Clinical Sciences/Health Conditions
Margaret Wilson, DO
Resident
Burke Rehabilitation
Mamaroneck, New York, United States
Issac Ichoa, DO
Resident
Burke Rehabilitation Hospital
White Plains, New York, United States
Thomas Pasquale, DO
Resident
Burke Rehabilitation
White Plains, New York, United States
Kenny Tse, DO
Rehabilitation Following Bilateral Osseointegrated Transtibial Amputation After Vasopressor-Induced
Burke Rehabilitation Hospital
Astoria, New York, United States
Andrew Tom, MD
Physiatrist
Burke Rehabilitation
White Plains, New York, United States
Rehabilitation Protocol for Bilateral Transtibial Amputation with Osseointegration Following Vasopressor-Induced Limb Ischemia.
Case Description:
A 73-year-old male developed septic shock secondary to urosepsis requiring vasopressor support, resulting in ischemic necrosis of all four extremities. He then underwent bilateral transtibial amputations with placement of osseointegration implants. Persistent gangrene of both hands necessitated strict bilateral upper-extremity non–weightbearing precautions. The patient was admitted to an acute inpatient rehabilitation facility with severe impairments in mobility, balance, transfers, and activities of daily living, with significant phantom limb sensations.
Rehabilitation interventions included bed mobility training, progressive lower-extremity strengthening, endurance training using a Kinetron device, neuromuscular re-education, and Bone-anchored Enhanced Movement Optimization. Sensory re-integration strategies for phantom limb symptoms included patient education, mirror-based visual feedback, graded exposure to axial loading through the osseointegrated implants, tactile tolerance training, and diaphragmatic breathing with positioning to modulate pain during activity. Sit-to-stand training from elevated surfaces and progressed to supported standing. Gait training using a cardiac walker to a bilateral upper-extremity platform walker.
Discussions:
Although osseointegration is a promising alternative to socket-based prosthetics, there are not standardized rehabilitation protocols. In this case, rehabilitation progression was guided by tissue response, pain, and functional tolerance rather than milestones. Over a four-week rehabilitation course, mobility progressed from dependent bed mobility and non-ambulatory status to contact guard–assisted bed mobility, supervised ambulatory transfers from standard-height surfaces, and ambulation of ≥150 feet using a bilateral platform walker.
Conclusions:
This case underscores a gap in standardized rehabilitation protocols for bilateral osseointegrated amputees. Adaptive, tolerance-based rehabilitation can result in meaningful functional gains and may inform future protocol development.
