Date of Award


Degree Name

Doctor of Medical Science

Schools and Centres


First Supervisor

Prof. George L. Mendz

Second Supervisor

Dr Kevin Testworth


Loss of a leg or arm is a tremendous disability. Immediate and obvious impairments are decreased mobility or diminished functional capacity. Not quite as obvious are the difficulties associated with activities of daily living, quality of life impairments, sometimes loss of independence or employment, and the mental health issues which often accompany limb loss. The interface between native tissue and the prosthetic limb presents the greatest challenge to amputee rehabilitation. Computer-controlled robotic limbs have been widely available since the 1990s. However, the weight of prosthetic limbs, coupled with the difficulty of where to locate the components, requires substantial loads to be transferred through the humanimplant interface. This interface has always been a skin-squeezing mechanism which results in repetitive soft-tissue loading and trauma, in both compression and shear, which inevitably causes multiple problems (pain, skin breakdown and infection, hyperhidrosis, allergic reaction to the material) leading to periodic or prolonged prosthesis disuse. So unfortunately, despite all the effort and expense invested in the prosthetic limb itself, patients often were unable to benefit.

Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) is a revolutionary technique that involves anchoring a metal implant directly to a patient’s skeleton, then permanently passed through the patient’s skin, and attached to a prosthetic limb. By doing this, the weight of the prosthesis is borne by the patient’s skeleton and is directly powered by muscles, leading to a lighter and more native experience. The skin is no longer compressed and traumatised, eliminating the aforementioned issues. Since learning about this technology in the mid-2000s and performing my first independent procedure in 2009, I have investigated and pioneered the world’s leading surgical techniques and rehabilitative methods for PEPOL. Treating nearly 1000 amputees via the Osseointegration Group of Australia and the MQ Health Limb Reconstruction Centre at Macquarie University has allowed research to be performed on this technology, documented, and discussed in the 2 Body of Work. Patients almost always improve their objective and assessed mobility performance (Overall 38.6% distance improvement on the 6MWT), they wear their prosthetic limb more (Overall 38.1% increase in the Q-TFA Prosthetic Use Score), and they are subjectively more satisfied with their condition as an amputee (Overall 41.1% increase in the Q-TFA Global Score) . While these benefits are consistent, my research has also identified the fortunately limited problems with infection and soft tissue management (29% of all patients required re-operations due to direct or indirect complications). PEPOL clearly provides excellent improvement for the vast majority of patients, and the continued investigation of this technology should lead to even greater improvements in progressing from what is already successful, make it more readily available, and ameliorate its existing challenges.

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