The Clinical History and Basic Science Origins of Transcutaneous Osseointegration for Amputees

Abstract

Transcutaneous osseointegration for amputees (TOFA) refers to an intramedullary metal endoprosthesis which passes transcutaneously to connect with a limb exoprosthesis. The first recognizably modern experiments and attempts occurred in the 1940s. Multiple researchers using a plethora of materials and techniques over the following 50 years identified principles and obstacles which informed the first long-term successful surgery in 1990. Unfortunately, the current mainstream TOFA literature presents almost exclusively subsequent developments, generally omitting prior research, leading to some historical mistakes being repeated. Given the increasing interest and surgical volume of TOFA, this literature review was performed to delineate TOFA’s basic science and surgical origins and to integrate these early efforts within the contemporary understanding. Studying this research could protect and benefit future patients, surgeons, and implant developers as TOFA is entering a phase of increased attention and innovation. The aim of this article is to provide a focused reference of foundational research, much of which is difficult to identify and retrieve, for clinicians and researchers.

Bone density changes after five or more years of unilateral lower extremity osseointegration: Observational cohort study

“…However, despite TOFA being used clinically to reconstruct lower extremity amputees for over 30 years ( Hoellwarth et al, 2022f ; Hoellwarth et al, 2020b ), only two human in vivo studies were identified reporting the effect on proximal femur bone density, both published in 2019. Hansen reported on 19 transfemoral amputees followed up to 30 months ( Hansen et al, 2019 ).…”

“…Transcutaneous osseointegration for amputees (TOFA), recently reviewed ( Hoellwarth et al, 2020a ; Hoellwarth et al, 2022f ), is a surgical reconstruction technique wherein an intramedullary metal implant is anchored directly to the skeleton and then attached to a standard external prosthetic limb via a permanent transcutaneous connector. Versus TP, TOFA improves prosthetic use and quality of life ( Hagberg et al, 2008 ; Lundberg et al, 2011 ) without minimal associated risk of complications leading to proximal limb amputation or mortality ( Hoellwarth et al, 2022a ).…”

Osseointegration Following Transfemoral Amputation After Infected Total Knee Replacement: A Case Series of 10 Patients With a Mean Follow-up of 5 Years

“…As such, the basic and clinical sciences are still rapidly progressing. Recent articles [ 11 , 49 , 50 ] provide in-depth yet clinically oriented explorations of the historical origins, basic science progression, and clinical evolution. Some critical topics are worth highlighting here.…”

Bone-anchored prostheses for transfemoral amputation: a systematic review of outcomes, complications, patient experiences, and cost-effectiveness

“…This process, termed osseointegration (OI), results in a bone-anchored prosthesis in which the implant that extends percutaneously, i.e., through the skin, allows a direct functional and structural connection to the prosthetic components ( 22 , 23 ). Bone-anchored implants have been used for dental and maxillofacial reconstructions for decades, and since the 1990s, they have been used for prosthetic reconstructions for individuals with transfemoral amputations ( 24 ). Bone-anchored prosthesis is a treatment option for various amputation levels in several areas worldwide.…”