Meta-analytic evaluation of complications and longevity of bone-anchored prostheses in lower extremity amputees: does design matter?

Bone-anchored prostheses (BAPs) are an alternative option for lower-limb amputees with problematic suspended socket prostheses (SSPs). We sought to meta-analytically quantify complication burden and revision-free survival for BAPs, whilst investigating possible differences in complication rates between common screw-fit (OPRA) and press-fit (ILP/OPL) designs. A multi-database search of PubMed, EMBASE, CiNAHL, Cochrane Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus and Web of Science from inception to September 2025 was conducted. Proportions were pooled using a random-effects model. This review was registered in PROPSPERO (ID: CRD42024507070). A total of 22 studies reporting 979 patients were included. An overall complication rate of 65% (95% CI: 0.53-0.75, I² = 69%) was found. The most common complication was breakage of the abutment or dual-cone adaptor (DCA) (0.38, 95% CI: 0.19-0.62, I² = 97%), which constituted 94% of all mechanical failures (95% CI: 0.87-0.98, I² = 51%). Second was infection (0.36, 95% CI: 0.25-0.50, I² = 92%) with 72% of infections being grade I (95% CI: 0.57-0.83, I² = 72%). Estimated revision-free survival was 89% (95% CI: 0.84-0.93, I² = 0%) at five years and 77% (95% CI: 0.70-0.82, I² = 0%) at ten years. The largest difference between implant designs was for overall proportion of mechanical failure, OPRA at 68% (95% CI: 0.34-0.90, I² = 98%), ILP/OPL at 19% (0.09-0.36, I² = 85%). BAPs do carry appreciable risks for superficial infection and mechanical (abutment/DCA) breakage, with screw-fit designs appearing to have a higher mechanical failure rate. However, the revision-free survival rate overall remains acceptable up to 10 years demonstrating the viability of BAPs in lower-limb amputees.