A Cost-Utility Analysis of Amputation versus Salvage for Gustilo Type IIIB and IIIC Open Tibial Fractures

Abstract

Background: Lower extremity trauma is common. Despite an abundance of literature on severe injuries that can be treated with salvage or amputation, the appropriate management of these injuries remains uncertain. In this situation, a cost-utility analysis is an important tool in providing evidence-based practice an approach to guide treatment decisions. Methods: Costs following amputation and salvage were derived from data presented in a study that emerged from the Lower Extremity Assessment Project. We extracted relevant data on projected lifetime costs and analyzed them to include discounting and sensitivity analysis for consider patient age. The utilities for the various health states (amputation or salvage, including possible complications) were previously measured using the standard gamble method and a decision tree simulation to determine quality-adjusted life years (QALYs). Results: Amputation is more expensive than salvage independent of varied ongoing prosthesis needs, discount rate, and patient age at presentation. Moreover, amputation yields fewer QALYs than salvage. Salvage is deemed the dominant, cost-saving strategy. Conclusions: Unless the injury is so severe that salvage is not a possibility, based on this economic model, surgeons should consider limb salvage, which will yield lower costs and higher utility when compared to amputation.

Introductory Chapter: Toward Near-Natural Assistive Devices

“…A traumatic lower limb amputation, as tracked in the NIH LEAP study, is expected to cost the amputee $350,465 over 40 years, with $91,105 incurred within the first 2 years of the injury. Of this total, an individual will spend $181,500 on prosthetics at approximately $10,232 per unit [13]. These costs are also corroborated in several unrelated studies on civilian and veteran lower limb amputation costs [5,19].…”

Spare Parts Surgery—Salvage of a Below Knee Amputation Stump

“…Besides the avoidance of donor site morbidity, the other goals of BKA are met giving patients maximal functional and aesthetic results. In this case, the availability of the entire sole and heel pad provided an ideal salvage optionsoft tissue bulk, thick durable skin, ability to withstand sheer forces [2]. Tibial nerve coaptation also provides the potential for sensory reinnervation.…”

“…They face significant alteration of their lifestyle, loss of physical capabilities, the need for occupational re-training and potential difficultties with social reintegration [1]. Socioeconomically, limb amputation has been demonstrated to be more expensive than limb salvage [2]. Consequently, amputation remains the choice of last resort.…”

Plastic Surgery for the Oncological Patient

“…In soft-tissue sarcomas, for example, we have seen a shift of the paradigms regarding the width of surgical resection, from limb amputation over resections of the whole compartment to marginal resections (1)(2)(3). Although the topic of amputation vs. limb salvage remains controversial to this date regarding the quality of life of the patients, limb salvage leads to lower lifetime medical costs and high rates of independent mobility, especially in older patients (1,(4)(5)(6)(7). The case of a patient with an advanced soft-tissue sarcoma (not otherwise specified, NOS) of the thigh and pelvic region is depicted in Figures 1 and 2.…”