Tibial Bone-Anchored Prostheses: A Narrative Review of the Literature and Reflection on 10 Years of Surgical Practice

Historically, bone-anchored prosthesis (BAP) treatment was developed for the treatment of individuals with a transfemoral amputation. However, increasing experience with osseointegration implant (OI) surgery has resulted in its use in individuals with a transtibial amputation. In this article, we describe the emergence and evolution of BAP treatment for individuals with a transtibial amputation, review the current literature, and report on 10 years of clinical experience at our center.

The first tibial OI cases experienced high failure rates due to infection and aseptic loosening. However, all the following published studies reported improvements to functional outcomes and low rates of major complications. In the past, there was a clear lack of fixed follow-up, longer term studies, and stratification of outcomes. At our center, we have treated a total of 124 patients with 133 tibial BAPs over the course of 10 years, starting in 2014, and followed up for a mean of 58 months, ranging from 9 to 131 months. Five different OI designs were used over this period, showing the evolution of design philosophies and adaptations to challenges over time. A total of 11 OIs failed/were removed for reasons such as implant breakage (2), chronic knee pain (2), early infection (3), late infection (2), failure of osseointegration (2). Tibial BAP treatment has proven increasingly safe with growing patient demand. Initial fears about failure of fixation/loosening seem unfounded due to optimization of the designs. Our current aim is to improve implant survival and to answer questions about: optimal patient selection, minimum area of osseointegration necessary, need for additional screw fixation, and optimal level of implant placement.