Osseointegration Complications & Pain Management

While osseointegration is a very safe procedure, it does not come without complications.

Patients can experience general complications, characteristic of any surgery, that can be associated with anaesthesia, surgical incisions, and postoperative recovery course, and can be derivative of the patient’s general condition and comorbidities.

Our Multidisciplinary Team focuses on an adequate perioperative assessment and management, to minimize any avoidable complications.

Patients can also experience complications that are specific to having a transcutaneous implant anchored in one’s bone.

Osseointegration-specific complications:

1. Superficial infection
2. Deep infection
3. Tissue granulation
4. Ooze and odour
5. Maggots
6. Periprosthetic fracture
7. Aseptic loosening
8. Pain
9. Need of revision surgery or reamputation

1. Superficial infection:

Stoma is a permanent aperture in the skin, through which the intraosseous implant can connect to the external prosthesis. It enables access for local skin flora into soft tissues around stoma. On most occasions all the apertures in your body maintain a good balance between natural flora and pathogens. Hot, red, swollen, painful stoma with or without a discharge is a sign of infection and local predominance of pathogens. Almost all osseointegration patients will experience one early superficial infection, until the balance is obtained. The superficial infection is treated with a course of antibiotics.

2. Deep infections:

Deep infections penetrate the inner soft tissue layers or bone causing abscesses (pus collection), or osteomyelitis (bone infection). The deep infection needs surgical intervention to remove contaminated tissues. Occasionally it necessitates the removal of the implant, in such cases, after eradication of infection, the implant can be successfully reinserted. Almost 1/5 of osseo patients experience deep infection.

‍Stoma hygiene is vital to avoid recurrent superficial or deep infections.

3. Tissue hypergranulation

Mechanical contact between the stoma and implant surface can cause an overgrowth of connective tissue, that can occasionally be potentially painful. Hypergranulation can be easily treated with local application of silver nitrate. Osseointegration International has designed its implants to have an ultra-polished surface at its metal-stoma interface, to minimize this complication.

4. Ooze and odour

Ooze is also a consequence of mechanical irritation of the implant’s surface to the soft tissues. The stoma is always colonised by patient-specific flora, which guarantees a microbiological balance and prevents the development of pathogens. General patient conditions will determine the amount of ooze that one is experiencing. Some will experience daily ooze, for others the stoma will be completely dry. The stoma matures and reaches its balance at about 12 months after surgery. The ooze should be a straw-yellow, transparent, watery fluid and is not a sign of infection. If the ooze turns turbid, dense and whitish, you need to consult your surgeon to exclude an infection. Bleeding around the stoma may also occur, especially in patients on blood thinners.

Odour is related to the predominance of certain flora. By itself, it also is not a sign of infection.

Our MDT can help you manage excessive ooze and odour, and the peer support group also can assist with some tips and tricks.

5. Maggots

Patients living in hot and humid climates may occasionally experience maggots infestation around the stoma, this can happen to any open wound exposed to such environments. In some parts of Australia, the maggots are seasonal. Adequate care, hygiene and protection of stoma while working in the garden or during bushwalking will prevent maggots. But if you experience maggots, our team has adequate protocols to treat the condition successfully.

6. Periprosthetic fractures:

The break of the bone around the implant is called a periprosthetic fracture.  It can happen during the surgery, or as a result of an injury, for example, a fall. The treatment for fractures around the osseointegration implant does not differ from surgery for other periprosthetic fractures (around the artificial knee or hip, for example) and involves standard methods of fracture fixation and a period of restricted weight-bearing.

7. Implant loosening:

Implant loosening may occur primarily in the event of the failure of the bone to integrate with the implant, or secondarily, in the previously integrated implant, as a result of mechanical force (injury) or infection. If the implant becomes loose, it is removed, the bone bed is examined for infection and the osseointegration can be reinserted after infection has been excluded or after it has been treated.

8. Pain

Pain is a uniform complication observed in any amputee patient regardless of their use of a wheelchair, socket or osseointegration-mounted prosthesis. Pain can originate from index trauma or previous surgeries in all amputees and suboptimal prosthetic alignment in all prosthesis users. Socket-mounted prosthetics give socket-specific pain. Direct bone mounting of the prosthesis has its own range of pain issues.  It is crucial to distinguish osseointegration-specific from nonspecific pain and to identify its source. Any amputee may experience phantom pain, neuropathic sensations from neuroma formation or chronic regional pain syndrome. Deep pain can result from fascia retraction, deep scarring or infection.  The osseointegration procedure specifically does not influence the course of the above types of pain. Distinctive for osseointegration is a pain related to stoma (irritation from the implant or infection), or to implant loosening (mechanical or infection).

9. Need of revision surgery or reamputation.

Revisions may be necessary after osseointegration, for a number of causes (not all of them being preventable). With time passing or alterations of one’s body habitus, the soft tissues may start sagging around the stoma, causing painful irritation. Stump refashioning will be performed to reduce tissue in the vicinity of the implant. If pain is caused by growing neuromas, that can be addressed with a so-called TMR or RPNI nerve surgery.  Long-standing infections will necessitate meticulous debridement and recreation of the stoma. Implant loosening and deep infection will need implant removal, addressing the primary problem and reimplantation of the prosthesis in the two-stage process. On very rare occasions, when the condition is not salvageable, a further shortening of the limb stump may be necessary, or the patient may opt to remove the implant and return to the socket-based prosthesis.