What You Should Know Before Getting a Prosthetic Leg

Prosthetic legs, or prostheses, can help people with leg amputations get around more easily. They mimic the function and, sometimes, even the appearance of a real leg. Some people still need a cane, walker or crutches to walk with a prosthetic leg, while others can walk freely.

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If you have a lower limb amputation, or you will soon, a prosthetic leg is probably an option you&#;re thinking about. There are a few considerations you should take into account first. 

Not Everyone Benefits from a Prosthetic Leg

While many people with limb loss do well with their prosthetic legs, not everyone is a good candidate for a leg prosthesis. A few questions you may want to discuss with your doctor before opting for a prosthetic leg include:

• Is there enough soft tissue to cushion the remaining bone?
• How much pain are you in?
• What is the condition of the skin on the limb?
• How much range of motion does the residual limb have?
• Is the other leg healthy?
• What was your activity level before the amputation?
• What are your mobility goals?

The type of amputation (above or below the knee) can also affect your decision. It&#;s generally easier to use a below-the-knee prosthetic leg than an above-the-knee prosthesis. If the knee joint is intact, the prosthetic leg takes much less effort to move and allows for more mobility.

The reason behind the amputation is also a factor, as it may impact the health of the residual limb. Your physical health and lifestyle are also important to consider. If you were not very active and lost your leg due to peripheral vascular disease or diabetes, for example, you will struggle more with a prosthesis than someone who was extremely active but lost a limb in a car accident.

When it comes to amputation, each person is unique. The decision to move forward with a prosthesis should be a collaborative one between you and your doctor.

Prosthetic Legs Are Not One Size Fits All

If your doctor prescribes a prosthetic leg, you might not know where to begin. It helps to understand how different parts of a prosthesis work together:

• The prosthetic leg itself is made of lightweight yet durable materials. Depending on the location of the amputation, the leg may or may not feature functional knee and ankle joints.
• The socket is a precise mold of your residual limb that fits snugly over the limb. It helps attach the prosthetic leg to your body.
• The suspension system is how the prosthesis stays attached, whether through sleeve suction, vacuum suspension/suction or distal locking through pin or lanyard.

There are numerous options for each of the above components, each with their own pros and cons. &#;To get the right type and fit, it&#;s important to work closely with your prosthetist &#; a relationship you might have for life.

A prosthetist is a health care professional who specializes in prosthetic limbs and can help you select the right components. You&#;ll have frequent appointments, especially in the beginning, so it&#;s important to feel comfortable with the prosthetist you choose.

Rehabilitation Is an Ongoing, Collaborative Process

Once you&#;ve selected your prosthetic leg components, you will need rehabilitation to strengthen your legs, arms and cardiovascular system, as you learn to walk with your new limb. You&#;ll work closely with rehabilitation physicians, physical therapists and occupational therapists to develop a rehabilitation plan based on your mobility goals. A big part of this plan is to keep your healthy leg in good shape: while prosthetic technology is always advancing, nothing can replicate a healthy leg. 

Getting Used to a Prosthetic Leg Isn&#;t Easy

Learning to get around with a prosthetic leg can be a challenge. Even after initial rehabilitation is over, you might experience some issues that your prosthetist and rehabilitation team can help you manage. Common obstacles include:

• Excessive sweating (hyperhidrosis), which can affect the fit of the prosthesis and lead to skin issues.
• Changing residual limb shape. This usually occurs in the first year after an amputation as the tissue settles into its more permanent shape, and may affect the fit of the socket.
• Weakness in the residual limb, which may make it difficult to use the prosthesis for long periods of time.
• Phantom limb pain could be intense enough to impact your ability to use the prosthesis.

A Note on Phantom Limb Pain

Phantom limb pain, or pain that seems to come from the amputated limb, is a very real problem that you may face after an amputation. About 80% of people with amputations experience phantom limb pain that has no clear cause, although pain in the limb before amputation may be a risk factor.

Mirror therapy, where you perform exercises with a mirror, may help with certain types of phantom limb pain. Looking at yourself in the mirror simulates the presence of the amputated leg, which can trick the brain into thinking it&#;s still there and stop the pain.

In other cases, phantom limb pain might stem from another condition affecting the residual limb, such as sciatica or neuroma. Addressing these root causes can help eliminate the phantom pain.

Your Leg Prosthesis Needs May Change

At some point, you may notice that you aren&#;t as functional as you&#;d like to be with your current leg prosthesis. Maybe your residual limb has stabilized and you&#;re ready to transition from a temporary prosthesis that lasts a few months to one that can last three to five years. Or maybe you&#;ve &#;outwalked&#; your prosthesis by moving more or differently than the prosthesis is designed for. New pain, discomfort and lack of stability are some of the signs that it may be time to check in with your prosthetist to reevaluate your needs.

Your prosthetist might recommend adjusting your current equipment or replacing one of the components. Or you might get a prescription for a new prosthetic leg, which happens on average every three to five years. If you receive new components, it&#;s important to take the time to understand how they work. Physical therapy can help adjust to the new components or your new prosthetic leg.

Prosthetic Leg Technology Is Always Evolving

There are always new developments in prosthetic limb technology, such as microprocessor-driven and activity-specific components.

• Microprocessor joints feature computer chips and sensors to provide a more natural gait. They may even have different modes for walking on flat surfaces or up and down the stairs.
• There are also specialized prosthetic legs for different activities, such as running, showering or swimming, which you can switch to as needed. In some cases, your everyday prosthetic leg can be modified by your prosthetist to serve different purposes.
• Osseointegration surgery is another option. This procedure involves the insertion of a metal implant directly into the bone, so there is no need for a socket. The prosthetic leg then attaches directly to that implant. While this procedure is not right for everyone and is still under study, it can provide improved range of motion and sensory perception.

It&#;s important to remember that you&#;re not alone in navigating the many different prosthetic leg options. Your care team will help you weigh the pros and cons of each and decide on the ideal prosthetic leg that matches your lifestyle.

Johns Hopkins Comprehensive Amputee Rehabilitation Program

Having the support of a dedicated team of experts is essential when recovering from the amputation of a limb. At Johns Hopkins, our team of physiatrists, orthotists, prosthetists, physical and occupational therapists, rehabilitation psychologists and other specialists works together to create your custom rehabilitation plan.

Learn more about our amputee rehabilitation program

The HSS Osseointegration Limb Replacement Center at Hospital for Special Surgery provides a major advance in amputation reconstruction surgery for amputees who have not tolerated or do not want to use a traditional prosthetic socket. The interdisciplinary team of amputation reconstruction specialists, upper- and lower-extremity surgeons are devoted to helping amputees improve their mobility and daily lives. Hospital for Special Surgery is continually ranked #1 orthopedic hospital in the United States, and HSS surgeons were the first in the United States to perform osseointegration limb replacement for people with transtibial amputations.

What is osseointegration?

Osseointegration is the scientific term for bone ingrowth into a metal implant. An artificial implant is permanently, surgically anchored and integrated into bone, which then grows into the implant.

Osseointegration is most commonly used in dental implants and joint replacement surgery. It has been very successful in these uses for decades.

What is osseointegration limb replacement?

In this surgery, a limb prosthesis is connected directly to the skeleton. The prosthesis is a custom-made, porous, coated titanium implant that is aligned with the bone of the residual limb. (Find a doctor at HSS who performs osseointegration limb replacement.)

HSS was the first hospital in the United States to use osseointegration to treat people with transtibial amputations (below the knee).

Osseointegration limb replacement surgery can be done in the following bones:

• the femur (thighbone)
• tibia (leg bone)
• humerus (upper arm bone)
• radius and ulna (forearm bones)

What are the advantages of osseointegration over traditional prosthetic limbs?

In general, this procedure:

• improves mobility (control of the prosthetic leg)
• improves

  proprioception

• reduces nerve pain
• eliminates common problems associated with sockets

Patients with an osseointegrated limb have better physical control over &#; and a more intimate, emotional connection to &#; their prosthetic leg or arm, compared to those using a traditional socket prosthesis. The direct skeletal connection between the prosthesis and the patient&#;s own natural bone provides superior stability, strength and energy transfer (in which muscle strength from the residual limb is diminished where it connects with the prosthesis).

In particular, patients who have an osseointegrated prosthetic limb have dramatically improved proprioception, called osseoperception. Touch vibrations to the implant (such as during impact with the ground while walking) can be transferred through to the person&#;s natural bone. This helps patients walk more smoothly, feel more stable and effectively transfer all of the strength of their residual limb to the prosthesis.

Video: Wounded warrior stands tall after bilateral osseointegration limb replacement

Bone-anchored prostheses have been shown to lead to better patient outcomes than standard, socket-based prostheses. An osseointegrated prosthetic limb reduces or eliminates common problems associated with sockets, including:

• pinching
• sweating
• poor fit or need for frequent refitting
• poor ability to control the prosthesis
• lack of patient confidence due to mobility challenges
• nerve pain
• skin, irritation, sores and ulcers

In traditional prosthetic leg systems, there can be a poor fit between the residual limb and the socket. Many patients experience significant changes in the size and shape of their residual limb during the first 12 to 18 months after amputation surgery.

In addition, the angle at which the remaining leg bone rests inside the socket is frequently uneven with the prosthetic leg. This is called malalignment. Such awkward angles can cause balance problems and poor energy transfer. This can make it difficult for patients to move well and can even lead to falls and fractures.

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Additional resources:
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Osseointegration procedural animations

Osseointegration limb replacement surgery for transfemoral amputation

Managing a tibia amputation with osseointegration reconstruction

 

Improved movement in the upper limbs

In patients with arm and hand prostheses, the large harness and socket that is often used in upper extremity prosthetics is eliminated. This enables the patient to actively use their body&#;s natural shoulder and elbow movement.

Osseointegrated arm implants are also compatible with myoelectric (bionic) prostheses. These allow muscle twitches in the residual arm to communicate with the arm prosthesis to allow patients to actively move their prosthetic elbow, wrist and hand. New technologies use pattern recognition algorithms to relay muscle movement signals in real time from the residual limb to the brain and then back to microcontrollers that control the movement of the bionic arm or hand. In some cases, targeted muscle reinnervation (TMR) is used to enhance the muscle signals.

Individual types of prosthetic limbs designed for different purposes, such as swimming or running, can be easily connected to and disconnected from the implant abutment using an Allen wrench (hex key) or quick-connect hardware.

Reduced nerve pain

Many amputees also experience nerve pain in the residual limb, which is caused by a neuroma. This is often described as &#;phantom&#; leg or arm pain. In most cases, wearing a socket prosthesis puts added pressure on the remaining limb, which worsens this nerve pain.

New surgical procedures to ease the pain associated with amputation neuromas can now also be performed together with osseointegration surgery. These include:

• targeted muscle reinnervation (TMR)
• regenerative peripheral nerve interface (RPNI) with free muscle graft

Who is a candidate for osseointegration limb replacement?

Osseintegration leg or arm replacment is especially helpful for amputees who are having a poor experience with their socket prosthesis.

The use of a socket is often especially difficult for patients whose residual limb is any of the following:

• short
• wide
• scarred
• painful

Before-and-after X-ray images showing malalignment between an above-the-knee amputation residual limb with a socket-based prosthesis (left); and an aligned, osseointegrated leg implant and connected prosthesis (right)

 

How is osseointegration limb replacement surgery done?

The process begins with front- and side-view X-rays and CT scans of the limb. These are taken to determine precise measurements for a custom-made implant built to fit inside the bone.

The implant is created and inserted into the residual limb bone and connected to a dual post, also known as a dual cone. The surgery to prepare and install the implant is done during a single hospital stay, rather than in separate surgeries. Surgeons also address any neuromas or problems with soft tissues and partner with plastic surgeons to perform soft-tissue contouring to enhance the benefits of limb replacement. This usually involves removing, lifting and tightening excess or loose soft tissue.

At HSS, we have assembled an interdisciplinary team of healthcare practitioners for osseointegration procedures. Each person plays an essential role in ensuring the best outcomes for the patient. The team includes:

• surgeons, anesthesiologists and nurses
• prosthetics professionals known as orthotists or prosthetists
• physical and occupational therapists

What is the recovery time for osseointegration surgery?

The average hospital stay is three to four days. The growth of the bone into the implant takes about three months. Most patients can walk without crutches within about three months after surgery.

Osseointegrated leg implant recovery: The first days and weeks

On the day after surgery, a rubber footie is applied to the end of the abutment, and patients can gradually put weight on the new implant. This &#;loading&#; process begins with 20 pounds of loading for 10 to 15 minutes, four to six times per day. Patients then use crutches and work with an outpatient physical therapist over several weeks to gradually increase weight loading until the prosthetic leg is attached.

After four days, patients can start a daily shower and clean the stoma with soap and water. For the first few weeks, the surgical area will be wrapped in gauze to prevent infection.

The prosthetic leg is attached to the implant between 3 to 10 weeks after surgery, depending on bone quality. After this, patients continue to use crutches for another six weeks.

Video: HSS patient Jesse Levine demonstrates connecting and disconnecting his osseointegrated leg prosthesis

What are the risks of osseointegration?

The odds of experiencing risks are low, but they can include:

• implant loosening
• fracture
• infection

Learn why HSS has exceptionally lower infection rates than many other hospitals.

To protect patients in case of a severe fall, the connection between the implant and the prosthesis has a fail-safe mechanism to protect the bone and implant. This is similar to ski bindings that automatically release during a fall.

How long does an osseointegrated prosthesis last?

The implant is expected to last for many years after successful osseointegration with the bone. Connection parts with the prosthetic may, over time, need to be changed by the prosthetist.

This procedure has been done in Sweden since , but is relatively new, so there is not a lot of long-term results available. Implant designs have improved in recent years, and we expect these to function well over decades.

The need for revision surgery is possible in cases of fracture, loosening or deep infection.

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