When asked how she lost her right leg, there was a time Miranda Cashin, 26, would have spun a tall tale of a five-year-old girl learning to surf with her dad when a shark came and ripped her leg off. If you ask her that same question today, she tells the true story of a baby who was born with tibial hemimelia whose parents made the decision to have her leg amputated when she was 14 months old. “My right leg was underdeveloped and twisted, I had a right abdominal wall hernia, and [I didn’t have a] proper right hip joint due to the lack of a femur head,” explains the Australia native. The difference in stories, in large part, is due to a personal transformation that occurred as she underwent osseointegration surgery and recovery.
“I spent too long feeling ashamed and inadequate when really I should have been feeling proud,” Cashin says of her pre-osseointegration days. “But through this journey, that has all changed.” Cashin chronicled her journey through surgery, rehabilitation, and self-acceptance in a blog, “The Girl with the Cyborg Leg.” “Everyone knows about my leg,” she wrote in her blog. “There is no hiding it now. And really there is no need to hide it; it is a part of me after all.”
Cashin says she learned about osseointegration by chance. While visiting her prosthetist for repairs, she came across a pamphlet on osseointegration scattered among the old magazines. She went home and Googled the procedure. “I thought of it as the stuff of science fiction—I would essentially become a cyborg,” she says of the surgery that would leave a metal rod sticking out of her residual limb, to which a prosthesis would be attached. “[W]hile it seemed like a scary process, it would… give me a more natural gait and eliminate the pain I suffered on a daily basis. How could I pass up an opportunity to do that?”
Nonetheless, the decision to undergo the surgery, which Cashin did toward the end of 2012, was not something she took lightly. The two-part surgery, recovery, and rehabilitation would be lengthy and arduous, and as with any surgery, there was a risk of failure.
The Australian government approved osseointegration for prosthetic attachment about 18 months prior to Cashin beginning the process to have the procedure, and there was one surgeon in the country who could perform the operation—orthopedic surgeon Munjed Al Muderis, MD, with Osseointegration Group of Australia. Al Muderis, who had trained on the procedure in Germany, had already completed about 15 osseointegration surgeries. So in August 2012, Cashin flew from her home in Queensland, Australia, to Sydney, Australia, and accompanied by her parents, met with Al Muderis and his osseointegration team to discuss the process.
The team consisted of a prosthetist, physiotherapist, rehabilitation physician, and psychologist. They were all “crammed into the one office and all firing questions at a hundred miles an hour,” she says of that day. “They asked about my current lifestyle, pain level, how I felt about my body, why I wanted the surgery, what my expectations were, and how I thought it would change my life. They also examined my range of motion and sent me for x-rays and scans. The psychologist asked a lot about body image and how I had coped with hardships previously. He was assessing my mental health and whether I would be up for the journey ahead.”
Al Muderis and his team also outlined the procedure, the hospitalization time, the rehabilitation process, mechanics of the implant, as well as the risk of complications and infections. They also discussed what her future looked like with and without the surgery. “While the process seemed long and slightly nerve-wracking, I trusted him completely,” she says. (Author’s note: According to the Osseointegration Group of Australia website, Al Muderis has since performed osseointegration surgery on 40 patients from Australia, the United Kingdom, the United States, South Africa, and New Zealand. He uses the Orthodynamics Integral Leg Prosthesis (ILP) implant.)
Cashin underwent the first of the two surgeries in the process in October 2012, during which Al Muderis and his surgical team implanted a metal rod into the femur of her residual limb. She was discharged home for six weeks to recuperate and give her bone a chance to integrate with the implant. In December 2012, Cashin underwent the second surgery to have an adaptor linked to the implanted rod—the adaptor extends outside the distal end of her residual limb and is the interface to which the prosthesis is attached. After another month spent recuperating at home, she was then admitted to inpatient rehabilitation. Cashin describes her five weeks spent in rehabilitation as “the hardest, most grueling physical, emotional, and mental challenge” she has ever faced.
Rehabilitation
In actuality, Cashin started preparing physically for the surgery months ahead of time. No stranger to exercise or athletics, she week and took a variety of classes.
However, targeted exercise was required to prepare for walking with her new leg. Despite Cashin’s rigorous exercise routine, she had very little muscle in her right residual limb and gluteal muscles, which she did not have to use with her previous prosthesis. She found a physiotherapist who showed her how to do exercises that focused mostly on these muscles and could strengthen her hip flexor.
The hard work, however, came after the second surgery. First Cashin had to build up the amount of weight her femur could bear. “Despite the fact I had been walking about for 24 years, with the old prosthesis the bones actually didn’t take the load…,” she says. To strengthen her femur, she did weight-loading exercises three times a day for the month between the second surgery and rehabilitation, slowly increasing the weight from 5kg all the way to 50kg, she says.
Next came learning how to walk. Rehabilitation was a full-time job. “Each day I completed three-hour-long physiotherapy sessions as well as one to two hours of weights, core work, and cardio,” Cashin says. “It was hard work, but it was a very exciting time as I continued to see my progress each day.” Her first steps with her osseointegrated prosthesis were taken while walking between parallel bars one week from when she began rehabilitation. From there she progressed to walking with the aid of two crutches, then one crutch, and then to independent walking. She had to learn how to walk up and down stairs, ramps, and slopes, both empty-handed and while carrying objects, such as a laundry basket. She had to learn how to walk on changing terrains, ride an exercise bike with her right leg actually pushing on the pedal, and get up from the floor, among other things. She also did balance work on a foam mat to make sure she was weight shifting correctly and standing evenly. “Each day, my walking became smoother, my muscles stronger, and my confidence grew,” Cashin says.
Rehabilitation after osseointegration surgery was an extensive process that involved a lot of hard work, Cashin says, but the results are well worth it. Photographs courtesy of Miranda Cashin.
Miranda 2.0
The day before her discharge from inpatient rehabilitation, Cashin’s gait was analyzed again, and the video compared to the gait analysis that had been done prior to osseointegration. She used a similar knee for both gait analyses, an Ottobock 3R60. “In the new video, I was so much more upright, taller, more graceful, and there was barely a limp to be seen,” she says, adding that once she returned home, people often commented that she looked taller. “I think I have better posture. I find I don’t get a sore back from walking, and there is no painful rubbing or blisters [from her prosthesis]; gone are the days of my pack-a-day Band-Aid habit.” On her blog, she refers to herself post-osseointegration surgery as “Miranda 2.0.”
Among the other changes she has experienced are the ability to walk farther, to feel the ground beneath both feet, and to be able to sit comfortably for extended periods of time. She has more control over her leg and is never worried about it collapsing underneath her. In fact, she says, “I often forget about the leg as it just feels like it is a part of me.” She wears form-fitting clothes and dresses, and she no longer hides her leg from public view.
There are restrictions she has to abide by now that she has undergone osseointegration, such as not participating in high-impact activities that would place excessive and unnecessary force on her femur, such as running and jumping, and she can’t swim in public pools due to the risk of infection. “These are small prices to pay,” she says.
Cashin remains active and continues her exercise regime. In addition to her 3R60, she has a water leg for the shower and beach, and is working closely with a prosthetist. “You still need a prosthetist after this surgery,” she says. “They just play a slightly different role—they don’t need to fit or adjust the socket, only make adjustments to the knee and foot. The guy I am seeing now is brilliant and is great with any maintenance issues.”
She is also working with her physiotherapist from inpatient rehabilitation “on more advanced gait training and [to] fine tune a few things to ensure I am walking to the best of my ability.”
Since the surgeries, Cashin has undergone other changes as well. She’s moved, quit her job, and returned to school to pursue a physiotherapy degree. She says she wants to work with other amputees. “I’m excited to be able to make a difference in someone else’s life as my physiotherapist has done in mine,” she says.
Laura Fonda Hochnadel can be reached at
Editor’s note: Osseointegration for prosthetic attachment surgery is not approved in the United States at this time. However, U.S. Food and Drug Administration trials are currently in process.
