COPYRIGHT 2007 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Health-Care Costs Associated with

Amputation or Reconstruction
of a Limb-Threatening Injury
By Ellen J. MacKenzie, PhD, Alison Snow Jones, PhD, Michael J. Bosse, MD, Renan C. Castillo, MS, Andrew N. Pollak, MD,
Lawrence X. Webb, MD, Marc F. Swiontkowski, MD, James F. Kellam, MD, Douglas G. Smith, MD, Roy W. Sanders, MD,
Alan L. Jones, MD, Adam J. Starr, MD, Mark P. McAndrew, MD, Brendan M. Patterson, MD, and Andrew R. Burgess, MD
Investigation performed at Carolinas Medical Center, Charlotte, North Carolina; The R Adams Cowley Shock Trauma
Center of University of Maryland at Baltimore, Baltimore, Maryland; University of Washington Harborview Medical Center, Seattle,
Washington; Florida Orthopaedic Institute, Tampa, Florida; University of Texas Southwestern Medical Center, Dallas, Texas;
Vanderbilt University Medical Center, Nashville, Tennessee; Cleveland MetroHealth Medical Center, Cleveland, Ohio; Wake Forest
University Medical Center, Winston-Salem, North Carolina; and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
Background: Recent reports have suggested that functional outcomes are similar following either amputation or re-
construction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care
costs and projected lifetime health-care costs associated with these two treatment pathways.
Methods: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity
injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial
hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpa-
tient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic
devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price In-
dex. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future
annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of
prosthetic devices.
Results: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial
hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs
were added, there was a substantial difference between the two groups ($81,316 for patients treated with recon-
struction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients
who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275
and $163,282, respectively).
Conclusions: These estimates add support to previous conclusions that efforts to improve the rate of successful re-
constructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it re-
sults in lower lifetime costs.
Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description
of levels of evidence.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or
grants in excess of $10,000 from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases
(ROI-AR42659) and the Orthopaedic Trauma Association, and less than $10,000 from the Johns Hopkins Center for Injury Research and Policy
(R49/CE00198). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to pro-
vide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund,
foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate
families, are affiliated or associated.
J Bone Joint Surg Am. 2007;89:1685-92 doi:10.2106/JBJS.F.01350
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ecently published data from the Lower Extremity As-
sessment Project (LEAP) study indicate that func-
tional outcomes are similar following amputation or
reconstruction for the treatment of a limb-threatening lower-
extremity injury
1-3
. Given this similarity in outcomes, it is im-
portant to examine health-care costs associated with these two
treatment pathways so that the trade-offs between costs and
effectiveness can be adequately addressed. The few investiga-
tors who have examined the costs of amputation and recon-
struction generally have agreed in their conclusions that
hospital and physician fee charges for limb salvage often ex-
ceed those for early amputation
4-9
. Coupled with evidence of
little difference in treatment outcomes, one might conclude
from those studies that early amputation is a reasonable strat-
egy for saving money. This conclusion has been challenged,
however, as the studies conducted to date have been based on
small numbers of patients and have not adequately taken into
account longer-term treatment costs and the cost of purchas-
ing and maintaining prosthetic devices
4,8
.
The goal of the present study was to compare total two-
year health-care and prosthesis-related costs incurred by patients
enrolled in the LEAP study. We hypothesized that, although
total medical treatment costs for patients treated with recon-
struction would exceed those for patients undergoing ampu-
tation, the long-term costs of prosthetic devices and related
services would be high for amputees, resulting in higher total
two-year costs for amputation than for reconstruction. On the
basis of less-detailed seven-year follow-up data and estimates
of life expectancy, we also projected lifetime costs for the two
groups of patients.
Materials and Methods
Setting and Patient Population
total of 601 patients were enrolled in the LEAP study over
a forty-month period (March 1994 through June 1997)
and were followed prospectively in person at three, six, twelve,
and twenty-four months after the injury
1
. At approximately
eighty-four months after the injury, an attempt was made to
locate and interview by telephone all LEAP participants who
had completed at least one follow-up interview within the first
two years after the injury
2,3
.
Patients were eligible for the LEAP study if they were
sixteen to sixty-nine years old and had been admitted to one
of eight level-I trauma centers for treatment of one or more
of the following injuries to the lower extremity: Gustilo
10
type-IIIB, IIIC, and selected type-IIIA fractures; dysvascular
limbs (knee dislocations, closed tibial fractures, or penetrat-
ing wounds with vascular injury); major soft-tissue injuries
(degloving or severe crush/avulsion injury); and severe foot
and ankle injuries (Gustilo type-IIIB ankle and all Gustilo
type-III intra-articular distal tibial [pilon] fractures and se-
vere hindfoot or midfoot injuries). Exclusion criteria have
been previously described; most notably, patients with a
major brain injury (a Glasgow Coma Scale score of <15
points at twenty-one days after the injury or at the time of
discharge), a spinal cord deficit, a prior amputation, or a
third-degree burn of the injured limb
1
.
For the present cost analysis, thirty-two patients with
bilateral injuries were excluded as were twenty-four patients
who had been enrolled in the study at the time of discharge
but could not be located subsequently. Of the remaining 545
patients, 149 underwent amputation during the initial hospi-
talization (including thirty-seven who had a traumatic am-
putation). After the initial hospital discharge, twenty-seven
additional patients underwent amputation: twelve had the
amputation within three months after the injury; six, be-
tween three and six months; seven, between six and twenty-
four months; and two between twenty-four and eighty-four
months. There were no significant differences in the sociode-
mographic characteristics between the patients who had un-
dergone an amputation and those who had undergone a
reconstruction
1
. The majority of the study patients were male
(76.7%) and between the ages of twenty and forty-five years
(72.1%). Approximately one-third (35.2%) of the LEAP pa-
tients lived in households below the federal poverty line at
the time of the injury. An additional 21.3% lived in house-
holds classified as near-poor (a household income within 125%
to 200% of the federal poverty line). Most injuries resulted
from motor-vehicle (29%), motorcycle (22%), or pedestrian-
vehicular (13%) collisions.
As previously reported
1
, rates of two-year postinjury fol-
low-up exceeded 80% (92.1% were followed for three months;
92.3%, for six months; 90.5%, for twelve months; and 84.4%,
for twenty-four months). The rate of follow-up for eighty-
four months was somewhat lower (75.8%)
2
. Patients with in-
complete data due to attrition were more likely to be male and
without a high-school education (p < 0.05). However, attri-
tion rates did not differ significantly between the two treat-
ment groups (amputation and reconstruction) or according to
the extent and severity of the lower-extremity injury.
The study was approved by the institutional review
boards at the coordinating center and at each study site.
Data Sources and Procedures
for Estimating Two-Year Costs
Direct health-care costs for the first two years after the injury
were calculated as the sum of costs associated with (1) the
initial hospitalization, (2) all rehospitalizations for acute
care related to the limb injury, (3) inpatient rehabilitation,
(4) outpatient doctor visits, (5) outpatient physical and oc-
cupational therapy, and (6) prosthetic devices and related
services. In order to obtain dollar amounts that more accu-
rately reflected the opportunity costs of care, billed charges
were adjusted by Medicare cost-to-charge ratios (for hospital
charges and prosthetic devices) or by insurer or payer reim-
bursement rates (for billed provider fees). Costs of inpatient
rehabilitation stays and follow-up outpatient services were
based on average reimbursed amounts, rather than billed
amounts. All dollar figures were inflated to constant 2002
dollars with use of the medical service Consumer Price Index
for the year in which the admission or cost occurred. Con-
sumer Price Index adjustments were obtained from United
R
A
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States Department of Labor, Bureau of Labor Statistics
11
. De-
tails regarding the estimation of individual cost components
follow.
Hospital Costs
Data on billed inpatient charges associated with the patients
initial hospitalization as well as all limb-related acute rehospi-
talizations were collected directly from the hospitals where pa-
tients received treatment. These data were available for 513
(94.1%) of the 545 index hospitalizations and 187 (64.5%) of
the 290 patients with one or more rehospitalizations. When
actual charge data were not available, they were imputed with
use of coefficients obtained from generalized linear regres-
sions of the log of total charges (for patients with complete
charge data) as a function of several variables known for all
patients, including length of hospital stay, amputation status,
Injury Severity Score (ISS)
12
, Abbreviated Injury Scale (AIS)
score of the contralateral limb injury
13
, mechanism of injury
(motorcycle, pedestrian, fall, or other blunt and penetrating),
type of health insurance, and several variables describing the
type and extent of injury to the bone and surrounding soft tis-
sues. Estimates of inpatient hospital costs were obtained by
multiplying billed charges by the Medicare cost-to-charge ra-
tio from each hospitals Medicare Cost Report for the year in
which costs were incurred.
Physician Fees Associated
with Hospitalizations
Billed professional fees associated with the index hospitaliza-
tion and rehospitalizations were determined from three of the
eight participating sites, which together accounted for 196
(36.0%) of all patients in the study. Professional fees at all
other sites were imputed by multiplying individuals hospital
charges by the mean ratio of billed fees to hospital charges cal-
culated from reporting sites, stratified by amputation status
and ISS (a score of <17 points or a score of 17 points) at the
index admission and by amputation status for rehospitaliza-
tions. To more accurately reflect opportunity costs, billed fees
were further adjusted to reflect each sites average payer-
specific fee recovery rate.
Inpatient Rehabilitation
The costs associated with inpatient rehabilitation were esti-
mated by multiplying the patient-reported length of stay for
rehabilitation by the average per diem cost for rehabilitation.
The average per diem cost was the average of the amounts re-
ported (for patients with a lower-limb injury but no head or
spine injury) by the rehabilitation facilities that were used
most frequently by LEAP sites. Per diem costs were reported in
2000 dollars and inflated to 2002 dollars as described above.
Outpatient Visits
Costs of outpatient visits were determined by multiplying
the average per visit cost by the number of outpatient medi-
cal, physical, or occupational therapy visits reported by the
patient in follow-up interviews. Average per visit costs for
each type of visit were calculated with use of data from the
Medstat MarketScan, a proprietary database containing
health insurance claims data for approximately 4 million in-
sured persons. Estimates were derived for patients in the
MarketScan database who had comparable injuries and were
based on average reimbursed amounts, rather than billed
amounts.
Prosthetic Charges
The information regarding the prosthetic charges was ob-
tained directly from the prosthetists for 134 (77.0%) of the
174 patients who had undergone an amputation at some time
during the twenty-four months after the injury. These charges
included those associated with the purchase of devices as well
as the labor and related hardware needed to maintain func-
tional use of the devices. For patients for whom charge data
were not available, estimates were imputed with use of coeffi-
cients obtained from generalized linear regressions of logged
charges (for patients with complete charge data) as a function
of the level of amputation, age and gender, ISS, AIS score of
the contralateral limb injury, type of health insurance, and
number of prosthesis-related visits reported by the patient as
part of the follow-up interview. Average billed prosthetic
charges were estimated for each of four amputation categories
(partial foot, below-the-knee, through-the-knee, and above-
the-knee). The Medicare Part-B fee schedule for each of these
five categories in 2002 dollars was then divided by average
billed charges for each category to obtain a cost-to-charge ra-
tio that was used to adjust billed charges to reflect costs. These
cost-to-charge ratios were 0.46, 0.50, 0.87, and 0.90 for partial
foot, below-the-knee, through-the-knee, and above-the-knee
prostheses, respectively.
Data Sources and Procedures
for Projecting Lifetime Costs
To project lifetime costs beyond two years, we multiplied the
number of patient-specific expected life years based on gen-
der and age (at two years after the injury) by an estimate of
future annual health-care costs associated with hospitaliza-
tions and total ambulatory care visits, including those for
both general medical care and physical or occupational ther-
apy. Average life expectancy by age and gender was estimated
on the basis of the United States Life Tables for 2003
14
. To
these costs, we added an estimate of future costs associated
with the purchase and maintenance of new prosthetic de-
vices for amputees.
Projected Health-Care Costs
Projected annual costs associated with hospitalizations and to-
tal ambulatory care visits were derived by multiplying mean
utilization reported by patients in their seventh year after the
injury by per diem or per visit costs as described above. This
approach assumes that the average annual number of hospital
days and number of ambulatory care visits after two years un-
til death are constant and approximate utilization reported in
the seventh year after the injury.
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Projected Prosthetic Costs
Projected costs for the use of prostheses were derived by
multiplying the average cost of the device worn by the pa-
tient at seven years after the injury by the frequency with
which a new prosthesis was purchased within two to seven
years after the injury. The average cost of the device worn at
seven years after the injury and the frequency with which
new devices were purchased were estimated from informa-
tion obtained at the seven-year interview. To account for
costs associated with routine supplies and repairs, we added
an annual amount equal to 20% of the cost of the prosthesis.
This percentage was based on the expert opinion of a pros-
thetist with experience managing patients who had under-
gone trauma-related amputation and projecting the lifetime
costs of prosthetic care for a variety of clients, including case
managers and lawyers
15
.
Total lifetime costs were calculated by adding the two-
year costs to the projected lifetime costs beginning in the third
year after the injury and occurring until death. Recognizing
the importance of our estimates of projected prosthetic costs
in the comparisons between patients treated with reconstruc-
tion and those treated with amputation, alternative estimates
of total lifetime health-care costs were derived by varying both
the frequency with which prosthetic limbs were assumed to be
replaced and the cost of supplies and repairs.
Data Summary and Analysis
Mean health-care-utilization and associated costs were summa-
rized for two groups of patients defined by their treatment sta-
tus at three months after the injury. The first group consisted of
384 patients who had undergone reconstruction and had an in-
tact lower limb at three months after the injury. Included in this
group were six patients who had undergone an amputation be-
tween three and six months, seven who had undergone an am-
putation between seven and twenty-four months, and two who
had undergone an amputation between twenty-four and
eighty-four months. It should be noted that, when calculating
both the two-year and lifetime costs for the reconstruction
group, we included the costs for the subsequent amputation for
these fifteen patients. The second group consisted of 161 pa-
tients who had undergone amputation within three months af-
ter the injury, including twelve patients who had been initially
discharged with the lower limb intact but were subsequently re-
hospitalized for an amputation. We further classified patients
treated with reconstruction by the type of injury (fracture of the
tibial shaft, articular fracture of the tibia, foot fracture, and soft-
tissue injury). Patients treated with an amputation were classi-
fied according to the level of amputation.
Multivariate regression techniques were used to deter-
mine whether observed differences in costs persisted after
adjustment for the type and extent of the lower-limb injury
(including type and extent of osseous damage, extent of soft-
tissue injury, initial pulse assessment, and plantar sensation),
AIS score of the contralateral lower-limb injury, the presence
of injuries to multiple body regions (as defined by an ISS of
17 points), and selected patient demographics (age, gender,
preexisting medical conditions, and insurance coverage at
the time of the injury). To specifically examine the impact of
associated injuries and limb-related complications on treat-
ment costs, total costs are separately reported according to
the Injury Severity Score (ISS) and any rehospitalizations for
one or more of the following conditions: late amputation or
stump revision, fracture nonunion, hardware failure, flap
loss, wound infection, or osteomyelitis.
TABLE I Utilization of Health Services Two Years After the Injury According to the Type of Treatment and Injury
No. of
Patients
Mean Duration
of Index Hos-
pitalization (days)
Percent
Rehospitalized
in Acute-Care
Hospital
Mean No. of
Acute-Care
Rehospital-
izations
Percent
Hospitalized
for
Rehabilitation
Mean No. of
Outpatient
Doctor Visits
Mean No. of
Outpatient
Physical or
Occupational
Therapy Visits
All LEAP patients 545 17.8 53.21 1.06 12.66 14.21 35.42
All reconstructions* 384 17.9 60.7 1.3 10.4 13.9 34.2
Tibial shaft fracture 105 19.4 72.4 1.6 10.5 14.1 31.5
Tibial articular fracture 205 17.6 62.9 1.4 11.2 13.8 35.2
Foot fracture 44 13.5 47.7 0.9 6.8 15.0 35.5
Soft-tissue injury 30 21.5 23.3 0.3 10.0 11.8 35.5
All amputations 161 17.7 35.4 0.5 18.0 15.0 38.2
Partial foot 12 13.1 50.0 1.0 8.3 22.0 19.6
Below the knee 100 17.4 36.0 0.6 13.0 15.6 37.6
Through the knee 18 23.7 33.3 0.3 16.7 9.9 24.0
Above the knee 31 16.7 29.0 0.4 38.7 13.3 55.9
*Includes fifteen patients who had an amputation after three months. Includes twelve patients who had an amputation after being dis-
charged from the initial hospitalization but within three months after the injury.
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Results
Two-Year Costs
he LEAP patients stayed in the hospital for an average
(and standard deviation) of 17.8 12.8 days (range, two
to eighty-five days) for initial treatment of the injuries (Table
I). During the index admission, the LEAP patients underwent
an average of 2.1 0.83 surgical procedures (range, one to
seven procedures).
Although there was no difference in the average length
of the hospital stay or the number of surgical procedures be-
tween patients treated with amputation and those treated with
reconstruction, there was variation according to the type of
injury (among patients treated with reconstruction) and the
level of amputation (among patients treated with amputa-
tion). This variation is reflected in the costs related to the in-
dex hospitalization (including professional fees) (Table II).
Initial treatment costs were highest for through-the-knee am-
putations ($81,086), above-the-knee amputations ($66,912),
and tibial shaft reconstructions ($63,389) and lowest for par-
tial foot amputations ($30,493) and foot fractures ($44,550).
While rehospitalization for acute treatment related to
the injuries was more frequent for patients treated with recon-
struction (60.7% were rehospitalized) than for patients treated
with amputation (35.4% were rehospitalized), patients treated
with amputation were more likely to be admitted to a rehabili-
tation hospital or a rehabilitation unit within an acute-care
hospital (18.0% were admitted compared with 10.4% of pa-
tients treated with reconstruction) (Table I). Of particular
note are the high rates of rehospitalization for acute care
among the patients treated with a tibial reconstruction (72.4%
of those with a fracture of the tibial shaft and 62.9% of those
with a tibial articular fracture) as well as the high rate of in-
patient rehabilitation among those who had undergone an
above-the-knee amputation (38.7%). The mean numbers of
both outpatient doctor visits and visits for physical and occu-
pational therapy were slightly higher for patients treated with
amputation than for those treated with reconstruction. Like
inpatient service use, outpatient service use varied somewhat
according to the type of injury and the level of amputation.
When costs associated with rehospitalizations and post-
acute care were added to the cost of the initial hospitalization,
the total costs for reconstruction and amputation were simi-
lar ($81,091 and $78,221, respectively) (Table II). When pros-
thesis-related costs were added ($225 for reconstructions and
$12,885 for amputations), the difference in health-care costs
between the two groups of patients ($81,316 for patients
treated with reconstruction and $91,106 for patients treated
with amputation) increased. These differences persisted after
we controlled for injury severity and patient demographics in
a multivariate regression analysis and were significant with and
without adjustment (p < 0.05). Average total two-year health-
care costs were highest for those with a through-the-knee
amputation ($112,811) or an above-the-knee amputation
($110,039) and lowest for those with a partial foot amputation
($50,153). It should be noted that the inclusion of the twelve
patients who had an amputation within three months after
the injury because the reconstruction failed or as a result of
delayed decision-making did not significantly increase the av-
erage health-care costs for the amputation group. The average
cost for the entire amputation group was $91,106 (Table II);
the average excluding the twelve patients was $90,460.
Rehospitalizations for limb-related complications added
T
TABLE II Mean Costs According to Type of Expenditure and Type of Treatment and Injury (2002 Dollars)
No. of
Patients
Total
Cost
Index
Hospitalization
Rehospital-
izations
Inpatient
Rehabilitation
Prosthetic
Devices
Outpatient
Doctor Visits
Outpatient
Physical or
Occupational
Therapy Visits
All LEAP patients 545 $84,207 $57,811 $9663 $3062 $3965 $4005 $5701
All reconstructions* 384 $81,316 $57,036 $11,974 $2657 $225 $3913 $5511
Tibial shaft
fracture
105 $90,478 $63,389 $15,285 $2749 $0 $3983 $5072
Tibial articular
fracture
205 $82,328 $57,248 $12,263 $2875 $380 $3898 $5664
Foot fracture 44 $65,355 $44,550 $8470 $2218 $190 $4221 $5706
Soft-tissue injury 30 $65,735 $51,670 $3540 $1490 $0 $3316 $5719
All amputations 161 $91,106 $59,659 $4154 $4028 $12,885 $4226 $6154
Partial foot 12 $50,153 $30,493 $4906 $507 $4894 $6201 $3152
Below the knee 100 $86,244 $57,054 $4495 $4196 $10,058 $4394 $6047
Through the knee 18 $112,811 $81,086 $4356 $1101 $19,602 $2803 $3863
Above the knee 31 $110,039 $66,912 $2643 $6547 $21,199 $3746 $8992
*Includes fifteen patients who had an amputation after three months. Includes twelve patients who had an amputation after being dis-
charged from the initial hospitalization but within three months after the injury.
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substantially to the two-year health-care costs for the patients
who had undergone reconstruction. The costs for those with
complications were 46% higher than the costs for those with-
out complications (Table III). When the costs for the patients
who were not rehospitalized because of complications were
compared ($88,010 for the amputation group and $66,987 for
the reconstruction group), the difference between the recon-
struction and amputation groups increased. Overall, rehospi-
talizations accounted for 15% of the total two-year costs for
the patients treated with reconstruction compared with only
5% for the amputees.
Health-care costs were substantially higher for patients
with injuries to multiple body systems, as reflected by an ISS
of 17 points ($115,887 compared with $75,359 for those with
an ISS of <17 points, Table III). However, the relative differ-
ence in the mean total two-year costs between the patients
treated with reconstruction and those treated with amputa-
tion was fairly similar after stratification by trauma to other
body systems. (The costs for those with an ISS of 17 points
was approximately 55% higher than that for the patients with
an ISS of <17 points.)
Projected Lifetime Costs
The total lifetime health-care cost projected for patients under-
going amputation ($509,275) was more than three times higher
than that for patients undergoing reconstruction ($163,282).
This difference can be ascribed largely to the additional costs as-
sociated with the purchase and maintenance of new prosthetic
devices. On the average, the LEAP patients reported purchasing
a new prosthesis every 2.3 years, at an average cost (in 2002 dol-
lars) of $7784 for a below-the-knee prosthesis, $16,028 for a
through-the-knee prosthesis, and $18,722 for an above-the-
knee prosthesis. They also reported visiting their prosthetist an
average of four to five times per year.
Limb-related rehospitalizations in the seven years after
the injury were similar between the patients treated with am-
putation and those treated with reconstruction. Approxi-
mately 3.9% of all LEAP patients reported one or more days in
the hospital per year, with an average length of stay of 5.8 days
for admitted patients. However, amputees reported a some-
what higher number of total outpatient visits (4.5 compared
with 3.7 for the patients treated with reconstruction).
To examine the robustness of our estimates of lifetime
costs, we derived alternative estimates by decreasing the fre-
quency of prosthetic replacement (after the seventh post-
injury year) from once every 2.3 years to once every five years.
This change resulted in projected costs of $345,456 and
$157,553 for patients treated with amputation and recon-
struction, respectively. Although this change in assumption
decreased the difference between the groups, total lifetime
costs for patients treated with amputation were still more than
two times higher than those for patients treated with recon-
struction. We further decreased the estimate of annual costs
associated with routine supplies and repairs from 20% to 10%
of the cost of the prosthesis. This adjustment resulted in pro-
jections of $331,159 and $157,072 for the patients treated with
amputation and reconstruction, respectively.
Discussion
he results of this analysis show comparable two-year
health-care costs associated with amputation and recon-
struction following severe lower-extremity injury. However,
T
TABLE III Mean Total Two-Year Costs According to Whether There Were Major Complications, ISS, and Type of Treatment and
Injury (2002 Dollars)
No. of
Patients
Total
Two-Year
Cost
Cost When No
Complication
Resulting in
Rehospitalization
(No. of Patients)
Cost When 1
Complications
Resulting in
Rehospitalizations
(No. of Patients)
Cost When
ISS <17 Points
(No. of Patients)
Cost When
ISS 17 Points
(No. of Patients)
All LEAP patients 545 $84,208 $74,238 (316) $97,964 (229) $75,359 (426) $115,887 (119)
All reconstructions* 384 $81,316 $66,987 (207) $98,072 (177) $73,097 (305) $113,051 (79)
Tibial shaft fracture 105 $90,478 $79,483 (46) $99,049 (59) $83,709 (79) $111,040 (26)
Tibial articular fracture 205 $82,329 $63,520 (109) $103,683 (96) $73,607 (164) $117,215 (41)
Foot fracture 44 $65,355 $58,976 (26) $74,570 (18) $55,707 (35) $102,876 (9)
Soft-tissue injury 30 $65,735 $67,425 (26) $54,757 (4) $61,474 (27) $104,085 (3)
All amputations 161 $91,105 $88,010 (109) $97,598 (52) $78,106 (121) $121,357 (40)
Partial foot 12 $50,152 $43,718 (7) $59,162 (5) $50,152 (12)
Below the knee 100 $86,244 $84,410 (67) $89,971 (33) $75,578 (77) $121,952 (23)
Through the knee 18 $112,810 $116,049 (13) $104,391 (5) $110,462 (14) $121,031 (4)
Above the knee 31 $110,039 $96,497 (22) $143,142 (9) $98,944 (18) $125,400 (13)
*Includes fifteen patients who had an amputation after three months. Includes twelve patients who had an amputation after being dis-
charged from the initial hospitalization but within three months after the injury.
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total lifetime health-care costs were substantially higher for
patients treated with amputation than for patients treated
with reconstruction. This was largely due to the costs associ-
ated with the repair and replacement of prostheses for the
forty to forty-five years of remaining life years in this sample.
Our estimates of both two-year and projected lifetime
health-care costs were subject to bias given the limitations of
the data and the assumptions required to derive the estimates.
First, we did not include all direct costs incurred by either the
patients treated with amputation or those treated with recon-
struction. Most notably absent were pharmacy-related costs,
costs associated with adaptive equipment, and those associ-
ated with modifications of the patients residence, motor vehi-
cle, or workplace. All of these are likely to increase estimated
costs significantly. It is also important to emphasize that our
estimates did not take into account indirect costs associated
with lost work and residual disability. As previously reported,
however, rates of return to work and self-reported disability at
two and seven years after the injury were comparable for the
amputation and reconstruction groups
2
.
A second limitation relates to the data available for esti-
mating two-year costs. Although the costs associated with the
initial hospitalization and injury-related rehospitalizations
were based on actual billed inpatient charges, the costs associ-
ated with inpatient rehabilitation and outpatient services re-
lied on self-reported use and average per diem or per visit
costs estimated from other sources of data. Although the reli-
ability of self-reported data on outpatient visits has been
shown to be adequate at recall intervals of two to four weeks,
it is more questionable after longer recall periods
16
. We suspect
that recall bias results in underreporting of use of services,
leading to underestimates of the true costs. There is no reason
to believe, however, that the magnitude or direction of the bias
would be different between patients who had undergone am-
putation and those who had undergone reconstruction.
Our estimates are also limited by missing data. Al-
though data for estimating hospital costs for the index hospi-
talization were available for 94% of all patients, similar data
for acute rehospitalizations were missing for 64.5% of the
patients. Most problematic were data on professional fees.
Physician fees associated with the index hospitalization and
rehospitalizations were available for only one-third and one-
quarter of the patients, respectively. Finally, charge data were
available from the prosthetists for only 77% of the amputees.
However, the multivariate models that we used to impute val-
ues for missing data were robust. Furthermore, the imputa-
tion methods employed were conservative, tending to shrink
estimates toward the mean of the distributions from which
they were estimated. Consequently, while these estimates
should be viewed with some caution, they should also be
viewed as conservative.
Projecting total lifetime costs required many assump-
tions, most of which are not testable because of the paucity of
data on long-term consequences of major limb injuries. First,
we assumed that life expectancy is similar between patients
treated with an amputation and those treated with a recon-
struction and is comparable with that of the general popula-
tion. In addition, average costs per rehospitalization, per visit,
and per device were trended forward on the basis of the as-
sumption that service use and device replacement during the
seventh year after the injury were similar to those over each
patients lifetime. Abandonment of devices and increased use
of wheelchairs are common among the elderly, but those pos-
sibilities were not taken into account in the derivation of our
projections. We also did not account for future health-care
costs associated with the onset of long-term complications
and secondary conditions such as arthritis and chronic pain,
which may affect both groups, or the development of neuro-
mas, loss of myodesis, and heterotopic bone, which may lead
to higher health-care utilization and revisions among the am-
putees. It is interesting to note that the average number of out-
patient visits was somewhat higher for the amputees than for
the patients treated with limb salvage. These additional visits
may be related to the treatment of skin sores, infections, and
cysts, which are common among amputees.
We also did not account for the purchase of multiple de-
vices, which is becoming more common among young, active,
and high-end users. Nor did we account for the increase in the
cost of devices due to technological advances in both materials
and mechanical functioning. Finally, it is important to note
that, because the LEAP study is observational, it is possible
that the patients who underwent amputation may have been
more severely injured, requiring more complex treatment. If
those patients had undergone reconstruction, their overall
health-care costs might have been greater. Although we at-
tempted to adjust for differences in the severity of both the
lower-limb and the associated injuries in the multivariate re-
gression analysis, the possibility of this bias in our results can-
not be eliminated.
Despite these limitations, we believe that our estimates
add support to our previous conclusions that efforts to im-
prove the rate of successful reconstructions have merit
1-3
. Not
only is the reconstruction of a severely injured extremity be-
low the distal part of the femur a reasonable goal at an experi-
enced level-I trauma center, it appears to result in lower
lifetime health-care costs. At the very least, it is clear that di-
rect costs per se should not be used to deny a patient the op-
portunity for limb reconstruction.
Ellen J. MacKenzie, PhD
Renan C. Castillo, MS
Center for Injury Research and Policy, Johns Hopkins Bloomberg School
of Public Health, 624 North Broadway, Room 482, Baltimore, MD 21205.
E-mail address for E.J. MacKenzie: emackenz@jhsph.edu
Alison Snow Jones, PhD
Department of Social Sciences and Health Policy, Wake Forest University
School of Medicine, 2000 West 1
st
Street, Winston-Salem, NC 27157
Michael J. Bosse, MD
James F. Kellam, MD
Department of Orthopaedic Surgery, Carolinas Medical Center, 1616
Scott Avenue, Charlotte, NC 28203
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HEALTH-CARE COSTS ASSOCI ATED WI TH AMPUTATI ON OR
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Andrew N. Pollak, MD
The R Adams Cowley Shock Trauma Center, University of Maryland at
Baltimore, 22 South Green Street, Suite T3R54, Baltimore, MD 21201
Lawrence X. Webb, MD
Department of Orthopaedic Surgery, Wake Forest University Medical
Center, Medical Center Boulevard, Winston-Salem, NC 27157
Marc F. Swiontkowski, MD
Department of Orthopaedic Surgery, University of Minnesota Medical
School, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55454
Douglas G. Smith, MD
Department of Orthopaedic Surgery, University of Washington, 325
Ninth Avenue, Box 359798, Seattle, WA 98104
Roy W. Sanders, MD
Orthopaedic Trauma Service, Florida Orthopaedic Institute, 4 Columbia
Drive, Suite 710, Tampa, FL 33606
Alan L. Jones, MD
Orthopedic Trauma Association of North Texas, 3600 Gaston Avenue,
Suite 1101, Barnett Tower, Dallas, TX 75246
Adam J. Starr, MD
Department of Orthopaedic Surgery, University of Texas Southwestern
Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
Mark P. McAndrew, MD
Division of Orthopaedics and Rehabilitation, Department of Surgery,
Southern Illinois University, P.O. Box 19679, Springfield, IL 62794
Brendan M. Patterson, MD
Department of Orthopaedic Surgery, Cleveland MetroHealth Medical
Center, 2500 MetroHealth Drive, Cleveland, OH 44109
Andrew R. Burgess, MD
Department of Orthopaedic Surgery, Orlando Regional Medical Center,
22 West Underwood Street, 4
th
Floor, Orlando, FL 32806
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