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 an evidence-based practice 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. The authors extracted relevant data on projected lifetime costs and analyzed them to include discounting and sensitivity analysis by considering patient age. The utilities for the various health states (amputation or salvage, including possible complications) were measured previously using the standard gamble method and a decision tree simulation to determine quality-adjusted life-years.

Results: Amputation is more expensive than salvage, independently of varied ongoing prosthesis needs, discount rate, and patient age at presentation. Moreover, amputation yields fewer quality-adjusted life-years than salvage. Salvage is deemed the dominant, cost-saving strategy.

Conclusion: 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 with amputation.

Figure 1

Lifetime Costs of Salvage Based on Years of Life Remaining. Both higher discount rates and lower life expectancy reduce lifetime cost of reconstruction.

Figure 2

Lifetime Costs of Amputation Based on Years of Life Remaining. Higher discount rates and lower life expectancy reduce lifetime cost of amputation. Discount rate has a larger effect on amputation because of the high long-term costs associated with prosthetic purchase and maintenance. This figure also illustrates the importance of discounting. By not taking into account the time value of money (the dotted line, “0%”), the true present value of treatment is overestimated.

Figure 3

Excess Lifetime Cost of Amputation over Salvage. Because amputation is more expensive even in the short term, it remains more expensive than salvage through the entire range. The difference is less exaggerated when we account for discounting and when we consider patients with fewer remaining years to live.