Patients with unilateral transfemoral amputation treated with a percutaneous osseointegrated prosthesis: a cost-effectiveness analysis

Delivery of UK military upper limb prosthetics: current concepts and future directions

Upper limb prosthetics have a challenging task. A natural upper limb combines strength, coordination and dexterity to accomplish daily activities such as eating, writing, working and social interaction. Artificially replicating these functions requires a prosthetic with composite, synchronous motor function while maintaining sensory feedback and skeletal stability. Achieving these functions requires interfaces between biology and machine across nerve, muscle, bone and skin. This leads to issues related to infection, foreign material encapsulation and implant stability, and electrical signal transduction and interpretation. Over the last 20 years the advent of technologies such as osseointegration, targeted muscle reinnervation, implantable myoelectric sensors, peripheral nerve interfaces and pattern recognition technology has sought to address these problems.Due to many advances in prehospital care, truncated timelines to damage control surgery and improved combat personal protective equipment, the numbers of amputees have increased with more patients surviving injury. From October 2001 to March 2019 there were 333 amputees from Afghanistan and Iraq compared with 457 fatalities over a similar period. Over a third of these were significant multiple amputees. With a functional, robust upper limb prosthetic which mirrors or exceeds normal function, injured service personnel could be returned to an active combat role. This has benefits for their physical and mental health, improves employability prospects and allows Defence to retain some of its most highly motivated and skilled people who represent significant financial investment.

Soft and Hard Tissue Integration around Percutaneous Bone-Anchored Titanium Prostheses: Toward Achieving Holistic Biointegration

A holistic biointegration of percutaneous bone-anchored metallic prostheses with both hard and soft tissues dictates their longevity in the human body. While titanium (Ti) has nearly solved osseointegration, soft tissue integration of percutaneous metallic prostheses is a perennial problem. Unlike the firm soft tissue sealing in biological percutaneous structures (fingernails and teeth), foreign body response of the skin to titanium (Ti) leads to inflammation, epidermal downgrowth and inferior peri-implant soft tissue sealing. This review discusses various implant surface treatments/texturing and coatings for osseointegration, soft tissue integration, and against bacterial attachment. While surface microroughness by SLA (sandblasting with large grit and acid etched) and porous calcium phosphate (CaP) coatings improve Ti osseointegration, smooth and textured titania nanopores, nanotubes, microgrooves, and biomolecular coatings encourage soft tissue attachment. However, the inferior peri-implant soft tissue sealing compared to natural teeth can lead to peri-implantitis. Toward this end, the application of smart multifunctional bioadhesives with strong adhesion to soft tissues, mechanical resilience, durability, antibacterial, and immunomodulatory properties for soft tissue attachment to metallic prostheses is proposed.

Bone-anchored prostheses for transfemoral amputation: a systematic review of outcomes, complications, patient experiences, and cost-effectiveness

Introduction

Bone-anchored prostheses (BAP) are an advanced reconstructive surgical approach for individuals who had transfemoral amputation and are unable to use the conventional socket-suspension systems for their prostheses. Access to this technology has been limited in part due to the lag between the start of a new procedure and the availability of evidence that is required before making decisions about widespread provision. This systematic review presents as a single resource up-to-date information on aspects most relevant to decision makers, i.e., clinical efficacy, safety parameters, patient experiences, and health economic outcomes of this technology.

Methods

A systematic search of the literature was conducted by an information specialist in PubMed, MEDLINE, Embase, CINAHL, Cochrane Library, the Core Collection of Web of Science, CADTH's Grey Matters, and Google Scholar up until May 31, 2023. Peer-reviewed original research articles on the outcomes of clinical effectiveness (health-related quality of life, mobility, and prosthesis usage), complications and adverse events, patient experiences, and health economic outcomes were included. The quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and ROBINS-I, as appropriate.

Results

Fifty studies met the inclusion criteria, of which 12 were excluded. Thirty-eight studies were finally included in this review, of which 21 reported on clinical outcomes and complications, 9 case series and 1 cohort study focused specifically on complications and adverse events, and 2 and 5 qualitative studies reported on patient experience and health economic assessments, respectively. The most common study design is a single-arm trial (pre-/post-intervention design) with varying lengths of follow-up.

Discussion

The clinical efficacy of this technology is evident in selected populations. Overall, patients reported increased health-related quality of life, mobility, and prosthesis usage post-intervention. The most common complication is a superficial or soft-tissue infection, and more serious complications are rare. Patient-reported experiences have generally been positive. Evidence indicates that bone-anchored implants for prosthesis fixation are cost-effective for those individuals who face significant challenges in using socket-suspension systems, although they may offer no additional advantage to those who are functioning well with their socket-suspended prostheses.

Lifetime cost-effectiveness analysis osseointegrated transfemoral versus socket prosthesis using Markov modelling

Aims

Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient's quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

Methods

Lifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated.

Results

For treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467.

Conclusion

The use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness.

Estimation of Value-Based Price for 48 High-Technology Medical Devices

Value-based price is estimated quite frequently for medicines, but its application to medical devices is scarce. While some reports have been published in which this parameter has occasionally been determined for devices, no large-scale application has yet been reported. Our objective was to pursue a systematic analysis of the literature published on value-based prices of medical devices. Pertinent papers were selected upon the criterion that the value-based price was reported for the device examined. The real prices of the devices were compared with their values of value-based price and the ratios between real price versus value-based price were calculated. A total of 239 economic articles focused on high-technology medical devices were selected from a standard PubMed search. Among these, the proportion of analyses unsuitable for value-based price estimation was high (191/239; 80%), whereas adequate clinical and economic information for estimating this parameter was available in 48 cases (20%). Standard equations of cost-effectiveness were applied. The value-based price was determined according to a willingness-to-pay threshold of 60,000 € per quality-adjusted life year. Real prices of devices were compared with the corresponding estimates of value-based prices. From each analysis, we extracted also the value of incremental cost-effectiveness ratio (ICER). Our final dataset included 47 analyses because one was published twice. There were five analyses in which the ICER could be estimated for the treatment, but not for the device. In the dataset of 42 analyses with complete information, 36 out of 42 devices (86%) were found to have an ICER lower than the pre-specified threshold (favorable ICER). Three ICERs were borderline. A separate analysis was conducted on the other three devices that showed an ICER substantially greater than the threshold (unfavorable ICER). Regarding value-based prices, the values of real price were appreciably lower than the corresponding value-based price in 36 cases (86%). For three devices, the real price was substantially higher than the value-based price. In the remaining three cases, real prices and value-based prices were very similar. To our knowledge, this is the first experience in which a systematic analysis of the literature has been focused on the application of value-based pricing in the field of high-technology devices. Our results are encouraging and suggest a wider application of cost-effectiveness in this field.

Interpreting decision-analytic modelling-based economic evaluations in orthopaedics

Economic evaluation provides a framework for assessing the costs and consequences of alternative programmes or interventions. One common vehicle for economic evaluations in the healthcare context is the decision-analytic model, which synthesizes information on parameter inputs (for example, probabilities or costs of clinical events or health states) from multiple sources and requires application of mathematical techniques, usually within a software program. A plethora of decision-analytic modelling-based economic evaluations of orthopaedic interventions have been published in recent years. This annotation outlines a number of issues that can help readers, reviewers, and decision-makers interpret evidence from decision-analytic modelling-based economic evaluations of orthopaedic interventions.Cite this article: Bone Joint J 2023;105-B(1):17-20.

Improving outcomes for amputees: The health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees

AIM

Some amputees are unable to adequately ambulate using conventional socket prosthetics, osseointegrated prosthetics have been described as an alternative strategy in this patient group. This paper aims to assess the effect of osseointegrated prosthetics, commonly simply referred to as osseointegration, in transfemoral amputees on health-related quality of life and cost analysis.

METHODS

Two centre analysis of patients receiving transcutaneous femoral osseointegration using The Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) implant. Retrospective health utility and cost analysis of prospectively collected patient reported health outcome data. Osseointegration cost was compared with the yearly cost of a poorly fitting conventional prosthetic determining cost/Quality Adjusted Life Year.

RESULTS

Eighty amputees received osseointegration. Mean age was 39 years (range 20-57) and 66% were male (n = 53). The majority of subjects underwent unilateral (n = 62, 77.5%) rather than bilateral surgery (n = 18, 22.5%). Trauma was the most common indication (n = 59, 74%). Maximum follow up was 10.5-years. Mean preoperative EQ5D HUV in pooled data was 0.64 (SEM 0.025) increasing to 0.73 (0.036) at 5-years and 0.78 (0.051) at 6 years with continued improvement up to 10.5-years. In subgroup analysis those with a starting EQ5D HUV <0.60 reached a cost/QALY of <£30,000 at 5-years postoperatively and show statistically significant improvement in EQ5D HUV. The UK military experience was wholly positive with a mean starting EQ5D HUV of 0.48 (0.017) with significant (p < 0.05) improvement in EQ5D HUV at each time point and a resultant reducing cost/QALY at each time point being £28,616.89 at 5 years.

CONCLUSION

There is both a quality of life and financial argument in favour of osseointegration in select patients with above transfemoral amputations. In those unable to mobilise satisfactorily with traditional prostheses and a pre-intervention score of <0.60, a consistent cost effectiveness and quality of life benefit can be seen. Such patients should be considered for osseointegration as these patients reap the maximum benefit and cost effectiveness of the device. This evidence lends strongly to the debate advocating the use of osseointegration through centrally funded resources, including the NHS.

Osseointegrated prostheses for the rehabilitation of patients with transfemoral amputations: A prospective ten-year cohort study of patient-reported outcomes and complications

Background

Methods

Results

Conclusion

Cost-effectiveness analysis of prosthesis provision for patients with transfemoral amputation in Tanzania

BACKGROUND

Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited.

OBJECTIVES

This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis.

RESULTS

From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763.

CONCLUSIONS

These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results.

Contemporary Outcomes of Transfemoral Amputation After Total Knee Arthroplasty

BACKGROUND

Transfemoral amputation (TFA) is a salvage procedure for unreconstructable failed total knee arthroplasty (TKA). Prior studies have reported poor outcomes, patient survival, and prosthetic use. The purpose of this study was to analyze patient outcomes and prosthetic utilization in a contemporary group of patients undergoing TFA in the setting of a TKA.

METHODS

We reviewed 112 patients undergoing TFA with a prior TKA. Indications for amputation and postoperative functional measures were captured through chart review. Patients were contacted by survey to assess the quality of life. The mean follow-up after TFA was 4 years.

RESULTS

Amputations were performed for a chronically infected TKA (n = 87, 78%) and an ischemic limb without signs of an infected TKA (n = 22, 20%). The 10-year survival after TFA was 21%. Of the patients not lost to follow-up, 53 (47%) patients were fitted for a prosthesis. Patients who underwent a TFA after the year 2000 were more likely to be fit for a prosthesis (odds ratio 7.27, P < .01); however, patients were likely to be ambulatory before TFA than after TFA (odds ratio 3.68, P < .01). After TFA, the mean 12-Item Short Form Survey scores for the mental and physical components were 54 ± 13 and 34 ± 7, with no difference in scores between patients fitted for a prosthesis and those who were not (P > .05).

CONCLUSION

Patients undergoing a TFA after TKA due to failure of the TKA are more likely to be fit for a prosthesis; however, they reported no better quality of life and satisfaction compared with patients not fit for a prosthesis.

LEVELS OF EVIDENCE

Level III, Therapeutic.

Health Economics in the Field of Prosthetics and Orthotics: A Global Perspective

The rapid advancement of prosthetic and orthotic (P&O) technology raises the question how the industry can ensure that patients have access to the benefits and providers get paid properly and fairly by healthcare payers. This is a challenge that not only P&O but all areas of health technology face. In many areas of medicine and health products, such as drugs and medical devices, health-technology assessments (HTA) have become a standard procedure in the coverage and reimbursement process. In most countries, P&O is lagging behind that development, although some countries have already formalized HTA for prosthetic and orthotic products and may even use cost-effectiveness analyses to determine pricing and payment amounts. This article gives an overview on the coverage and reimbursement processes in the United States, Canada, Germany, France, Sweden, the United Kingdom, Poland, Japan, and China. This selection reflects the variety and diversity of coverage and reimbursement processes that the P&O industry faces globally. The paper continues with an overview on the necessary research and investment efforts that manufacturers will have to make in the future, and contemplates the likely consequences for the manufacturer community in the market place. Health economics may help support the transition from price-based to value-based coverage and reimbursement but will come at considerable costs to the industry.

Trends and Opportunities in Health Economic Evaluations of Prosthetic Care Innovations

Overcoming obstacles to prosthetic fittings requires frequent tryouts of sockets and components. Repetitions of interventions are upsetting for users and place substantial economic burden on healthcare systems. Encouraging prosthetic care innovations capable of alleviating clinical and financial shortcomings of socket-based solutions is essential. Nonetheless, evidence of socio-economic benefits of an innovation are required to facilitate access to markets. Unfortunately, complex decisions must be made when allocating resources toward the most relevant health economic evaluation (HEE) at a given stage of development of an innovation. This paper first, aimed to show the importance and challenges of HEEs of intervention facilitating prosthetic fittings. Next, the main trends in HEEs at various phases of product development and clinical acceptance of prosthetic care innovations were outlined. Then, opportunities for a basic framework of a preliminary cost-utility analysis (CUA) during the mid-stage of development of prosthetic care innovations were highlighted. To do this, fundamental and applied health economic literature and prosthetic-specific publications were reviewed to extract and analyse the trends in HEEs of new medical and prosthetic technologies, respectively. The findings show there is consensus around the weaknesses of full CUAs (e.g., lack of timeliness, resource-intensive) and strengths of preliminary CUAs (e.g., identify evidence gaps, educate design of full CUA, fast-track approval). However, several obstacles must be overcome before preliminary CUA of prosthetic care innovations will be routinely carried out. Disparities of methods and constructs of usual preliminary CUA are barriers that could be alleviated by a more standardized framework. The paper concludes by identifying that there are opportunities for the development of a basic framework of preliminary CUA of prosthetic care innovations. Ultimately, the collaborative design of a framework could simplify selection of the methods, standardise outcomes, ease comparisons between innovations and streamline pathways for adoption. This might facilitate access to economical solutions that could improve the life of individuals suffering from limb loss.

A Preliminary Cost-Utility Analysis of the Prosthetic Care Innovations: Basic Framework

A preliminary cost-utility analysis (CUA) of prosthetic care innovations can provide timely information during the early stage of product development and clinical usage. Concepts of preliminary CUAs are emerging. However, several obstacles must be overcome before these analyses are performed routinely. Disparities of methods and high uncertainty make the outcomes of usual preliminary CUAs challenging to interpret, appraise and share. These shortcomings create opportunities for a basic framework of preliminary CUAs. First, I introduced a basic framework of a preliminary CUA built around a series of constructs and hands-on recommendations. Then, I appraised this framework considering the strengths and weaknesses, barriers and facilitators, and return on investment. The design of the basic framework was determined through the review of health economic and prosthetic-specific literature. A preliminary CUA comparing the costs and utilities between usual intervention and an innovation could be achieved through a 15-step iterative process focusing on feasibility, constructs, analysis, and interpretation of outcomes. This CUA provides sufficient evidence to identify knowledge gaps and improvement areas, educate about the design of subsequent full CUAs, and obtain fast-track approval from governing bodies. Like previous CUAs, the main limitations were inherent to the constructs (e.g., narrow perspective, plausible scenarios, mid-term time horizon, substantial assumptions, data mismatch, high uncertainty). Key facilitators potentially transferable across preliminary CUAs of prosthetic care innovations included choosing abided constructs, capitalizing on prior schedules of expenses, and benchmarking baseline or incremental utilities. This new approach with preliminary CUA can simplify the selection of methods, standardize outcomes, ease comparisons between innovations, and streamline pathways for adoption. Further collegial efforts toward validating standard preliminary CUAs will facilitate access to economic prosthetic care innovations, improving the lives of individuals suffering from limb loss worldwide.

Health Service Delivery and Economic Evaluation of Limb Lower Bone-Anchored Prostheses: A Summary of the Queensland Artificial Limb Service's Experience

The emergence of skeletal prosthetic attachments leaves governmental organizations facing the challenge of implementing equitable policies that support the provision of bone-anchored prostheses (BAPs). In 2013, the Queensland Artificial Limb Service (QALS) started a five-year research project focusing on health service delivery and economic evaluation of BAPs. This paper reflects on the QALS experience, particularly the lessons learned. QALS' jurisdiction and drivers are presented first, followed by the impact of outcomes, barriers, and facilitators, as well as future developments of this work. The 21 publications produced during this project (e.g., reimbursement policy, role of prosthetists, continuous improvement procedure, quality of life, preliminary cost-utilities) were summarized. Literature on past, current, and upcoming developments of BAP was reviewed to discuss the practical implications of this work. A primary outcome of this project was a policy developed by QALS supporting up to 22 h of labor for the provision of BAP care. The indicative incremental cost-utility ratio for transfemoral and transtibial BAPs was approximately AUD$17,000 and AUD$12,000, respectively, per quality-adjusted life-year compared to socket prostheses. This project was challenged by 17 barriers (e.g., limited resources, inconsistency of care pathways, design of preliminary cost-utility analyses) but eased by 18 facilitators (e.g., action research plan, customized database, use of free repositories). In conclusion, we concluded that lower limb BAP might be an acceptable alternative to socket prostheses from an Australian government prosthetic care perspective. Hopefully, this work will inform promoters of prosthetic innovations committed to making bionic solutions widely accessible to a growing population of individuals suffering from limb loss worldwide.

A Preliminary Cost-Utility Analysis of the Prosthetic Care Innovations: Case of the Keep Walking Implant

Several obstacles must be overcome before preliminary cost-utility analyses (CUA) of prosthetic care innovations can be routinely performed. The basic framework of preliminary CUAs and hands- on recommendations suggested previously might contribute to wider adoption. However, a practical application for an emerging intervention is needed to showcase the capacity of this proposed preliminary CUA framework. This study presented the outcomes of preliminary CUA of the distal weight bearing Keep Walking Implant (KWI), an emerging prosthetic care innovation that may reduce socket fittings for individuals with transfemoral amputation. The preliminary CUAs compared the provision of prosthetic care without (usual intervention) and with the KWI (new intervention) using a 15-step iterative process focused on feasibility, constructs, analysis, and interpretations of outcomes from an Australia government prosthetic care perspective over a six-year time horizon. Baseline and incremental costs were extracted from schedules of allowable expenses. Baseline utilities were extracted from a study and converted into quality-adjusted life-year (QALY). Incremental utilities were calculated based on sensible gains of QALY from baselines. The provision of the prosthetic care with the KWI could generate an indicative incremental cost-utility ratio (ICUR) of -$36,890 per QALY, which was $76,890 per QALY below willingness-to-pay threshold, provided that the KWI reduces costs by $17,910 while increasing utility by 0.485 QALY compared to usual interventions. This preliminary CUA provided administrators of healthcare organizations in Australia and elsewhere with prerequisite evidence justifying further access to market and clinical introduction of the KWI. Altogether, this work suggests that the basic framework of the preliminary CUA of a prosthetic care innovation proposed previously is feasible and informative when a series of assumptions are carefully considered. This study further confirms that preliminary CUAs prosthetic care interventions might be a relevant alternative to full CUA for other medical treatments.

Patient-reported benefits of bone-anchored transfemoral prostheses as assessed by MedTech20: A general outcome measure for medical products

BACKGROUND

The medical community demands evidence for the benefits of medical devices such as bone-anchored prostheses (BAPs). MedTech20  is a novel instrument aiming to address general benefits of medical devices.

OBJECTIVE

To describe general patient-reported benefits of BAPs measured with MedTech20.

STUDY DESIGN

This is a cross-sectional descriptive survey.

METHODS

Patients treated in Sweden who had used a BAP for >1 year were mailed the MedTech20  Questionnaire. Responses to each attribute were described, and the MedTech20   Index (0-1), in which a higher figure represents larger benefits from the product, was calculated. Index values were compared based on demographic variables (sex, unilateral or bilateral transfemoral amputation (TFA), and those having experienced any complication of implant parts or the prosthetic connection device).

RESULTS

The response rate was 72%. The 62 participants (41 men and 21 women; mean age 57 years) had 11 ± 6.9 mean years of BAP experience. Single attributes stated as highly relevant and with high benefit for BAPs included perceived reliability, perceived safety, sense of control of the disability, facilitation of movement outside home, no discomfort at use, and ease of use. Attributes with less relevance included aid to remember tasks, reduction of barriers to a good sleep, and reduced sense of compromised integrity. The MedTech20  Index was 0.655 ± 0.188 and was not statistically significantly different based on any of the demographic variables.

CONCLUSIONS

By using a general measure on attributes of medical devices, this study provides new insights strengthening the evidence regarding the benefits that BAPs provide for patients with TFA who had difficulties with socket-suspended prostheses.

A systematic review of health economic evaluation in orthotics and prosthetics: Part 2-orthotics

BACKGROUND

Health economic evaluations (HEEs) in orthotics are in their infancy. Identification of evidence gaps and method design issues will inform the design of future HEEs that advance knowledge and contributes to policy and investment decisions.

OBJECTIVES

The aim of this systematic review was to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues, and the extent to which the literature informs orthotic policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and HEE-related terms. The Consolidated Health Economic Checklist-Extended and the Checklist for Health Economic Evaluation Reporting Standards were used to identify issues with method design and reporting.

RESULTS

Nine orthotic HEEs were narrowly focused on the cost-effectiveness of low-cost orthotic devices (eg, ankle orthoses for ankle sprains). Method design (eg, cost identification and valuation) and reporting issues (eg, lack of detail about the study population) limited the extent to which this literature can inform policy and investment decisions.

CONCLUSIONS

HEEs comparing a wider variety of interventions are required, particularly for commonly used orthoses (eg, ankle-foot orthoses) and clinical presentations (eg, post-stroke). There are opportunities to strengthen future orthotic HEEs by adopting method design features (eg, microcosting and sensitivity analyses) as recommended by HEE appraisal and reporting tools.

The Use of Decision Analytic Modeling in the Evaluation of Surgical Innovations: A Scoping Review

OBJECTIVES

The main objective of this review was to map how decision analytic models are used in surgical innovation (in which research phase, with what aim) and to understand how challenges related to the assessment of surgical interventions are incorporated.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library for studies published in 2018. We included original articles using a decision analytic model to compare surgical strategies. We included modeling studies of surgical innovations. General, innovation, and modeling characteristics were extracted, as were outcomes, recommendations, and handling of challenges related to the assessment of surgical interventions (learning curve, incremental innovation, dynamic pricing, quality variation, organizational impact).

RESULTS

We included 46 studies. The number of studies increased with each research phase, from 4% (n = 2) in the preclinical phase to 40% (n = 20) in phase 3 studies. Eighty-one studies were excluded because they investigated established surgical procedures, indicating that modeling is predominantly applied after the innovation process. Regardless of the research stage, the aim to determine cost-effectiveness was most frequently identified (n = 40, 87%), whereas exploratory aims (eg, exploring when a strategy becomes cost-effective) were less common (n = 9, 20%). Most challenges related to the assessment of surgical interventions were rarely incorporated in models (eg, learning curve [n = 1, 2%], organizational impact [n = 2, 4%], and incremental innovation [n = 1, 2%]), except for dynamic pricing (n = 10, 22%) and quality variation (n = 6, 13%).

CONCLUSIONS

In surgical innovation, modeling is predominantly used in later research stages to assess cost-effectiveness. The exploratory use of modeling seems still largely overlooked in surgery; therefore, the opportunity to inform research and development may not be optimally used.

The cost-effectiveness of Cochlear implants in Swedish adults

BACKGROUND

Research has shown unilateral cochlear implants (CIs) significantly improve clinical outcomes and quality of life in adults. However, only 13% of eligible Swedish adults currently use a unilateral CI. The objective was to estimate the cost-effectiveness of unilateral CIs compared to a hearing aid for Swedish adults with severe to profound hearing loss.

METHODS

A Markov model with a lifetime horizon and six-month cycle length was developed to estimate the benefits and costs of unilateral CIs from the Swedish health system perspective. A treatment pathway was developed through consultation with clinical experts to estimate resource use and costs. Unit costs were derived from the Swedish National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. Health outcomes were reported in terms of Quality Adjusted Life Years (QALYs).

RESULTS

Unilateral CIs for Swedish adults with severe to profound hearing loss are likely to be deemed cost-effective when compared to a hearing aid (SEK 140,474 per QALY gained). The results were most sensitive to the age when patients are implanted with a CI and the proportion of patients eligible for CIs after triage.

CONCLUSIONS

An increase in the prevalence of Swedish adults with severe to profound hearing loss is expected as the population ages. Earlier implantation of unilateral CIs improves the cost-effectiveness among people eligible for CIs. Unilateral CIs are an efficacious and cost-effective option to improve hearing and quality of life in Swedish adults with severe to profound hearing loss.

Cost Analyses of Prosthetic Devices: A Systematic Review

OBJECTIVE

To synthesize extant literature on the cost-effectiveness of prosthetic interventions and explore applicability to low- and middle-income country (LMIC) settings.

DATA SOURCES

A systematic literature review using subject headings including "prosthetics," "amputation," and "cost analysis" was performed with PubMed, Embase, and Web of Science search engines, yielding 1194 articles. An additional 22 articles were identified via backward citation searching for 1144 total after duplicate removal. The search was last run in May of 2019.

STUDY SELECTION

Studies were included if they conducted an economic analysis of an upper or lower extremity prosthetic device. Studies were excluded if (1) full text was unavailable in English; (2) study was a systematic review or meta-analysis; or (3) study did not have a prosthetic comparison group. Using DistillerSR software, 2 authors independently conducted title and abstract screening. One author conducted full-text screening. The proportion of initially identified studies that met final inclusion criteria was 1% (12 of 1144).

DATA EXTRACTION

Data were dually extracted by 2 authors and reviewed by 3 additional authors.

DATA SYNTHESIS

All included studies (N=12) examined lower extremity amputations comparing advanced technology. No studies were conducted in LMICs. Comparable data between studies demonstrated (1) the cost-effectiveness of microprocessor- over nonmicroprocessor-controlled knees for transfemoral amputation in high-income settings; (2) equivocal findings regarding osseointegrated vs socket-suspended prostheses; and (3) increased cost for ICEX and modular socket systems over patellar tendon-bearing socket systems with no functional improvement.

CONCLUSIONS

There are few prosthetic cost analyses in the literature. Additional analyses are needed to determine the direct and indirect costs associated with prosthetic acquisition, fitting, and maintenance; the costs of amputee rehabilitation; and long-term economic and quality-of-life benefits. Such studies may guide future prosthetic and rehabilitative care, especially in resource-austere settings where prosthetic needs are greatest.

A systematic review of health economic evaluations in orthotics and prosthetics: Part 1 - prosthetics

BACKGROUND

The extent to which current prosthetic health economic evaluations inform healthcare policy and investment decisions is unclear. To further the knowledge in this area, existing evidence gaps and method design issues must be identified, thereby informing the design of future research.

OBJECTIVES

The aim of this systematic review was to identify evidence gaps, critical method design and reporting issues and determine the extent to which the literature informs a wide range of policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and health economic evaluation-related terms. Issues with methodological design and reporting were evaluated using the Consolidated Health Economic Checklist - Extended and the Checklist for Health Economic Evaluation Reporting Standards.

RESULTS

The existing health economic evaluation literature was narrowly focused on informing within-participant component decisions. There were common method design (e.g. time horizon too short) and reporting issues (e.g. competing intervention descriptions) that limit the extent to which this literature can inform policy and investment decisions.

CONCLUSION

There are opportunities to conduct a wider variety of health economic evaluations to support within- and across-sector policy and investment decisions. Changes to aspects of the method design and reporting are encouraged for future research in order to improve the rigour of the health economic evaluation evidence.

CLINICAL RELEVANCE

This systematic review will inform the clinical focus and method design of future prosthetic health economic evaluations. It will also guide readers and policy-makers in their interpretation of the current literature and their understanding of the extent to which the current literature can be used to inform policy and investment decisions.

Advanced techniques in amputation surgery and prosthetic technology in the lower extremity

Bone-anchored implants give patients with unmanageable stump problems hope for drastic improvements in function and quality of life and are therefore increasingly considered a viable solution for lower-limb amputees and their orthopaedic surgeons, despite high infection rates.Regarding diversity and increasing numbers of implants worldwide, efforts are to be supported to arrange an international bone-anchored implant register to transparently overview pros and cons.Due to few, but high-quality, articles about the beneficial effects of targeted muscle innervation (TMR) and regenerative peripheral nerve interface (RPNI), these surgical techniques ought to be directly transferred into clinical protocols, observations and routines.Bionics of the lower extremity is an emerging cutting-edge technology. The main goal lies in the reduction of recognition and classification errors in changes of ambulant modes. Agonist-antagonist myoneuronal interfaces may be a most promising start in controlling of actively powered ankle joints.As advanced amputation surgical techniques are becoming part of clinical routine, the development of financing strategies besides medical strategies ought to be boosted, leading to cutting-edge technology at an affordable price.Microprocessor-controlled components are broadly available, and amputees do see benefits. Devices from different manufacturers differ in gait kinematics with huge inter-individual varieties between amputees that cannot be explained by age. Active microprocessor-controlled knees/ankles (A-MPK/As) might succeed in uneven ground-walking. Patients ought to be supported to receive appropriate prosthetic components to reach their everyday goals in a desirable way.Increased funding of research in the field of prosthetic technology could enhance more high-quality research in order to generate a high level of evidence and to identify individuals who can profit most from microprocessor-controlled prosthetic components. Cite this article: EFORT Open Rev 2020;5:724-741. DOI: 10.1302/2058-5241.5.190070.

Periprosthetic osseointegration fractures are infrequent and management is familiar

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

Methods

A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed.

Results

There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312).

Conclusion

The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential.

Cite this article: Bone Joint J 2020;102-B(2):162–169.

The future of the amputees with osseointegration: A systematic review of literature

OBJECTIVE

Socket prosthesis attachment is the current gold standard for limb amputees. Osseointegrated implantation is a novel technique that has many proposed advantages over the current gold standard. Clear advantages for its use over socket prosthetic attachment has been well established in literature. It decreases socket problems as pinching, pressure points, chronic skin problems and frequent socket change due to atrophy of muscles.

METHODS

We reviewed primary research articles documenting complication rates and outcome measures in patients with osseointegrated prosthesis implantation after limb amputation.

RESULTS

Nine studies were identified with a total of 211-242 patients. Clinical, radiographic, and functional outcomes, as well as complications were considered. The mean duration of follow-up was greater than 12 months in all studies.

CONCLUSIONS

Osseointegration is an effective alternative to socket prosthesis in transfemoral amputees. Transtibial and upper extremity implants are underreported in the literature and clear indication for their effectiveness over socket prosthesis does not exist. Minor complications are most common, such as soft tissue infections, and may be mitigated in the future by improvements in surgical technique and implant design.The level of evidence is 3.

A 15-year follow-up of transfemoral amputees with bone-anchored transcutaneous prostheses

AIMS

The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.

METHODS

In this cohort study, all patients with a unilateral TFA treated with the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) implant system in Sahlgrenska University Hospital, Gothenburg, Sweden, between January 1999 and December 2017 were included. The cohort comprised 111 patients (78 male (70%)), with a mean age 45 years (17 to 70). The main reason for amputation was trauma in 75 (68%) and tumours in 23 (21%). Patients answered the Questionnaire for Persons with Transfemoral Amputation (Q-TFA) before treatment and at two, five, seven, ten, and 15 years' follow-up. A prosthetic activity grade was assigned to each patient at each timepoint. All mechanical complications, defined as fracture, bending, or wear to any part of the implant system resulting in removal or change, were recorded.

RESULTS

The Q-TFA scores at two, five, seven, and ten years showed significantly more prosthetic use, better mobility, fewer problems, and an improved global situation, compared with baseline. The survival rate of the osseointegrated implant part (the fixture) was 89% and 72% after seven and 15 years, respectively. A total of 61 patients (55%) had mechanical complications (mean 3.3 (SD 5.76)), resulting in exchange of the percutaneous implant parts. There was a positive relationship between a higher activity grade and the number of mechanical complications.

CONCLUSION

Compared with before treatment, the patient-reported outcome was significantly better and remained so over time. Although osseointegration and the ability to transfer loads over a 15-year period have been demonstrated, a large number of mechanical failures in the external implant parts were found. Since these were related to higher activity, restrictions in activity and improvements to the mechanical properties of the implant system are required. Cite this article: Bone Joint J 2020;102-B(1):55-63.

Osseointegrated Prosthetic Implants for People With Lower-Limb Amputation: A Health Technology Assessment

BACKGROUND

Osseointegrated prosthetic implants are biocompatible metal devices that are inserted into the residual bone to integrate with the bone and attach to the external prosthesis, eliminating the need for socket prostheses and the problems that may accompany their use. We conducted a health technology assessment of osseointegrated prosthetic implants, compared with conventional socket prostheses, for people with lower-limb amputation who experience chronic problems with their prosthetic socket, leading to prosthesis intolerance and reduced mobility. Our analysis included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding osseointegrated prosthetic implants, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence on the safety and effectiveness of the latest iterations of three implant systems: the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) Implant System, the Endo-Exo-Femur-Prosthesis, and the Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL). We assessed the risk of bias of individual studies and determined the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a lifetime horizon from a public payer perspective. We also analyzed the net budget impact of publicly funding osseointegrated prosthetic implants in Ontario. To contextualize the potential value of osseointegrated prosthetic implants, we spoke with people with lower-limb amputations.

RESULTS

We included nine studies in the clinical evidence review. All studies included patients with above-the-knee amputation who underwent two-stage surgery and mostly had short-term follow-up. With osseointegrated prosthetic implants, scores for functional outcomes improved significantly as measured by 6-Minute Walk Test (6MWT), Timed Up and Go (TUG) test, and Questionnaire for Persons with a Transfemoral Amputation (Q-TFA). The scores for quality of life measured by SF-36 showed significant improvement in the physical component summary but a nonsignificant decline for the mental component summary. The most frequently seen adverse event was superficial infection, occurring in about half of patients in some studies. Deep or bone infection was a serious adverse event, with variable rates among the studies depending on the length of follow-up. The treatment of deep or bone infection required long-term antibiotic use, surgical debridement, revision surgery, and implant extraction in some cases. Other adverse events included femoral bone fracture, implant breakage, issues with extramedullary parts that required replacement, and implant removal. Our assessment of the quality of the clinical evidence according to the GRADE criteria found low certainty in terms of improvement in functional outcomes, low certainty for quality of life, and high certainty of an increase in adverse events; all findings compared receiving an osseointegrated prosthetic implant with not receiving an osseointegrated prosthetic implant.In our economic model, osseointegrated prosthetic implants were found to be more effective and more expensive than having people remain users of an uncomfortable socket prosthesis. Our best estimate of the incremental cost-effectiveness ratio (ICER) for osseointegration, compared with an uncomfortable socket, was $94,987 per quality-adjusted life-year (QALY) gained. The probability of osseointegration being cost-effective was 54.2% at a willingness-to-pay value of $100,000 per QALY gained. The annual net budget impact of publicly funding osseointegrated prosthetic implants in Ontario over the next 5 years, for a small population of eligible candidates, would range from $1.5 million in year 1 to $0.6 million in year 5, for a 5-year total of $5.3 million.We interviewed 13 people with a lower-limb amputation; nine had experience with both a conventional socket prosthesis and an osseointegrated prosthetic implant, three had experience with a conventional socket prosthesis only, and one had only recently undergone amputation and had not yet chosen a prosthesis. People who had received an osseointegrated prosthetic implant said they had better mobility and quality of life than before receiving this implant but had concerns about the ongoing risk of infection and potential for problems with implant maintenance. People using a conventional socket prosthesis said cost was the only factor preventing them from undergoing an osseointegration procedure.

CONCLUSIONS

In the studies included in the clinical evidence review, most people who received osseointegrated prosthetic implants were followed for only a few years. Studies showed that functional outcomes and physical ability improved with osseointegrated prosthetic implants (GRADE: Low), but there was uncertainty about the impact of these implants on people's emotional health (GRADE: Low). Osseointegrated prosthetic implants can lead to serious adverse events such as bone infection and bone fracture in some patients, which may require additional surgeries (GRADE: High). The reference case of the primary economic evaluation represented a conservative estimate of cost-effectiveness and found osseointegration may be cost-effective, but there is a large degree of uncertainty given parameter uncertainty and the need to use proxy costs. Scenario analyses explored potential variations in approaches to modelling and parameter selection. Qualitative interviews with people with a lower-limb amputation and caregivers underscored the challenges of conventional socket prostheses, but cost remains an important barrier to pursuing osseointegrated prosthetic implantation.

Analysis of the Stomal Microbiota of a Percutaneous Osseointegrated Prosthesis: A Longitudinal Prospective Cohort Study

Percutaneous osseointegrated (OI) prostheses (POPs) are used to skeletally attach artificial limbs in amputees. While any permanent percutaneous interface is at risk of becoming infected by the resident microbiota colonizing the stoma, most of these patients remain infection-free. Avoidance of infection likely depends upon a mechanically and/or biologically stable skin-to-implant interface. The ultimate question remains, "why do some stomata become infected while others do not?" The answer might be found in the dynamic bacterial communities of the patient and within the stomal site itself. This study is an appendix to the first Food and Drug Administration approved prospective early feasibility study of OI prosthetic docking, in which, 10 transfemoral amputees were implanted with a unique POP device. In this analytical, longitudinal cohort study, each patient's skin and stomal microbiota were analyzed from the initial surgery to 1 year following the second-stage surgery. During each follow-up visit, three swab samples-stomal, device thigh skin and contralateral thigh skin-were obtained. DNA was extracted, and bacterial 16S ribosomal RNA (rRNA) genes were amplified and sequenced to profile microbial communities. The stomal microbiota were distinct from the microbiota on the adjacent thigh skin and the skin of the contralateral thigh, with a significantly increased abundance of Staphylococcus aureus within the stoma. Early on stomal microbiota were characterized by high diversity and high relative abundance of obligate anaerobes. Over time, the stomal microbiota shifted and stabilized in communities of lower diversity dominated by Streptococcus, Corynebacterium, and/or Staphylococcus spp. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2645-2654, 2019.

Does migration of osseointegrated implants for transfemoral amputees predict later revision? A prospective 2-year radiostereometric analysis with 5-years clinical follow-up

BACKGROUND

The osseointegrated (OI) prosthesis is a treatment option for transfemoral amputees with a short residual femur and/or difficulties caused by using the prosthetic socket. Implant removal due to aseptic or septic loosening is not uncommon, but the association between implant migration patterns and the need for removal has not previously been studied. We conducted a prospective model-based radiostereometric analysis study to investigate: if the OI implant migration pattern 1) differs between later removed implants and non-removed implants, (2) predicts later implant removal, and (3) if the precision of the method is acceptable.

HYPOTHESIS

Model-based radiostereometric analysis of the OI implant migration pattern can be used to predict later OI implant removal.

MATERIAL AND METHODS

A prospective cohort of 17 consecutive transfemoral amputees suitable for surgery (11 males), mean age 50 (range 32-66) were treated with an OI implant (Integrum AB, Sweden). Postoperative stereoradiographs of the OI implant were obtained during 24-month follow-up. X, Y, and Z translations and total translations were evaluated using CAD-implant models. Implant survival was followed for up to 60 months.

RESULTS

Six total implant removals (fixture and abutment) and four partial removals (abutment) were conducted (10/17 (59%)), and one patient did not use the OI implant. The removed implants group migrated a mean (±standard deviation) 0.55mm±0.75mm (p=0.009) and the non-removed implants group migrated 0.31mm±0.51mm (p=0.22) in total translations from 3 months to last follow-up. Odds ratio for implant removal was 22.5 (95% CI: 1.6 to 314 (p=0.021)) if the OI implants migrated distally.

CONCLUSION

Later removed OI implants migrated from 3 months to last follow-up and more than the non-removed OI implants. Distal implant migration greatly increased the odds of implant removal. Ten out of 17 OI implants were removed within 5 years of follow-up. We advise to use OI implants with caution and close follow-up in consideration of the risk of complications.

LEVEL OF EVIDENCE

IV, Prospective study.

Health economic evaluation in orthotics and prosthetics: a systematic review protocol

BACKGROUND

Health economic evaluations are essential to support health care policy and investment decisions. To date, health economic evaluations in orthotics and prosthetics have focused on discrete components of an orthosis/prosthesis (e.g. a microprocessor controlled prosthetic knee joint) rather than the broader service provided by orthotist/prosthetists. As such, the contribution to orthotic/prosthetic policy and investment decisions is unclear. Whilst there are opportunities to conduct more informative health economic evaluations that describe the costs and benefits of the orthotic/prosthetic service, it is important that prospective research is informed by a critical review of the method design challenges and an understanding of how this research can be improved. The aim of this systematic review is to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues and the extent to which the literature informs orthotic/prosthetic policy and investment decisions.

METHODS

A comprehensive range of databases-AMED, EMBASE, MEDLINE and PsychINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, Web of Science, Cochrane Database of Systematic Reviews (CDSR) and specialty health economic databases-will be searched using National Library of Medicine Medical Subject Headings (MeSH) terms as well as the title, abstract, and keyword terms. Search terms related to the intervention (e.g. orthosis), including variants used by varying professional disciplines (e.g. brace), will be used in preference to defining the populations that use orthotic and prosthetic services (e.g. people living with rheumatoid arthritis). Search terms related to health economic evaluations will be guided by previously developed and tested search strings and align with recommendations by the Canadian Agency for Drugs and Technologies in Health. Articles meeting the inclusion criteria will be hand-searched for relevant citations, and a forward citation search using Google Scholar will also be conducted to identify early online articles not yet indexed in traditional databases. Original research published in the English language and after 1 January 2000 will be included. The Checklist for Health Economic Evaluation Reporting Standards (CHEERS) and the Consensus on Health Economic Criteria (CHEC)-Extended list will be used to appraise the methodological quality and identify sources of bias. Data extraction and appraisal will be conducted by one reviewer independently using appraisal instrument guidelines and a content specific decision aid with exemplars. A subsequent review by a second researcher will be undertaken to confirm the accuracy of the extraction and appraisal, and a final review by a third where consensus cannot be reached. The data will be extracted to a purpose-built data extraction template with decision-making guidelines to support consistency. Where possible, the findings of the review will be reported as a meta-analysis, although the heterogeneity of the literature will likely mean a narrative review that illuminates method design issues that contribute to imprecision and variation will be more appropriate.

DISCUSSION

This protocol has been purposefully designed to summarise the existing evidence and appraise the methodological approaches used and the quality of the health economic evaluations in orthotics and prosthetics. What we learn from this review will be used to guide further work in this area and design more rigorous health economic evaluations into the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116910.

Functional performance and safety of bone-anchored prostheses in persons with a transfemoral or transtibial amputation: a prospective one-year follow-up cohort study

OBJECTIVES:

(1) To compare level of function, activity, health-related quality of life (HRQoL) and satisfaction in persons with a lower extremity amputation before surgery and 6- and 12-months after implantation of an osseointegration implant and (2) to report adverse events.

DESIGN:

Prospective cohort study.

SETTING:

University medical centre.

SUBJECTS:

A total of 40 consecutive persons (median age: 56 years) who received a transfemoral (31) or transtibial (9) osseointegration implant, between April 2014 and March 2016.

INTERVENTION:

Osseointegration implant surgery followed by a predefined rehabilitation programme.

MAIN MEASURES:

Hip abductor strength, prosthetic use, back pain frequency, postoperative pain, mobility level (Timed-Up and Go (TUG) and wheelchair-boundedness), walking ability (6 minute walking test (6MWT) and walking distance in daily life), HRQoL, satisfaction regarding the prosthesis, and adverse events.

RESULTS:

Strength, prosthetic use, walking distance, HRQoL, and satisfaction level increased significantly at 6- and 12-month follow-up compared to baseline ( P ⩽ 0.002). The TUG showed no change at 6-month follow-up ( P = 0.420) but improved significantly at 12-month follow-up compared to baseline ( P = 0.005). Wheelchair-boundedness decreased from 12/40 participants at baseline to 0 at follow-ups. The 6MWT ( P ⩾ 0.038) and back pain ( P ⩾ 0.437) did not change over time. Stump pain was present in 28/39 and 22/40 of the participants at 6-and 12-month follow-up, respectively. The major adverse events were managed successfully and included three dual-cone breakages and four bone fractures. An uneventful course was completed by 19/31 transfemoral and 4/9 transtibial bone-anchored prostheses users.

CONCLUSION:

Bone-anchored prostheses lead to improved performance and appear to be safe, so they might be considered for persons with socket-related problems.

Transfemoral amputation following total knee arthroplasty

Aims

The aim of this study was to characterize the factors leading to transfemoral amputation after total knee arthroplasty (TKA), as well as the rates of mortality and functional independence after this procedure in these patients.

Patients and Methods

This was a multicentre retrospective review with a prospective telephone survey for the assessment of function. All patients with a TKA who subsequently required transfemoral amputation between January 2001 and December 2015 were included. Demographic information, medical comorbidities, and postoperative mortality data were collected. A 19-item survey was used for the assessment of function in surviving patients.

Results

A total of 111 patients were included. Their mean age was 61.0 years (42.0 to 88.0) at the time of TKA, with a subsequent mean of 3.7 operations (0 to 15) over a mean period of 6.1 years (0.05 to 30.1) before amputation. The indication for amputation was chronic infection in 97 patients (87.4%). The rate of five-year survival was 51.7%, and advanced age (p = 0.001) and renal failure (p = 0.045) were associated with an increased risk of mortality. Of the 62 surviving patients, 34 completed the survey; 32 (94.1%) owned a prosthesis but only 19 (55.9%) used it; 19 (55.9%) primarily used a wheelchair for mobility; 27 (79.5%) had phantom pain; and 16 (47.1%) required chronic pain medication. Only 18 patients (52.9%) were satisfied with the quality of life.

Conclusion

Patients with complications after TKA, in whom transfemoral amputation is considered, should be made aware of the high rate of mortality and the poor functional outcome in the survivors. Alternative forms of treatment including arthrodesis of the knee should be investigated.