Last month we described osseointegration (OI) from the perspective of an ideal candidate for the procedure. But few cases are as straightforward of Munya Mahiya’s. Most amputees face the kinds of hard choices and complications that confronted Cindy Asch-Martin.
Now 10 months post-surgery, the middle-aged Asch-Martin describes herself as “a happy camper” and considers herself an OI success story. She’s increased her mobility and decreased her pain, which in turn has led to improvements in her overall health. But those gains didn’t come easily or immediately, nor without risk. Asch-Martin received scant assurances that OI would improve her situation. On the contrary, she knew it might set her back. She went through with it anyway.
The operation literally cost Asch-Martin part of her residual limb—she went from being a below-knee to an above-knee amputee. (We’ll explain why shortly.) She also had to fly all over North America looking for a surgeon who would take her case, and ultimately wound up traveling to Australia for the procedure. Asch-Martin had to pay for everything out of pocket, which she could only afford through the generosity of friends and family members. She had to change prosthetists. And she endured multiple post-operative difficulties (including pain and infection) that took several months to resolve.
“I did have dark days where I wondered if I made a mistake,” admits Asch-Martin, a fitness junkie from Washington state who makes her living as a personal trainer. “But even though I had a time of it, I tried to forget about the negative and focus on the positive. And now I have nothing but positive.”
She’s also got insights about many of the common hurdles amputees face when it comes to osseointegration. Here are some of the obstacles Asch-Martin bumped into, and how she worked around them.
Wrestling With the Residual Limb
Asch-Martin met the first criterion for OI candidacy: She had little to no mobility in a socket prosthesis, which not only eroded her quality of life but also affected her professionally.
“I was a below-knee amputee who could not wear a socket,” she says. “I tried every socket system, every liner. I went to specialists all over the country, and everybody said they could help me—but no, they couldn’t.” Martin suffers from complex regional pain syndrome (CRPS), which makes it impossible for her to tolerate any tight-fitting coverings on her residual limb. “Just sitting with my liner on was torture,” she says. “It got to the point where I would put my leg on first thing in the morning, feed my animals, get my breakfast, and then take my leg off and train my clients with one leg.”
Over a period of eight years Asch-Martin tried to lessen the pain via medication, neurostimulation, accupuncture, and multiple types of sockets and liners. None of it worked. She relied heavily on crutches and was prone to falls, at least one of which resulted in broken bones. Inactivity weakened the bone in her residual limb, making it that much harder for her to use a socket prosthesis successfully. By the time she turned to osseointegration, she’d reached the end of her rope. “I had nothing to lose,” she says. “I was already on crutches.”
But when she started investigating OI, Asch-Martin discovered that the same nerve and bone issues that bedeviled her in a socket also posed problems when it came to surgery. She was examined by OI specialists in California, Colorado, the East Coast, and Montreal. All of them balked at performing the surgery.
“I had a short tibia with thinning bone,” she explains, “so I got labeled high-risk. They all got afraid of me. They said, ‘You’re too complex, I’m sorry.'”
Those consultations yielded a promising idea, however. If Asch-Martin would submit to above-knee amputation, she could improve her odds of OI success because the implant could be attached to her femur—which was still strong enough to form a sturdy bond—rather than her withered tibia. But there was a big catch: To become eligible for the procedure she would first have to try, and fail, in a socket as an above-knee amputee. And after more than eight years of nonperforming sockets, that was a deal-breaker for Asch-Martin.
“I said thank you to the Canadian doctor, and thank you to all the American doctors,” Asch-Martin says. “And I went to Australia.”
Going Down Under, Getting Over Hurdles
In contrast to the U.S. health care system, Australia’s medical regulations would permit Asch-Martin to have the above-knee amputation and the OI implantation in a single operation, without first needing to try an above-knee socket prosthesis. In addition, one of the world’s leading OI surgeons practices in Sydney: Dr. Munjed al Muderis of the Osseointegration Group of Australia. That was way, way out of network for Asch-Martin, of course, so she’d have to find a way cover all the costs herself. That’s when her family stepped in.
“They saw me on crutches, getting older, getting injured,” Asch-Martin says. “And they said, ‘For your birthday—and it was a big one—we’re going to send you to the leading surgeon so you can get your life back.'”
She flew to Sydney last November and had the surgery performed early in the month. Al Muderis uses a press fit OI implant system that he designed himself, with an aggressive rehab protocol that includes initial weight bearing within a few days of surgery. After years as a BK amputee, Asch-Martin had to learn a new gait as an above-knee amputee; within a couple of weeks she was taking strides with parallel bars, and she swiftly graduated to crutches. Her recovery came off without a major hitch, and she returned to her home in Washington state in December to continue rehab with her regular prosthetist and physical therapist.
It almost seemed too easy, especially after all the difficulty Asch-Martin had in finding a surgeon who’d take on her case. The day after Christmas, about six weeks post-surgery, Asch-Martin noticed some clear liquid oozing out of the scar on her residual limb—a clear sign of infection. She hustled to an urgent care facility, and as soon as she got into the examining room the wound burst.
“I had a pus pocket where the internal sutures were on the lateral side of my limb,” she explains. “That’s what had gotten infected. I let [Dr. al Muderis] know immediately. I sent him pictures and had him talk to the doctors on the scene, and the surgeon here followed his directives.”
Clearing up the infection required intrusive treatment, including IV antibiotics and several weeks on a wound vac. Martin was able to continue rehabbing anyway, but then she got another scare when a radiologist flagged some surveillance X-rays with a suggestion that her implant might be loosening. Asch-Martin says she “freaked out” over that possibility. Fortunately, her U.S. doctor found nothing amiss after an in-person examination, and Dr. al Muderis concurred after reading the X-rays.
The ups and downs continued for about four months, leaving Asch-Martin to question whether all the time, effort, and money would prove to be worth it. She has been free of serious complications since April. But if she’d known at the outset all the difficulties she would have to endure, would she still go through with osseointegration surgery?
“Absolutely,” Asch-Martin says. “Because now I’m walking over 3,000 steps a day. I’m walking without crutches. I haven’t had any more falls. Sometimes I get some nerve pain around the stoma and have to put some Lydocaine on it, but that’s it. Everything is great.”
Not everyone would give the same answer. Either way, Asch-Martin’s case realistically depicts the trials and tradeoffs that are often involved in OI surgery.