Osseointegrated (or bone-anchored) prosthetic implants, are often considered by clients with an amputation who are struggling with poor socket fit, discomfort, recurrent skin infections, volume fluctuations of the stump and/or pain in the residual limb.1

Nutrition factors frequently determine a client’s eligibility for this procedure and can have a significant impact on the frequency of surgical complications and how well the bone and surrounding tissues heal after the procedure.  This is because key nutrients in food such as protein, calcium and vitamin C, act as essential building blocks to repair bone fractures, heal wounds on the skin and generally help with surgical recovery.

Contraindications

While osseointegration is contraindicated in people with severe peripheral vascular disease, chemotherapy treatment, pregnancy, mental illness, smoking, skin disease and infection, the key nutrition- and dietetic-related contraindications include the following:1

1. Body weight in excess of 100kg

Excess body weight, particularly in the form of visceral fat around the abdomen, increases the production of pro-inflammatory cytokines.  These cytokines increase the breakdown of bone, suppress bone building/repair and increase insulin resistance.2  Having a Body Mass Index (BMI) over 25kg/m2 also triples the risk of post-surgical infections.3

2. Diabetes

People with diabetes take longer to osseointegrate and have a higher risk of implant failure due to reduced bone-implant contact.2,4,5 High blood glucose levels also reduce bone quality and bone strength, reduce collagen synthesis, inhibit certain growth factors and result in diabetic osteopathy.6,7  Diabetes also increases the risk of having a surgical site infection.8

3. Osteoporosis

Fragile bones, with poor bone quality due to osteoporosis, increases the risk of implant failure due to a deficiency of bone formation.9 Osteoporosis is incredibly difficult to correct once the bone mass has deteriorated, so the goal is always to prevent this from happening.  Adequate calcium and vitamin D (in addition to weight bearing activity), can help do this.

Top 3 nutrition tips for optimal bone health

1. Maintain a healthy weight

As outlined above, excess body weight is detrimental to bone health and clients who are already over 100kg will need to lose weight in order to be eligible for osseointegration surgery. Clients therefore need to be monitoring their weight regularly post-injury, to prevent any unwanted weight gain.  Maintaining a healthy weight is often a huge challenge after an amputation, because inflammation, reduced activity levels and/or inadequate nutrition, frequently result in reduced muscle mass and a slower metabolic rate.

2. Ensure an adequate nutrient intake

The nutrients most important for building, maintaining and repairing healthy bones include the following: 10,11

• Calcium – this is the main component of bone and an inadequate intake of calcium results in bone loss.  Low fat dairy products are an excellent source of calcium.
• Vitamin D – this nutrient helps the body absorb and retain calcium.  While vitamin D is produced when the skin is exposed directly to UVB rays from the sun between April and October, most people don’t realise that UVB rays are blocked by windows, sunscreen, and clothing.  A vitamin D supplement is therefore the best option for most people and 400 IU of vitamin D per day is required for everyone in the UK between October and April.  For more information go to Vitamin D deficiency after a catastrophic injury.
• Vitamin C – this vitamin accelerates bone healing by helping to create collagen, which is the “bone frame” where the calcium is deposited.  Citrus fruit is an excellent source of vitamin C.
• Vitamin K – this vitamin works synergistically with vitamin D and is needed for strong, healthy bones.  Dark green leafy vegetables are a great source of vitamin K.
• Magnesium – this mineral converts vitamin D into its active form and is needed for calcium absorption and metabolism.  Nuts and legumes are great sources of magnesium.
• Protein – protein is a component of bone and makes up ~30% of bone mass, so adequate protein is essential.  Certain amino acids (lysine and proline) are also needed to make collagen, which is the “bone frame” where calcium is later deposited.  Legumes, tofu, eggs, fish, chicken and beef are all excellent sources of protein, lysine and proline. Vegetable sources of protein (e.g. legumes) are better for bone health than animal sources.

3.  Have blood tests to rule out deficiencies.

Vitamin D deficiency has been linked to a 300% increase in osseointegration implant failures, so this does need to be screened for and corrected early.12  Be sure to check iron levels (haemoglobin and ferritin) as well before surgery and ensure any deficiencies are corrected.  Pre-operative iron-deficiency anaemia increases post-operative complications, delays healing and results in longer hospital stays.13  Given that diabetes is a contraindication to osseointegration, it would seem sensible to check blood glucose/HbA1c prior to surgery to see if someone has diabetes and was perhaps unaware of it.  Surprisingly though, the NICE guidelines do not support this.

Dietitians can help clients get physically prepared for surgery and ensure they are doing everything possible to maximise bone healing and bone health.  You can find other helpful information related to this topic in Non-union, orthopaedic injuries…and nutrition as well as Nutrition before and after surgery.

If you require a dietitian for an assessment or to treat a client considering osseointegration, please contact us at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

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