Surgical Techniques

Single-stage osseointegration is the default surgical method; two-stage surgery is reserved for rare circumstances such as concurrent joint replacement. In simultaneous transfemoral amputation and osseointegration, bone resection must occur at least 150 mm proximal to the knee joint line. The minimum tibial resection level for simultaneous transtibial osseointegration is approximately 25 cm from the ground. Metaphyseal fixation is explicitly avoided in simultaneous transfemoral cases due to the risk of compromised bone–implant contact and mechanical complications. Five operative approaches are defined according to amputation level, timing, and soft-tissue availability. Peripheral nerves in simultaneous transtibial cases are managed using TMR or RPNI to reduce postoperative neuroma, neuropathic pain, and phantom limb pain.