Tony Cordell, a 35-year-old Midland, North Carolina, resident and father of two young boys, lost both of his legs in a work-related accident in June 2021. The former landscape production manager remembers waking up in the intensive care unit (ICU), fearing he’d never be able to walk or play with his two young children again.
“Being a bilateral amputee, the challenges are unreal,” says Tony. “You don’t know how much you use your legs until you don’t have them anymore. Things that were a normal part of your day—from playing with your kids to going to the restroom to going up and down the stairs—are now a challenge. It’s life-changing.”
While in the ICU, Tony met Dr. Joseph Hsu, a limb deformity and orthopedic trauma surgeon at Atrium Health Musculoskeletal Institute. Hsu specializes in complex limb reconstruction and offers an innovative new treatment for amputation reconstruction called osseointegration. Osseointegration is an alternative to socket-based prosthetics.
“Most amputations are managed with socket-based prosthetics,” says Dr. Hsu. “This means the limb goes into a socket made from carbon fiber. The challenge with socket-based prosthetics is people often have issues with socket fit, change in limb volume, sweating and the ability to generate enough power through the limb to effectively use the prosthetic.”
What is Osseointegration?
Osseointegration helps mitigate many of those problems because the prosthetic’s titanium anchor is attached directly to the bone, so a socket is no longer needed. The osseointegration anchor is then attached to the most modern prosthetics available.
“Tony was injured on the job and was in a life-threatening situation,” says Hsu. “He suffered traumatic amputations through the thighs that were very, very short, which meant he had no room for normal socket prostheses. I was asked to meet him to see if he would be a candidate for osseointegration due to the unique nature of his injuries.”
Osseointegration has been used in Europe for nearly 30 years and was recently approved in the United States. Hsu is among only a few surgeons who perform osseointegration surgery in the United States, with the Musculoskeletal Institute being one of the destination facilities for this type of innovation and one of few programs in the country that provide above-the-knee osseointegration.
“When I met with Dr. Hsu and he told me about osseointegration, it gave me hope that I would be able to walk again,” says Tony. “There was a lot of work ahead, but I had more peace of mind after my conversation with Dr. Hsu.”
Preparing for Treatment
Hsu says most candidates for osseointegration have had a previous socket-based amputation that’s not working well for them. Femur (thigh) osseointegration candidates may have trouble getting a good fit with their socket, nerve dysfunction, problems with sweating or hair growth and/or difficulty functioning with a stable prosthesis. Humerus (arm) osseointegration candidates may also have trouble with suspension or the ability to raise their arm overhead.
Tony’s situation was unique because Hsu knew from the beginning that if Tony was going to move, other than being in a wheelchair, the team needed a plan for osseointegration from the beginning. Tony had very short residual limbs with crushed tissue and not enough tissue to cover the end of the bone. With typical surgical amputations, the end of the bone can be covered with muscle fascia and skin.
“We really felt from the beginning that Tony would be a candidate for osseointegration and it allowed us to approach his acute problem very differently,” says Hsu. “We didn’t transfer muscle into the damaged wound bed and we didn’t have to keep cutting away the bone to get muscle, fascia and skin to cover the bone. We could only remove enough bone where we could get the skin over the bone and come back with the next step of osseointegration.”
Undergoing Surgery for Osseointegration
Osseointegration surgeries are typically done in two stages:
- Stage one: The surgeon implants the device and closes the skin over the device. The patient goes home the same day to recover.
- Stage two: Two to three months later, the surgeon does another operation to work on the nerves. This procedure is known as regenerative peripheral nerve interface. During the surgery, the physician wraps the nerve in a piece of muscle to prevent the patient from having nerve pain later. Then, the surgeon creates a tissue flap and a penetration site to allow the prosthesis to attach to the limb.
Hsu treated both of Tony’s legs and performed both stages of osseointegration in one operation.
“It was really unique and the first time we’ve done that here,” says Hsu.
Recovery and Rehabilitation
After stage two, patients typically go to Carolinas Rehabilitation Mount Holly and work with the osseointegration specialists there, including Dr. Douglas Thommen, a physical medicine and rehabilitation physician, and Angela Abernathy, a physical therapist.
“With these reconstructive amputations, it can take a long time for patients to get back into shape,” says Hsu. “Their function doesn’t come back from an operation, but rather from the hard work they put in during rehabilitation.”
Abernathy says Tony was the first osseointegration patient with a bilateral amputation to go through rehabilitation at her location.
“The cool thing about osseointegration is you get direct muscle control out of your bone,” says Abernathy. “With a socket, you don’t really have as much control because it’s sitting on top of your muscle. Osseointegration gives the patient ease, comfort and more control of their movement.”
After Tony healed from surgery, he spent several months in physical therapy with Abernathy to gain strength and flexibility in his hip flexors before he could put weight on the osseointegration implants. From there, he started working with 12-inch implants. Once Tony regained more hip flexor mobility, he was able to use long prosthetics that allowed him to get nearly back to his height before the accident.
“Being able to walk with an actual knee was really, really exciting,” he says.
Abernathy is amazed at Tony’s progress.
“He came in unable to stand and was very tight through his hips,” she says. “Seeing him get his full-length prosthetics and walk upright with a walker is phenomenal. His dedication to his ultimate goal of walking without any assistance is truly inspirational. I’m honored to work with him and see that through.”
Looking forward to the future
“I took a lot for granted before the accident and it’s changed my perspective on life,” says Tony. “I’m thankful to be alive and wake up and see my kids’ and wife’s faces.” 
He’s looking forward to being more active with his family, hiking in the mountains and swimming at the beach.
“I’m very excited for what the future holds after therapy,” says Tony. “I’m excited to get back on the mountain and do some snowboarding. I’m excited to teach my two boys to snowboard.”
His encouragement to other people who have undergone amputations: “Try to stay positive and look at the good things in life. It’s hard work, but it’s worth it in the end.”
Tony is grateful to his team at Atrium Health for helping him get closer to his goals each day.
“I’m so grateful to have each and every one of them help me out,” he says.
Finding Support
Hsu notes that the osseointegration process can be mentally, emotionally and physically demanding. He encourages his patients to connect with others who have gone through osseointegration.
“One of the best tools we have for restoring a patient’s confidence that we’ll be able to get them back to their life’s activities is other patients,” he says.
Patients who opt for osseointegration have a support group of peers they can meet with periodically through the Trauma Survivors Network and in peer groups throughout the Atrium Health system. They can also become Near Peer Mentors, which means they are further along in the process and can help educate and mentor others who are entering into the osseointegration process.
“We’re just on the forefront of osseointegration for amputation,” says Hsu. “The future is incredibly bright.”
Learn more about osseointegration at Atrium Health’s Musculoskeletal Institute.
Article updated 4/11/2023
