VA performs first osseointegration surgery in its history

The increasing numbers of Veterans living with limb loss would make focus around amputee care and prosthetics a priority, and that focus would lead to eventual changes in Veterans Affairs (VA) that make it an industry-wide leader in prosthetics and rehabilitation care. 

Once restricted by federal law that required the formerly named Veterans Administration to provide prosthetics through the use of low-bid contracts that suffered through a painfully long approval process, Congress enacted a provision into law that would allow VA to procure prosthetics “without regard to any other provision of law.” A change that meant VA could acquire and provide the best available prosthetics to our nation’s Veterans without worry about cost. 

"It’s a little-known fact that puts VA in a position to stay on the forefront of limb loss technology and provide the best possible options to Veterans in need," said Dr. Alexis Dang, Staff Physician at San Francisco VA Health Care System (SFVAHCS) and attending physician on this osseointegration case, the first in VA's history. 

“VA health care isn’t handcuffed in the ways traditional insurance providers are,” added Adam Jacobsen, Certified Prosthetist/Orthotist (CPO), Omaha VA Medical Center. “If it is FDA approved and medically justified, we can get it for the Veteran.”

Sitting home on his 100+ acre farm, Air Force Veteran Douglas Mayo, reflected on his journey from skeptic to VA convert that brought him to SFVAHCS from Nebraska, where he first met Jacobsen. 

“I remember going to visit my grandfather at the VA when I was a kid. It was filthy. It felt like death,” said Mayo, reflecting. “I didn’t want anything to do with the VA.”

Now, making final preparations for the second step of his pioneering osseointegration surgery at SFVAHCS, the Air Force Veteran sounds more like an evangelist.

“What an idiot I was,” Mayo said. “I should’ve never waited.”

An accident during his Air Force tenure would lead to knee replacement surgery for Mayo but his previous experience with VA kept him from using its available services, instead opting for care outside the VA system. After 13 surgeries in 3 years because of repeated failures of the replacement knee, and a subsequent infection, Mayo would be forced to have his right leg amputated.

“I could die, or they could cut it off,” said Mayo. “I didn’t need my knee too bad.”

Perhaps in a moment of serendipity, denial for his preferred prosthetic would bring him to VA, where Jacobsen was able to get Mayo his preferred socket.

“Doug is an active guy. If you know him, you know he gets after it in everything he does,” said Jacobsen. “His private sector prosthetist couldn’t get him the knee he wanted and that brought him to us at VA.”

Mayo would get the socket he wanted but it wasn’t long before his activity level demanded something that could give him more freedom, as well as less pain. 

“I’d work to the point where I’d take my liner off, and I poured blood out,” he said. “I’d tough it out, but I’d also think, ‘there has to be a better way’.”

According to Jacobsen, “We fit him with a traditional socket but with his activity, and the things he does, he wanted to get away from the restrictions of the traditional socket.”

Once Jacobsen told Mayo about osseointegration and Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA™) Implant System, newly available at VA after FDA approval, it was full steam ahead.

What is osseointegration?

Currently piloted at San Francisco VA Health Care System, osseointegration surgery is a type of procedure that eliminates the need for traditional socket prostheses by enhancing stability, functionality, comfort, and providing a more secure attachment for amputees.

First performed in the United States at the University of California, San Francisco, by Dr. Richard Branemark, along with Dr. Rosanna Wustrack and Dr. Richard J. O’Donnell in 2016, the heart of the innovation is the direct integration of the prosthetic limb with the patient’s bone structure across two surgeries. In the first surgery the titanium fixture is implanted in the femur (thigh bone). The patient then undergoes a healing period of about 3 - 6 months. During this period, the bone grows onto the implant anchoring it in the femur. After this healing period, patients undergo a second surgery. In this surgery, an abutment is joined to the implant. It extends outside the skin, allowing the external prosthesis to be attached. The healing period for the second surgery is about 6 months. 

One of the primary advantages of the procedure lies in the reduction of discomfort and skin-related issues. Traditional prosthetics often lead to skin irritation and pressure sores due to constant rubbing and compression within the socket, something Mayo looks forward to, having experienced daily issues with his own socket.

The procedure also contributes to improved proprioception – the body’s ability to sense the position and movement of its parts. With a direct connection to the bone, users experience a more natural feel and control over their prosthetic limb. This heightened awareness fosters a seamless integration of the prosthetic into daily activities, reducing the mental effort traditionally associated with maneuvering a prosthetic limb.

Mayo currently lives 90 miles from the nearest VA facility, one of the many Veterans served by VA who live in rural areas. Thanks to advances in care by VA, Mayo was able to conduct most of his initial consults from the comfort of his own home with providers in Minneapolis, Omaha, and San Francisco. 

“That’s the advantage of having a surgery like this done by VA,” said Dr. Dang. “VA Video Connect gives all our Veterans access to the highest level of specialized expertise at our medical centers.”

Technological advances across all of VA have also made communication a major strength of the organization, providing a distinct advantage over comparable procedures that are performed outside VA. Free of the typical lag time that comes with sharing sensitive patient health information when coordinating with community care providers, the surgical team was able to focus on more critical areas of surgical preparation.

“We utilized 3D printing at our VA, which is novel, to help prepare and plan for the surgery,” added Dr. Dang. “The print showed us where we needed to trim the bone and also remove residual cement from prior surgeries.”

“We have the ability to access records across the entire system,” said Jacobsen. “That’s not something that happens in the civilian sector. Being able to pull up a Veteran’s chart from anywhere in the country is invaluable.”

For Mayo, it was the staff that stood out. A stomach complication would see Mayo admitted to the hospital, delaying step one of the procedure for 3 weeks. The staff, which earned San Francisco VA Health Care System its recently awarded 92% trust score, left the Veteran impressed.

“I was totally enamored with the staff,” said Mayo. “They were focused on the quality of care. It was the best experience I’ve ever had in a hospital, and I’ve had my share.”

Now, only a few weeks away from step 2 of the osseointegration procedure, Mayo is beginning to see the light at the end of the tunnel and after his experience as the first Veteran to receive the procedure at VA, Mayo also hopes to be a resource for subsequent Veterans who are eligible and decide to follow in his footsteps.

“I didn’t have anyone I could talk to or lean on during this whole process,” said Mayo. “I did a lot of research on my own to figure out what I’d have to deal with as far as recovery and pain. I’d like to be a resource for the next Veteran who decides to do this. I know how lonely that felt.”

Always one to keep a good attitude with everything he does, Mayo quickly shifted his thoughts to better things. 

“I can’t wait to stand on two legs and take a shower,” said Mayo. “It’s going to be the most fantastic feeling, ever.”