Soft-Tissue Contouring and Nerve Management During Lower-Limb Osseointegration Surgery.

Background: Osseointegration provides a direct prosthesis interface for lower-limb amputees, many of whom are poor candidates for traditional socket-suspended prostheses. These skeletally anchored implants eliminate the skin-prosthesis interface, reducing complications such as soft-tissue breakdown, ulceration, and pain Description: In the present video article, we describe a technique for soft-tissue contouring during single-stage limb osseointegration that involves mobilizing the anterior and posterior musculature to cover the bone-implant interface without excess Alternatives: Alternatives to osseointegration include maximizing the functionality and comfort of a socket prosthesis, either by refitting the prosthesis or by revising the soft tissue of the residual limb. However, both of these strategies have been shown to lead to lower health-related quality of life and are not cost-effective techniques when compared with osseointegration Rationale: Lower-limb osseointegration is particularly beneficial for patients who have the desire to walk and are unable to tolerate traditional socket prostheses because of issues related to poor fit, pain, high metabolic demand, and/or skin breakdown Expected Outcomes: Single-institution studies and systematic reviews have shown that lower-limb osseointegration is safe and effective, often resulting in improved mobility and quality of life Important Tips: Ideally, at least a 4-cm space should be left between the end of the posterior skin flap and the skin aperture in order to minimize the risk of skin necrosis.Insetting the posterior skin flap with quilting sutures allows for enhanced contouring and decreased dead space.RPNI can be utilized in addition to TMR for peripheral nerve management, especially when there is a size mismatch between donor and recipient nerves.Postoperative skin aperture complications can be addressed with topical antibiotics (for infection), silver nitrate (for hypergranulation), and fat grafting and/or steroid injection (for pain).Challenges to adequate peripheral nerve management include failure of the TMR or RPNI to prevent neuroma growth, leading to phantom limb pain and/or residual limb pain. Acronyms and Abbreviations: TMR = targeted muscle reinnervationRPNI = regenerative peripheral nerve interfaceAKA = above-knee amputationBKA = below-knee amputationJP = Jackson-Pratt drainIV = intravenous.