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Health-Care Costs Associated with Amputation or Reconstruction of a Limb-Threatening Injury
Ellen J. MacKenzie, PhD1; Renan C. Castillo, MS1; Alison Snow Jones, PhD2; Michael J. Bosse, MD3; James F. Kellam, MD3; Andrew N. Pollak, MD4; Lawrence X. Webb, MD5; Marc F. Swiontkowski, MD6; Douglas G. Smith, MD7; Roy W. Sanders, MD8; Alan L. Jones, MD9; Adam J. Starr, MD10; Mark P. McAndrew, MD11; Brendan M. Patterson, MD12; Andrew R. Burgess, MD13
1 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
2 Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, 2000 West 1st Street, Winston-Salem, NC 27157
3 Department of Orthopaedic Surgery, Carolinas Medical Center, 1616 Scott Avenue, Charlotte, NC 28203
4 The R Adams Cowley Shock Trauma Center, University of Maryland at Baltimore, 22 South Green Street, Suite T3R54, Baltimore, MD 21201
5 Department of Orthopaedic Surgery, Wake Forest University Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157
6 Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55454
7 Department of Orthopaedic Surgery, University of Washington, 325 Ninth Avenue, Box 359798, Seattle, WA 98104
8 Orthopaedic Trauma Service, Florida Orthopaedic Institute, 4 Columbia Drive, Suite 710, Tampa, FL 33606
9 Orthopedic Trauma Association of North Texas, 3600 Gaston Avenue, Suite 1101, Barnett Tower, Dallas, TX 75246
10 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
11 Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University, P.O. Box 19679, Springfield, IL 62794
12 Department of Orthopaedic Surgery, Cleveland MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109
13 Department of Orthopaedic Surgery, Orlando Regional Medical Center, 22 West Underwood Street, 4th Floor, Orlando, FL 32806
View Disclosures and Other Information
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 provide 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.
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

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Aug 01;89(8):1685-1692. doi: 10.2106/JBJS.F.01350
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Background: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction 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) outpatient 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 Index. 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 reconstruction 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 reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results 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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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