Daily Dose

In spring 2021, Amy Lewallen, a 48-year-old resident of Black Mountain, North Carolina, was having "alarming" leg pain. Because she was healthy and active, she thought it was caused by aging. She eventually went to her doctor. Nothing showed up in her ultrasound, so she did some physical therapy for possible tendonitis.

By the fall, she noticed a lump on her leg. She saw an orthopedist in December. An X-ray revealed something around the bone on her left leg – in the area just below her knee (where the fibula and tibia meet). The orthopedist concluded it was most likely a cancerous tumor.

Amy scheduled an appointment with Dr. Cynthia Emory, orthopedic oncologist and surgeon at Atrium Health Wake Forest Baptist and professor and chair of orthopaedic surgery at Wake Forest University School of Medicine. In January 2022, Amy had a biopsy and several scans. The tests revealed she had chondrosarcoma, a type of bone cancer that does not respond to chemotherapy or radiation. Surgery is the standard treatment for chondrosarcoma.

Amy's cancer was wrapped around the main artery and nerves in her leg, making a leg-preserving surgery too risky to fully control the cancer. An above-the-knee amputation was the only way to fully remove the cancer and prevent it from spreading.

"The initial recognition and acceptance of amputation were very challenging," Amy explains. "I didn't want to be different."

Amy wanted to get multiple second opinions before moving forward, which Emory recommended and supported.

"I knew I needed to hear it more than once," she says. "So I met with other doctors who pretty much all said the same thing. By the time I heard the last opinion, I was resolved about my treatment. I decided I would figure it out and do the best I can."

Amy continues, "The collaborative approach of my doctors at Atrium Health showed a real willingness to work with others on my case. This helped me feel more comfortable when making decisions about my treatment."

Osseointegration seemed like a good fit for Amy, who wasn't ready to give up her active lifestyle. She loved spending time with her family in Alabama as well as running and hiking.

"When my doctors started talking about this innovative prosthetic, I felt a bit of excitement," she explains. "This was something new and different, and it would give me a chance to meet new people. There was also excitement around the potential of getting back to some of my life."

Amy became the first patient at Wake Forest Baptist to have an osseointegration implant. Emory and Dr. Jason Halvorson, orthopedic trauma surgeon and residency program director at Wake Forest Baptist and vice chair of education and associate professor of orthopaedic surgery at Wake Forest University School of Medicine, were part of Amy's surgical team.

Benefits of a Bony Fit

Doctors have been doing osseointegration in Europe for the past 10 to 15 years with excellent results. They started using it in the military to help soldiers who were severely injured from land mines, when soft tissues didn't provide a good socket fit. The technology is now starting to be used in the U.S.

"Traditional prosthetics rely on the soft tissues to provide a socket fit that works like a suction cup," says Halvorson, who led the osseointegration reconstructive part of Amy's operation. "Osseointegration is based on the same concept behind dental implants. They put a little metal rod in the bone, which sticks out from the skin. The prosthetic connects to the metal rod."

Halvorson continues, "Instead of a soft tissue fit, it creates a bony fit. So patients get a sense of self-movement within their bone, getting better feedback when they put their leg down."

"Patients do better with the bony fit of osseointegration," says Halvorson. "They tend to wear their prosthetic more often, and they’re more active with it. It's easier to take on and off. Because they’re able to move easier, they have a better quality of life."

Osseointegration requires a multidisciplinary team, including experts in physical therapy, prosthetics and plastic surgery.

Progressive Treatment, Physical Therapy

During Amy's first surgery, Emory amputated her left leg above the knee. Following the amputation, Halvorson inserted a titanium rod implant into Amy's femur. "I felt great after the first surgery," says Amy. "I had minimal side effects and was able to start physical therapy fairly quickly, which helped keep my leg from getting stiff."

Two and a half months later, Amy had her second surgery, where Halvorson screwed in the abutment (metal connector) that the prosthetic attaches to for support. Dr. Bennett Calder, plastic and reconstructive surgeon at Wake Forest Baptist and assistant professor of plastic and reconstructive surgery at Wake Forest University School of Medicine, helped close the wound to encouraged it to heal.

It took two to three months for the skin around the surgical area to heal. Amy had a little more leg pain during recovery and had to get used to having a piece of metal sticking out of her leg. She also had to carefully monitor any muscle or bone pain in order to prevent infection. She hasn't had any issues with infections or falls throughout her recovery.

Once she healed from the second surgery, she was cleared to start physical therapy. The implant requires patients to gradually do weight-bearing exercise, starting with a 40-pound trainer. This helps get the patient's bone get used to putting weight on it in preparation for the prosthetic fitting.

By the end of December 2022, Amy got up to putting 80% of her body weight on the implant. At that point, she was able to get the prosthetic and start her next phase of physical therapy.

"Months ago, I kept thinking that once I got the prosthetic, my life would go back to normal," Amy shares. "But I struggled the first week I had the prosthetic, seeing the challenge of learning to walk with it. I realized my life would take on a new normal that still had plenty to offer."

She continues, "But I can be very impatient. Now that I’ve had time to work with it and get better on it, I can do most of the things I want to do – just at a slower, more careful pace. I’ve learned that with every stage, you have to adapt and understand your life won't be the same."

She started using a prosthetic with a mechanical knee that was completely dependent on Amy's movement. When her body weight shifted while she was standing, her knee would move forward. Now she's using a microprocessor knee with a sensor in it. When she's standing, it locks to provide resistance and prevent her from falling forward. There's even a bike mode that she can use for riding her stationary bike.

"The goal is for my muscles in my hip and upper leg to gain some muscle memory in order to better know what my leg is doing and be able to control it," she says.

Attentive Care

"Every member of my phenomenal care team has supported me throughout my health journey," Amy says. "My doctors were very patient with me and willing to listen to and answer all my questions."

When Amy was in the hospital for her two surgeries, she happened to be placed in the same room each time. "I had the same nurses twice – and they were amazing," she says. "They don't treat you like you’re just one more person. They made me feel like an individual and remembered me."

Her care team also helped her navigate health insurance.

Leading the Way in Osseointegration

Atrium Health is at the forefront of osseointegration technology, providing clinical leadership and bringing together experts in the field.

Led by Dr. Joseph Hsu, professor of orthopedic trauma and director of the limb lengthening and deformity program at Atrium Health Musculoskeletal Institute, Atrium Health's Osseointegration Program is one of the nation's most comprehensive programs. It's one of only a few programs that offer upper and lower extremity osseointegration.

In 2022, Atrium Health Musculoskeletal Institute hosted the first Global Collaborative Conference on Osseointegration in Charlotte, North Carolina. Experts from across the country came together to share initiatives and best practices, establish research relationships and improve patient outcomes. The next global conference is scheduled for November 2023 and will be held in Charlotte.

Sharing Her Story

In addition to her care team, Amy has found support connecting with members of her church and other patients who have faced similar health challenges. That's why she wanted to share her story with others.

"I’ve learned that it's helpful to know there are other people out there going through something similar," she explains. "We can gain strength and encouragement from other people's stories. There's a part of us that knows we’re not alone – but we have to hear what others have gone through and get their perspective."

Amy is finishing up her physical therapy to strengthen her leg. Using only a cane, she's able to walk up to 1.5 miles outdoors for exercise.

Thanks to her prosthetic, Amy can now walk into the grocery store and pick up her own groceries. She enjoys her increased mobility and being able to do more things around her house.

"I feel more free – and I have the energy and desire to get things done," she explains. "It was hard to do those things before because it took so much effort. I’m still learning to be patient and not overdo it."

Amy hopes that in the future she can get back to running and hiking again.

Learn more about osseointegration at Atrium Health Musculoskeletal Institute.