Screening and patient selection for bone-anchored limb implantation and rehabilitation: what makes a good candidate?

Abstract

Osseointegration of a bone-anchored limb (BAL) is an emerging rehabilitation technique that offers significant advantages over traditional socket prostheses. By addressing functional limitations and recurrent cutaneous complications, BAL systems have shown an 82%-90% increase in daily prosthesis use among patients, who also report improvements in functional ability, balance, comfort, and overall quality of life. Despite these benefits, the process of patient selection for BAL remains underdeveloped, with evidence-based guidelines still in their infancy. This article aims to propose a workflow for patient selection and screening in BAL osseointegration, leveraging the current literature, interdisciplinary clinical experience, and established models. A comprehensive evaluation process is suggested that incorporates anatomical, physiological, psychological, and lifestyle factors. These include radiological evaluation, amputation history, prosthetic component assessment, laboratory tests, psychiatric history, cognitive assessments, and considerations of home safety and postoperative care. The evaluation should ideally be conducted by an interdisciplinary team to ensure a balanced consideration of risks and benefits for each candidate. As the understanding of BAL osseointegration advances, it is expected that patient indications will expand and contraindications will be more clearly defined. The proposed workflow aims to standardize patient selection, thereby optimizing surgical outcomes and rehabilitation processes. This approach is essential for maximizing the benefits of BAL systems while ensuring patient safety and improving long-term rehabilitation outcomes.

Figure 1.

Screening and selection workflow for bone-anchored limb candidates.

Figure 2.

(A–C) Routine physical examination of the residual limb and adjacent joint in a patient with unilateral transfemoral amputation. (D) Radiographs (standing hip-to-ankle X-ray with prosthesis) of a patient with unilateral transfemoral amputation using a socket prosthesis. (E) Axial CT scan of the right transfemoral residual bone assessing intramedullary canal integrity and diameter. (F) Radiographs (standing hip-to-ankle X-ray with an OPRA implant and BAL prosthesis) showing a unilateral osseointegrated OPRA implant in the residual femur attached to a prosthetic leg.

Figure 3.

(A–D) Routine physical examination of the residual limb and adjacent joint in a patient with unilateral transtibial amputation with complex soft-tissue envelope. (E) Supine radiograph of the residual left tibia and fibula with retained foreign bodies from traumatic injury.

Figure 4.

(A–D) Routine physical examination of patients with bilateral transtibial amputation with complex soft-tissue envelope. (E) Coronal view of a CT scan showing the right transtibial residual limb intramedullary canal architecture. (F) Radiographs (standing hip-to-ankle X-ray with prosthesis) of patients with bilateral transtibial amputation using socket prostheses. (G) Radiographs (standing hip-to-ankle X-ray with BAL prosthesis) showing the bilateral press-fit osseointegrated BAL implants in the residual tibia attached to a prosthetic leg. Note balanced knee centers and equal leg lengths.