having difficulty with their prosthesis. A lot of times having to do (with) difficulties with (how) their sockets fit. So in this clinic, we have obviously Dr. Doherty as a surgeon, myself as the rehabilitation doctor and then a physical therapist with expertise in limb loss and, in particular, osseointegration and the rehab that goes behind that. And then we might also look at patient's history and other medical issues that might complicate anything.But we can answer a lot of the questions that patients have in this setting with a lot of the experts that are in the room.

We take some time to go through imaging, to see if their limb is appropriate. And do other medical workup that would allow us to see if they had any other  risk factors that I mentioned. So, I think that that's one of the advantages to looking at this from a comprehensive team approach. And one of the things that we really strive to improve upon here.

Host: Sticking with you. Let's talk about that team. What is your role in the OI program at Memorial Hermann and UTHealth Houston?

Dr. Melton: As I mentioned, I'm the Limb Loss Director for the Amputee Program at TIRR Memorial Hermann, which is , the nationally ranked rehabilitation and research hospital in Houston. And I have for the last 15 years had an amputee clinic. So I have a pretty large patient population where I can work with amputees and fit them with prosthetic devices and really kind of look at them from continuity of care issue.

Long-term, my role in the osseointegration piece of this is to really maybe have the direct initial contact with patients, whether or not they are appropriate for  integration and then refer them into the osseointegration group for that team approach. Dr. Doherty and I work closely together as he is the surgeon, and then the rehab piece, following the surgical procedure, whether it's prehabilitation leading up to that in between the two different stages.

And then long-term rehab care post-op to start with  gait training and then just following them throughout their lifetime.

Host: And Dr. Doherty, tell us, please also about your role.

Dr. Doherty: So, for my role in the osseointegration program, I work closely with the rehab team. And as Dr. Melton was mentioning, she has a closer relationship with a larger amputee population and through her work for more traditional amputee care, she developed a relationship with a lot of these people and has developed a reputation also that draws people in seeking kind of the best rehabilitation care  for their limb loss and in working with them when they are starting to have difficulty with their socket mounted prostheses, and are struggling to obtain the ideal or attaching their prosthetic leg to their residual limb. They start to ask her if there are other options. And fortunately, during my residency at The University of Texas here in Houston, I had the opportunity to go and spend about three months doing a mini-fellowship with one of the pioneers of osseo-integration.

So I learned the techniques and the ins and outs of certain implant systems and things of that nature, and then performed further training and joint replacement, which is actually, there's a lot of corollaries to osseointegration. Because just to back up a little bit, the term osseointegrationhas been in existence in orthopedics for sixty or seventy years now.

And it is a descriptive term of the bone physically growing into metal and becoming biologically fixed to metal. So the surgery, osseointegration relies on the principle of osseointegration, of bone growing into metal to do it. And that's kind of where the name comes from. So, taking all of these little pieces of training that I've had through my career,I found myself in the unique position where I had a big clinical interest in bringing osseointegration and making it more visible to Texas and to Houston. And The University of Texas and Memorial Hermann were very supportive, and they helped me and Dr. Melton start to lay the groundwork for creating an osseointegration program.

And so, not only have we both been very involved with the kind of behind-the- scenes process of making sure the implant system is approved in the Memorial Hermann system, making sure the billing folks have weighed in and gotten some financial considerations taken care of. That's sort of my background role in osseointegration and the, I guess, nuts and bolts of how I fit into the clinical aspect of it is I, I perform the surgeries.

And so, once we have a patient that is motivated and has met the indications for surgery, the process is about a six-month process. We see them in clinic. We bring them to surgery,perform the first stage. Three months later, we perform the second stage and then they enter their more dedicated rehabilitation phase.

So, throughout that whole process, I'm present doing the procedure, making sure that the postoperative care is coordinated and making sure that the patient's surgical needs are met.

So, we have a team of surgical technologists, anesthesiologists and rehabilitation specialists all within the hospital system, perfectly trained to take care of these patients needs with essentially just a little bit of extra education from Dr. Melton and myself about the unique needs of the osseo- integration patients.

So it's been really fun to watch it all come together. Not only my training that I spent a lot of extra time doing unique things to give myself the expertise to perform these procedures, but also just seeing all of the behind-the-scenes work that the professionals at Memorial Hermann and University of Texas have put into this to make it all happen for these patients.

Host: Where would you say that OI fits into a patient's journey? Dr. Melton and what is so rewarding?

Dr. Melton: Yeah, that's a really great question. I'm glad you asked it. You know, I've had an opportunity now to, to probably have more than 30 patients who've had osseointegration in my practice, whether they've gone abroad to have it, or whether they've had it at our facility since we've started doing it within the last year.

When you talk to patients about this, they will tell you, this is life-changing. They will say that their quality of life is significantly improved. They're able to wear their prosthesis longer. They're have a significant improvement in their quality of life and the amount of time that it takes to put on their prosthesis or take it off.

They're able to walk longer distances. They're able to feel the ground underneath them. That's a term that we coined that's called osseo- perception. And for, for many of them, they'll also say that they have a decreased risk of falling because they can feel what they're stepping on. And so, yeah, it's exciting to watch and to see them get excited about this and, you know,  for us,  it's having the ability to really participate in that process to get them to a better place.

Host: Dr. Doherty, tell us about the benefits of OI, as opposed to the more common prosthetics and procedure options.

Dr. Doherty: I see the benefits of osseointegration and  some of my most memorable moments  in my career have been watching some of these patients walk on their prosthetic limbs after spending time in either a wheelchair on crutches, potentially have lost hope in, in their quality of life. So, those have been some of the most rewarding patients I can see. I mean, just watching people walk again is an incredibly moving thing to behold, but I readily admit that osseointegration is not for every patient. So, there are a lot of limb loss patients out there that do really well with sockets, and they do really well with their prosthetic limbs. And that's fantastic for them. And so, when we enter into this subset of patients that are struggling with their prosthetic fit or their inability to, you know, keep their prosthesis on for extended periods of time or they're having falls with it, once we're able to start talking to those patients, it's  pretty fun to start talking to them and explaining to them that there might be a better way to have their prosthetic limb attached to them. And the kind of excitement or the hope that that gives them sometimes  is what this patient really needed psychologically to really get motivated to continue on to see the possibility that they could, you know, return to their work or their job, or be the type of mother or father to their kids that they want to be. And things like that. So some of the benefits of osseointegration are that we do not use the socket. And so, specifically talking about this, you know, it's a common story that a lot of the osseointegration or rehabilitation specialists talk about that these prosthetic limbs that we have now have, I mean, essentially military jet technology and on. They've got microchips and they've got robotic processors in them and things like that. But then we attach them to patient's limbs in the same way that they were attaching prosthetic limbs in the ancient Greek or Roman times. There's hieroglyphics that show people with sockets, with fake legs attached to them.

And so it's a very much the weak link in the system at this point. So if you are having challenges with sockets, this completely eliminates the socket. You don't have to try and obtain a suction fit or try and jam your leg into a bucket essentially. And why? Our technology with sockets has improved.

There are still definitely patients that no matter what we do, they are not going to be very well served by a socket. And these are patients that have large amounts of scarring on their limb, or they might have residual tissue that is preventing them from utilizing the socket. Or in some cases their residual limb, their amputation   had to be performed at such a high level that a socket is just not an option.

And so, this really allows us to treat these patients and get them to the level where they can use one of these incredible prosthetic limbs now. And when you talk to these patients that have gone from a socket to osseointegration, it's incredible to hear them talk about it. The things that Dr. Melton has already mentioned about osseoperception.

I mean, if you watch a patient with a socket walk frequently, they're glancing at their feet constantly because they've learned their lesson. They've had a fall there. Their leg will spin on them. They'll trip on something with osseo-integration, the, the risk is less than because they have proprioception. They regained the ability to feel certain things in their foot and in their shoe that over time as they get used to it, they can start predicting when they're on carpet or grass or pavement. Other things that they really like about it, it takes even a very, very experienced socket user at least 30 seconds or a minute or so to just take their leg on and off or to make adjustments and frequently it takes even longer to do because there's several layers to the system. And with osseointegration, the connectors that connect the legs, take seconds. I mean,  it's as simple as clicking in to a pair of slip-on shoes or clicking into a ski boot or something like that. And so the time that it takes them to do it is insignificant. And so they'll put their leg next to their bed in the middle of the night. And if they need to go to use the restroom, they'll pop their leg on and go to the restroom. Whereas before that was unheard of, they'd have to get their crutches or a walker or spend the time to put their prosthetic on.

And so, this is for sure, a quality of life, procedure, and the quality of life improvements that we're offering are significant. It's not just simply like potentially walking with a little less pain or something. It's potentially the difference in walking versus sitting in a wheelchair. And so when we've identified the right patient, who's motivated, who's struggling with their limb loss and struggling with their socket-mounted prosthesis, this is a fantastic option for them to discuss. And it's not only improving their gait, their function, it's improving their psychology along with that as well. And so it's an extremely rewarding procedure and very, very fun to be part of a group of people who, you know, working so hard to push the boundaries and to advance the care that people are receiving.

Host: Well, as we wrap up here, back to you, Dr. Melton, is there anything else you would like us to know about OI or your role within the OI program?

Dr. Melton: Sure. So one of the things that I have really watched, not only with this program, but just over the course of the last 15 years of doing this is the advances that we've made with caring for people with limb loss.

And, you know, I like to term it optimizing limbs or trying to restore limbs. So it's not just about procedures, like osseointegration. There's other procedures that we have that I think are available. That when you put all of that together, we're getting one step closer to being able to have patients feel like they can restore their limbs.

And so, while prosthetic devices can only get o far, I think when you combine procedures like osseointegration and some of the other ones where we talk about sensory feedback, that's where this technology is going. And that is really where being a part of a group that has the experience and the ability to perform these state-of-the-art procedures is really kind of the future of limb loss.

And those of us that care for people with this, it's an exciting time.

Dr. Doherty: Absolutely. I would like to definitely reiterate that it is very much a team approach. And I come from a family of a lot of business people and teachers and no doctors or anything like that. So,  my experience in medicine has been one of an academic experience. I really enjoy being in the the University of Texas and Memorial Hermann systems, where we are a tertiary referral center. kWe get the opportunity to work with residents, fellows, medical students.

And I truly feel like it's my calling and the position that I'm in right now to advance the field, not just not just see patients and take care of patients, but to truly try and make a difference and advance the field. And for many kinds of coincidental reasons, my path has been led down this osteointegration path, and it's very exciting to me, and I completely recognize the opportunity.

I have to really make a difference. And it's a very exciting thing for me, because I've really been wanting to be part of a group in a system that is not just looking to try and do as many procedures as we can, make as much money and things like that as we can, but to really, really advance the scientific and medical aspect of the field and hopefully benefit the next generation of people.

And so, yes, being part of a multidisciplinary group is something that I've always really envisioned for my career. And it's exciting to be part of this group. Because we really are, I think, in this country, on the cutting edge and on the cusp of really advancing the field. So I'm very appreciative of the support of Memorial Hermann, University of Texas and TIRR Memorial Hermann, and it’s just a fun place to be a part of right now.

Host: Well, we so appreciate both of you taking the time to join us today and share this important information for more visit Memorial hermann.org/OI dash implant. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

This is Advance, the podcast series from Memorial Hermann I'm Caitlin Whyte.