Osseointegration Benefits Transtibial and Transfemoral Amputees, With Taylor J. Reif, MD

Osseointegration (OI) is a surgical procedure in which a titanium implant is anchored directly into a patient's residual bone, allowing a prosthetic limb to attach to the skeleton rather than a conventional socket.¹

Unlike socket-based prostheses, which are frequently associated with skin breakdown, restricted range of motion, and discomfort with prolonged wear, OI creates a direct structural connection between implant and bone, enabling more natural load transfer, improved sensory feedback, and greater daily wear tolerance.^2,3,4

New data presented at the 2026 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting challenges a long-standing clinical assumption: OI is best suited for transfemoral (above-the-knee) amputees.

“There are no studies in the scientific literature focusing on differences in safety and outcomes of patients who underwent transfemoral osseointegration as compared to those who had transtibial osseointegration,” Taylor J. Reif, MD, an orthopedic surgeon in the Osseointegration Limb Replacement Center at Hospital for Special Surgery (HSS).

Investigators at HSS studied 147 limb segments, 83 femoral and 64 tibial, and found both cohorts achieved significant postoperative improvements in mobility and quality of life. Transtibial patients demonstrated a greater magnitude of improvement across patient-reported outcome measures, including LD-SRS and PROMIS survey domains, despite entering surgery with higher baseline mobility than femoral patients (6-minute walk test: 280.5 m vs 211.7 m; P =.017). Complication rates, including infection and implant loosening, did not differ significantly between groups.

Standard clinical pathways have traditionally required a failed socket trial before OI is considered. HSS investigators compared 15 patients undergoing simultaneous amputation and OI with 124 patients receiving OI for an established amputation. Both groups achieved comparable improvements in mobility and patient-reported outcomes.

While the simultaneous femoral cohort trended toward higher rates of surgical debridement (50% vs 16%) and implant removal for infection (25% vs 1%), these differences did not reach statistical significance. For the well-informed patient, one who understands the procedure's rehabilitative demands and has engaged in shared decision-making with their surgical team, primary OI represents a viable clinical pathway may eliminate the morbidity associated with an interim socket trial.

For more on the study and background into osseointegraption, check out interview with Reif.

References

1. Rozbruch SR, Elghazy MA, Glassband Z, Reif TJ, Hoellwarth JS. Primary amputation with osseointegration versus osseointegration for existing amputation. Hospital for Special Surgery. 2026.
2. Glassband Z, Reif TJ, Rozbruch SR, Hoellwarth JS. Femur and tibia press-fit osseointegration - a comparison of safety and outcomes. Hospital for Special Surgery. 2026.
3. Rozbruch SR, Glassband Z, Hoellwarth JS, Reif TJ. Safety and early experience of osseointegration limb replacement with custom-fit implants. Hospital for Special Surgery. 2026.
4. The future of prosthetics: advancements in osseointegration surgery. Hospital for Special Surgery. March 2026.