Orthopaedic Osseointegration: State of the Art

Musa B. Zaid, MD; Richard J. O'Donnell, MD; Benjamin K. Potter, MD; Jonathan A. Forsberg, MD, PhD


J Am Acad Orthop Surg. 2019;27(22):e977-e985. 

In This Article

Abstract and Introduction


Osseointegration is a surgical approach that permitted the direct attachment of an external prosthesis to the skeleton in some select patients with amputation, who had failed to tolerate conventional sockets, thereby obviating related issues such as discomfort, skin breakdown, and poor fit. In this specific population, osseointegration offers the potential for enhanced biomechanical advantage and rehabilitative potential. Multiple percutaneous implant systems exist for clinical use internationally, each attempting to create a stable bone-implant interface while avoiding complications such as infection and loosening. Prospective clinical trials are now underway in the United States. This article will review the history and biology of osseointegration, indications and contraindications for use of currently available implant systems, and reported outcomes. Future directions of orthopaedic osseointegration technology, including electronic systems capable of biomimetic bidirectional volitional motor control of, and sensory/proprioceptive feedback from, external prosthetic devices, will also be discussed.


Amputation can occur secondary to multiple conditions, including trauma, malignancy, infection, and peripheral vascular disease. Positing a permanent change to a limb's anatomy and function, amputation carries lifelong risk of physical and psychological impairments, as well as social, vocational, and recreational activity reintegration barriers. Although the leading cause of extremity amputation in the developed world is dysvascular disease, trauma and war-related injury are the principal etiologies in the developing world.[1,2] In the United States, amputation has recently received increased attention because the US Military estimates that amputation represents up to 7.4% of major extremity injuries sustained during war,[3] often affecting young, highly functioning individuals.

Although modern artificial limbs have undergone substantial technological advancements, patients remain limited, often unable to return to their baseline level of activity. Conventional prostheses rely on attachment to a socket that fits over the residual limb with a compression- or suction-based fit and suspension. Use of a standard socket prosthesis is associated with a host of complications such as suboptimal fit, pain, and dermal issues, with an estimated 40% of patients suffering skin breakdown[4] and 30% of patients experiencing pain[5] in the residuum.

Osseointegration, first described by Per-Ingvar Brånemark in the early 1950s in a rabbit model[6] and then in dental implants,[7] is defined as the direct skeletal anchorage of a fixture by the formation of bony tissue around the device, without the growth of fibrous tissue at the bone-implant interface.[8] Over the decades, multiple applications of osseointegrated titanium devices have evolved, including bone-anchored hearing aids, maxillofacial reconstructions, and orbital implants.[9] In a patient with an amputation, a percutaneous osseointegrated device allows for a continuous structural connection to an external prosthesis, thus bypassing the issues associated with typical socketed design. In addition to eliminating socket-associated complications such as poor fit and skin difficulties, osseointegration carries many potential benefits for patients who tolerate their socket systems poorly, including reduced energy expenditure, improved range of motion, walking ability, and sitting comfort,[10,11] as well as indirect sensory feedback through what has been termed osseoproprioception or osseoperception.

Osseointegration as a concept in advancing prosthetic limb design has been gaining traction with trials of several systems being conducted in the United States and worldwide. The article aims to provide clinicians with an overview of the current status of orthopaedic osseointegration.