One of the things I really hate thinking about is the cost of treatment. Frankly, dealing with insurance companies and the constant battle with bean counters just makes me flat out angry. My medical assistants know exactly what things make me grouchy, and this is the most obvious one. With that said, it is an interesting – maybe painful – exercise to look at the cost of what we do compared with the benefits. Let’s take a look at a case of mine with a very unscientific cost benefit analysis thrown in.

Mr. R was a 59-year-old diabetic who had undergone multiple prior left foot surgeries for infection and ulceration culminating in a Lisfranc amputation. Subsequent to the amputation, he had many wound healing attempts with ulcer recurrence and infection episodes. He was now seeing me for a chronic plantar neuropathic ulcer. See below for his clinical and radiographic extremity appearance.

He continued to ulcerate plantarlaterally due to the varus position of the residual foot and equinus of the ankle. I performed a tibiotalocalcaneal fusion with posterior tibial tenotomy and Achilles tendon lengthening with the results you’ll note below (the images are one month postop). I had offered him a below knee amputation, but he continued to desire limb salvage. The patient was admitted to the hospital postoperatively and spent nine days there due to pneumonia. He then spent 12 more days in a rehabilitation facility for his limb (not the pneumonia).

Clinically, I obtained an adequate result. The varus and equinus are gone. However, you’ll note the early plate failure with gaping at the medial aspect of the ankle joint and cantilevering of the plate. Despite this, the limb remains stable and has not worsened.

Now, let’s discuss the costs of all this versus the benefits. First, it’s important to note that there are two cost/benefit ratios to consider: (1) that of the patient and (2) that of the surgeon. The following dollar amounts are based off of the explanation of benefits forms provided to the patient by his insurance company (with the patient’s permission) that cover about one month of care.

If we consider that a below knee amputation costs somewhere around $45,000 to $60,000, we could conclude that this patient’s surgery was not monetarily-speaking the right thing to do. The system would have saved a lot of money if we had simply amputated his leg.

But again, we’re not treating this patient’s wallet. We must consider the medical costs and benefits. Consider that there is a 50% risk of contralateral foot ulceration and 50% contralateral limb amputation within 2 to 5 years after below knee amputation¹. Consider also that the 3 and 5 year survival rates after BKA are only 50% and 40%, respectively².

Additionally consider that the energy cost of walking is significantly affected by the level of amputation. Waters and colleagues looked at velocity, cadence, stride length, and oxygen consumption in patients with above knee, below knee, and Symes amputations. They found improved indicators of gait and metabolic function with increasingly distal amputations³.

Finally, we know that patients have improved long-term survival with more distal amputations^4,5,6. If we compare these diabetes-related limb complications with cancer, which was so beautifully done by Dr. Armstrong and shown below⁷, it seems justifiable to address this patient’s limb salvage as aggressively as we would treat cancer. In essence, the cost is more than justified by the medical benefits obtained by keeping the limb.

However, there are limits to this approach. Just as patients with cancer sometimes sadly reach a point where further treatment is not helpful, and hospice is the best choice, so too is the case with some of our limb salvage patients. Where that point is for limb salvage is much more difficult to determine, and until quality research is completed to help guide us, we will need to rely on our own judgment working with our patients to determine the best course of action. Cost versus benefit? It’s up to each of us to decide.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

1. Larsson J, Agardh CD, Apelqvist J, et al. Long-term prognosis after healed amputation in patients with diabetes. Clin Orthop Relat Res. 1998;350:149-158.
2. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003 Feb;26(2):491-494.
3. Waters R, Perry J, Antonelli D, et al. Energy cost of walking amputees: the influence of level of amputation. J Bone Joint Surg. 1996 Jan;58:42-46.
4. Mayfield JA, Reiber GE, Maynard C, et al. Survival following lower-limb amputation in a veteran population. J Rehabil Res Dev. 2001;38:341-345.
5. Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA. Mortality of first-time amputees in diabetics: a 10-year observation. Diabetes Res Clin Pract. 2009;83:126-131.
6. Brown ML, Tang W, Patel A, Baumhauer JF. Partial foot amputation in patients with diabetic foot ulcers. Foot & Ankle Int. 2012 Sep;33(9):707-716.
7. Armstrong D, Wrobel J, Robbins J. Guest Editorial: are diabetes–related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286-287.