International Delphi Study Establishes Prosthetic Prescription Guidelines for Transtibial Bone-Anchored Limbs

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Summary of  Archives of Physical Medicine and Rehabilitation  https://doi.org/10.1016/j.apmr.2026.09.015
Dr. Eric J. Earley et al.

Points

University of Colorado Anschutz researchers conducted an international Delphi consensus study to establish foundational clinical guidelines for prescribing prosthetic components for transtibial bone anchored limbs.
Expert panel agreement confirmed three required components for osseointegrated transtibial limbs including a safety release connector a torque absorber and a dynamic carbon fiber foot.
Safety release connectors function as force limiting mechanical bindings designed to disconnect under excessive torque preventing dangerous stress transfer into host bone intramedullary implants.
Simple solid ankle cushion heel feet and microprocessor powered robotic ankles were generally disfavored due to suboptimal energy return or unstudied mechanical strain on bone anchors.
Authors concluded that establishing standardized component selection guidelines addresses current clinical training gaps improving patient safety functional rehabilitation outcomes and long term skeletal integrity.

Summary

This Delphi consensus study evaluated expert agreement regarding the selection and prescription of prosthetic components for patients with transtibial bone-anchored limbs (BAL). Published in Archives of Physical Medicine and Rehabilitation by researchers at the University of Colorado Anschutz School of Medicine, including lead investigator Dr. Eric Earley, the investigation addressed the lack of clinical practice guidelines for osseointegrated prostheses. Given that standard prosthetic prescription guidelines assume traditional socket-based limbs, the research sought to establish foundational expert consensus to mitigate bone fracture risk, optimize force attenuation, and guide clinical decision-making.

Using an iterative, anonymized Delphi methodology among an international panel of experts, the study evaluated componentry categories to establish clinical recommendations. The panel achieved formal consensus recommending three mandatory prosthetic components for transtibial bone-anchored limbs: a safety connector, a torque absorber, and a dynamic carbon-fiber (or fiberglass) split-toe foot. The safety connector acts as a load-limiting mechanism to decouple the external prosthesis during excessive force, balancing the threshold to prevent unexpected disconnects and falls while protecting the intramedullary implant and host bone from high-energy fractures. Conversely, simple solid ankle cushion heel (SACH) feet were generally not recommended, and powered or microprocessor-controlled robotic ankles were disfavored due to concerns regarding unstudied propulsive force transfer into the skeletal anchor.

The authors conclude that these consensus recommendations establish a foundational framework for prescribing prosthetic components in transtibial osseointegration. By identifying key biomechanical protections—such as torque attenuation and load-release mechanisms—the study addresses critical clinical knowledge gaps, provides a template for future clinical practice guidelines, and highlights research priorities to ensure long-term patient safety and functional rehabilitation.

Link to the article: https://www.archives-pmr.org/article/S0003-9993(26)00932-9/abstract

References

Earley, E. J., Milius, D. W., Awad, M. E., Melton, D. H., Ahmed, K., Leijendekkers, R. A., Potter, B. K., Stevens, P. M., Gaffney, B. M. M., Christiansen, C. L., & Stoneback, J. W. (2026). Establishing consensus for prescription of prosthetic components for transtibial bone-anchored limbs: An international delphi method study. Archives of Physical Medicine and Rehabilitation, S0003999326009329. https://doi.org/10.1016/j.apmr.2026.09.015