Amputation for CRPS is a controversial subject. Whilst many with the disease would gladly get rid of their affected limbs, one key issue that can occur after amputation is that the nerve pain simply moves to the new end of the limb, thus ensuring the terrible pain just continues at the new extremity of the limb stump. This often means sufferers cannot use a prosthesis as the intense pain and allodynia of CRPS just makes it too painful and is a major reason why most doctors won’t amputate for CRPS.
A different approach
However, there is now a treatment emerging that may provide hope to those suffering from CRPS in amputated limbs. Osseointegration is a technique whereby a titanium implant is attached directly to the bone of the stump. This means that an artificial limb can then be connected to the titanium, thus eliminating the need for a painful ‘socket’ attaching to the stump itself. It’s not a new procedure, having initially been invented in the 1990s, but it’s now gaining increased interest and traction, due in no small part to the number of military personnel requiring prostheses after being injured in combat.
Benefits over a traditional artificial limb include the fact that the attachment of the prosthesis is much more secure, leading to better and safer mobility. Patients also feel the prosthesis as part of their own body due to its attachment to the bone. Prosthetics last longer, allow longer walking distances, better sitting comfort and overall improved quality of life than traditional socket-based prosthetic limbs. Osseointegration has become established as a treatment for leg amputees and is now developing as a possibility for those with amputated arms too.
What does the treatment involve?
Surgery is a two step process. In part one, the stump is reshaped and the titanium implant is positioned inside the bone. Generally, the patient then recovers from this for six weeks, allowing the osseointegration to happen; literally, the bone grows onto the implant. In stage two, the exo prosthesis is attached. This is the section of the implant that is visible outside the body, connecting perfectly to a specially designed prosthetic limb. Sometimes, depending on the patient, both stages can be performed in one operation.
What does rehabilitation involve?
After the second surgical stage has attached the exo prosthesis, intensive physiotherapy begins almost immediately. For leg amputees, progressive weight bearing is an early aim, although this may be limited by muscle pain in the first few months after surgery. Patients work from walking between parallel bars through gait training with crutches to finally, learning to walk without crutches again.
It’s expected that below knee amputees will complete the rehab process in about four weeks, whilst above knee amputees should be able to walk without crutches in about two to three months.
Are there any downsides?
The major disadvantage is that you have a metal piece extending through the skin, which can lead to infections. However, this can generally be avoided as long as the small opening (called a stoma) through which the implant protrudes is kept clean; most doctors advise that simply washing it in the shower every day is enough to keep away infection. You’re likely to have some discharge from the stoma as well.
Where is it available and what does it cost?
In the UK, osseointegration is not currently available unless you’re in the military. Privately, it’s available in Germany, Sweden, Netherlands and Australia. Unfortunately as you might expect it’s not cheap, with quoted costs ranging from around £70,000 – £90,000. A UK medical trial was carried out for injured service personnel in Birmingham in 2016, so it is possible we may see this treatment come to the NHS in the future.
Who’s at the forefront of osseointegration?
Osseointegration has been pioneered by the Iraqi-born Australian surgeon Dr Munjed Al Muderis. Dr Al Muderis’ life reads like the plot of a movie; he was working as a junior surgeon in Baghdad in 1999 when a senior army officer brought three bus loads of army deserters and draft dodgers to the hospital. The officer demanded that all of them should have part of their ears surgically amputated as punishment, ordered by Saddam Hussein himself. The head of surgery objected, quoting the doctor’s Hippocratic oath which states that medical practitioners should “do no harm”. The soldiers took him outside and shot him. Al Muderis spent the next five hours hiding in a toilet stall, hoping desperately that he wasn’t found and listening to the horrifying sounds of his colleagues being forced to comply.
Later that day, Al Muderis fled Iraq, undertaking a terrifying journey that saw him travelling with another 150 asylum seekers by rickety boat, imprisoned in a detention centre in Australia where he was stripped of his name and known only by number, and eventually, almost miraculously, finding himself free in Sydney on the eve of the 2000 Olympics. From there, he continued his training, becoming a highly respected orthopaedic surgeon with a worldwide reputation. Dr Al Muderis is inspired and driven by his experience of war; seeing many people with lives so devastated by the loss of limbs that they considered it worse than dying, made him want to find a better way to help those affected. With osseointegration it looks like he’s done just that.
What does the future hold for CRPS patients?
So far, Dr Al Muderis has reportedly performed the surgery on several patients with CRPS and apparently achieved good results. It certainly sounds like osseointegration could potentially be a game changer for CRPS amputees unable to use traditional prostheses; it could even possibly be the treatment that changes the protocol on whether amputation is available for CRPS patients. I would, however, be interested to see if there are any cases where the trauma of inserting the metal implant into bone has itself created CRPS in a previously healthy stump. Regardless, there are many patients willing to wax lyrical about how osseointegration has changed their lives and that’s definitely a result that speaks for itself. Watch this space.