Cost-Effectiveness of Lower Extremity Nerve Decompression Surgery in the Prevention of Ulcers and Amputations: A Markov Analysis

Willem D Rinkel, Billy Franks, Erwin Birnie, Manuel Castro Cabezas, J Henk Coert

Research output: Contribution to journalArticleAcademicpeer-review


BACKGROUND: The costs and health effects associated with lower extremity complications in diabetes mellitus are an increasing burden to society. In selected patients, lower extremity nerve decompression is able to reduce symptoms of neuropathy and the concomitant risks of diabetic foot ulcers and amputations. To estimate the health and economic effects of this type of surgery, the cost-effectiveness of this intervention compared to current nonsurgical care was studied.

METHODS: To estimate the incremental cost-effectiveness of lower extremity nerve decompression over a 10-year period, a Markov model was developed to simulate the onset and progression of diabetic foot disease in patients with diabetes and neuropathy who underwent lower extremity nerve decompression surgery, compared to a group undergoing current nonsurgical care. Mean survival time, health-related quality of life, presence or risk of lower extremity complications, and in-hospital costs were the outcome measures assessed. Data from the Rotterdam Diabetic Foot Study were used as current care, complemented with information from international studies on the epidemiology of diabetic foot disease, resource use, and costs, to feed the model.

RESULTS: Lower extremity nerve decompression surgery resulted in improved life expectancy (88,369.5 life-years versus 86,513.6 life-years), gain of quality-adjusted life-years (67,652.5 versus 64,082.3), and reduced incidence of foot complications compared to current care (490 versus 1087). The incremental cost-effectiveness analysis was -€59,279.6 per quality-adjusted life-year gained, which is below the Dutch critical threshold of less than €80,000 per quality-adjusted life-year.

CONCLUSIONS: Decompression surgery of lower extremity nerves improves survival, reduces diabetic foot complications, and is cost saving and cost-effective compared with current care, suggesting considerable socioeconomic benefit for society.

Original languageEnglish
Pages (from-to)1135-1145
Number of pages11
JournalPlastic and Reconstructive Surgery
Issue number5
Publication statusPublished - 1 Nov 2021


  • Amputation/economics
  • Conservative Treatment/economics
  • Cost-Benefit Analysis
  • Decompression, Surgical/economics
  • Diabetic Foot/economics
  • Diabetic Neuropathies/economics
  • Health Care Costs/statistics & numerical data
  • Humans
  • Lower Extremity/innervation
  • Markov Chains
  • Middle Aged
  • Models, Economic
  • Netherlands/epidemiology
  • Quality of Life
  • Quality-Adjusted Life Years
  • Treatment Outcome


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