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A Solution to Poorly Tolerated Lower Limb Amputations: Osseointegrated Prostheses Prove Cost Effective in the United States
Grant Black, BA1, Xian Wu, MPH2, S. Robert Rozbruch, MD3, David M. Otterburn, MD4
1Weill Cornell Medical College, New York, NY, 2Brown University, Providence, RI, 3Hospital for Special Surgery, New York, NY, 4NewYork-Presbyterian Hospital, New York, NY

Purpose:: This study is the first cost-benefit analysis of osseointegrated implant (OI) prostheses compared to socket-suspended (SS) prostheses for lower limb amputees in the United States. The use of traditional SS prostheses for patients with transfemoral and transtibial amputations can be complicated by issues like poor fit, tissue damage, and pain at the socket- limb interface that require management by plastic surgeons. Osseointegration provides an alternative solution by anchoring the prosthesis directly to an implant in the userís residual limb. Soft tissue reconstruction at the time of implantation is performed by a plastic surgery team.
Methods: We used a Monte Carlo model to project costs and lifetime quality-adjusted life years (QALYs) for patients with OI and SS prostheses. Simulation parameters were derived from a cohort of 25 patients who underwent osseointegrated implantation following unilateral lower limb amputation at our institution between October 2017 and February 2020. Material and labor costs were collected via IRB-approved retrospective chart reviews. Utilities and SS prosthesis costs were derived from the literature. An incremental cost effectiveness ratio (ICER) was used to compare OI and SS prostheses.
Results: Our patients had an average age of 49.6 years at implantation and were followed for 17 months on overage. 84% of patients had traumatic amputations. We found the average cost of osseointegration surgery to be $54,503. 20% of patients required a pre-implantation residual limb revision surgery, averaging $49,191. Maintenance of a healthy OI prosthesis cost on average $2,626 per year. Complication rates per year and average costs were as follows: soft tissue infection (29%, $435), bone/implant infection (11%, $11,721), painful neuroma (14%, $14,659), and mechanical failure (17%, $46,513). The ICER of OI prostheses compared to SS prostheses was $44,660. A cost effectiveness acceptability curve showed that OI was favored over SS in 71% of cases at a willingness-to-pay of $50,000 per QALY. In one-way sensitivity analyses, the ICER was most sensitive to the mechanical failure rate, mechanical failure cost, and alternative yearly SS prosthesis cost.
Conclusions: Our model suggests that osseointegrated implantation can provide a higher quality of life at affordable costs when compared to poorly tolerated SS prostheses in patients with lower limb amputations in the US. Intraoperative reconstruction and postoperative management by a plastic surgeon is essential to minimize complications and thus improve cost effectiveness and patient satisfaction. More follow-up must be done to understand the long-term benefits and risks of OI-based prostheses.


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