Beyond the Air–Bone Gap: The Role of Bone Conduction Thresholds in Predicting Functional Outcomes and Guiding Surgical Decision-Making in Active Middle Ear and Bone Conduction Implants

<b>Introduction</b>: In patients with conductive and mixed hearing loss, implantable hearing devices such as active middle ear implants (AMEIs) and bone conduction implants (BCIs) are established alternatives when conventional hearing aids fail. Although bone conduction (BC) thresholds are routinely used as eligibility criteria, their role as frequency-specific predictors of postoperative functional outcomes remains poorly defined. This study aimed to evaluate the influence of preoperative BC thresholds across the audiometric spectrum on postoperative speech recognition outcomes after implantation with AMEIs and BCIs. <b>Methods</b>: A retrospective observational study was conducted at a tertiary referral center including patients implanted with BCIs or AMEIs. Pre- and postoperative audiological data were analyzed, including air and bone conduction thresholds, frequency-segmented BC measures (low, mid, and high frequencies), cochlear frequency gradient (ΔBC Slope), and speech recognition scores (SRSs) at 65 dB HL one year after implantation. <b>Results</b>: 102 patients were included (50 BCI, 52 AMEI). Both implant types achieved significant postoperative improvements in tonal thresholds and SRS compared with pre-implantation values (all <i>p</i> < 0.001). High-frequency BC thresholds (BC-High, 4-6 kHz) showed a significant inverse correlation with postoperative SRS in both BCI (r = -0.382, <i>p</i> = 0.001) and AMEI users (r = -0.398, <i>p</i> < 0.001), and emerged as the only independent predictor in multivariable models (BCI: β = -0.533, <i>p</i> = 0.022; AMEI: β = -0.491, <i>p</i> = 0.020). Low- and mid-frequency BC measures were not associated with postoperative speech outcomes (all <i>p</i> > 0.05). ROC analyses demonstrated excellent discriminative performance of BC-High for identifying suboptimal outcomes, with area under the curve values of 0.92 for BCI (<i>p</i> = 0.001) and 0.94 for AMEI (<i>p</i> = 0.002), and implant-specific cutoff values of >47 dB HL and >61 dB HL, respectively. <b>Conclusions</b>: High-frequency BC thresholds showed the strongest association with postoperative speech recognition after implantable hearing rehabilitation. BC-High could function as a prognostic marker of functional outcome rather than an eligibility criterion, providing clinically meaningful information to refine preoperative counseling and individualized decision-making within current indication frameworks.