Pain Management in Staged Osseointegration Procedures: A Retrospective Study and Foundation for Future Optimization

Osseointegration is an innovative procedure to attach an external prosthetic device directly to the skeleton. The technique has been shown to improve physical function and quality of life relative to conventional socket prosthetic devices. While much of the research in osseointegration has focused on functional outcomes, less is known regarding perioperative pain management. The purpose of this study was to describe perioperative and postoperative pain management approaches received by patients undergoing osseointegration procedures at a tertiary medical center.

This retrospective study was determined to be exempt from Institutional Review Board review by the Walter Reed National Military Medical Center Department of Research Programs. Perioperative and postoperative pain management approaches received by 41 patients who underwent 76 staged osseointegration procedures from 2016 to 2021 at Walter Reed National Military Medical Center were described.

Pain management approaches included perioperative ketamine (51% stage I, 55% stage II), epidurals (76% stage I, 77% stage II) with a median of 3-4 days across stages, peripheral nerve catheters (27% stage I, 16% stage II), and/or single-shot peripheral nerve block (<10% across stages). The median morphine equivalent dose provided during surgery was 65 mg across both stages, with 56% and 54% of patients also requiring opioid medication in the post-anesthesia care unit. In 11 of 76 (15%) procedures, patients required an increase in the rate or concentration of epidural or peripheral nerve catheter infusion. In six (8%) unique recovery periods, patients experienced a dislodged catheter. In 27 of 76 (36%) unique recovery periods, patients experienced a significant increase in postoperative pain requiring acute pain service intervention in the form of catheter adjustment, intravenous pain medications, and/or the addition of intravenous patient-controlled analgesia. Adequate pain control was achieved with minimal epidural or peripheral nerve catheter trouble-shooting and a bolus for 24 patients (89% requiring intervention). Summed 24-hour pain scores (SPI24) did not vary across stages. SPI24 was positively correlated with opioid doses received. Patients with single, relative to multiple, limb amputations had similar SPI24 values (P > .05).

Variability in pain management requirements calls forth opportunities to optimize osseointegration analgesia care and future research. As osseointegration becomes more accessible, the need for optimizing pain management through patient-centered research becomes more salient.