Bone-anchored prostheses (BAP) provide an alternative to traditional socket-suspended prostheses (SSP) for individuals with transfemoral amputation (TFA) by addressing socket-related complications. While most previous studies, primarily single-arm trials, report positive outcomes with BAP, these findings may be overestimated due to lower preoperative baseline function among individuals using SSP prior to BAP implantation. This review aims to offer a more balanced comparison of functional and clinical outcomes between BAP and SSP by focusing exclusively on two-arm comparative studies. A systematic review and meta-analysis was conducted from December 2024 to May 2025, following PRISMA guidelines. Databases including PUBMED, EMBASE, Scopus, Cochrane, and Web of Science were searched. All studies meeting the inclusion criteria were cross-sectional in design. Primary outcomes included mobility (Timed Up and Go [TUG]; Activities-specific Balance Confidence [ABC]) and quality of life (Q-TFA domains). Secondary outcomes: gait parameters, hip range of motion (ROM), osseoperception, and costs. Risk of bias was assessed using ROBINS-I adapted for observational designs. Random-effects meta-analyses pooled mean differences (MD) or standardized mean differences (SMD) with 95% CIs. Twelve studies (BAP n = 200; SSP n = 244) met criteria. Pooled analyses showed no significant differences for TUG (MD 0.16 s, 95% CI −2.09 to 2.41; I2 = 0%), ABC (MD 0.05, 95% CI −22.19 to 22.29; I2 = 76.3), Q-TFA Global (MD 1.14, 95% CI −22.02 to 24.30), Q-TFA Prosthetic Mobility (MD 0.37, 95% CI −9.93 to 10.68), Q-TFA Problems (MD –6.29, 95% CI –18.77 to 6.19), Q-TFA Prosthesis Use (MD 1.18, 95% CI −2.36 to 4.71), and gait speed (MD −0.03 m/s, 95% CI −0.31 to 0.25). Hip ROM tended to be higher with BAP in two studies; osseoperception favored BAP in two studies; one study reported on lower long-term cost with BAP. No comparative studies of infection were identified. While BAP is a promising alternative for individuals experiencing complications with SSP, its benefits for functional SSP users remain uncertain. The lack of comparative studies evaluating infection rates highlights an important area for future research.
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