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

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.