Cost-utility Analysis of Targeted Muscle Reinnervation Surgery versus Standard Surgery Followed by Pharmacological Therapy after Upper Limb Amputation: An NHS Perspective

Background and Objective: Individuals with limb loss frequently experience chronic postamputation pain. This includes residual limb pain and phantom limb pain. Residual limb pain may be nerve-related (e.g., symptomatic neuromas). This study evaluates the cost-effectiveness of targeted muscle reinnervation (TMR) surgery to treat neuroma pain and phantom limb pain in a cohort of patients with upper-limb amputation and compares it with standard surgery combined with pharmacological therapy from an NHS perspective over a lifetime horizon. Methods: A Markov model was created to simulate clinical pathways for individuals with an upper limb amputation undergoing TMR surgery. Costs were derived from NHS tariffs and British National Formulary data, while quality-adjusted life years (QALYs) were based on EQ-5D-5L questionnaires. Deterministic and probabilistic sensitivity analyses were used to assess robustness, and scenario analyses were used to examine different discount rates, time horizons, and medication disutilities. Results: Base-case analysis showed that TMR surgery yielded 2.39 additional QALYs and £12,558 in cost savings compared with standard care, resulting in a negative incremental cost-effectiveness ratio of –£5253 per QALY gained. This indicates that TMR is dominant—offering better outcomes at a lower cost. Sensitivity and scenario analyses confirmed these findings across all tested assumptions, including variations in complication costs and discount rates. Conclusions and Limitations: TMR surgery appears to be a cost-effective alternative to conventional management, improving quality of life and long-term economic outcomes for individuals with an amputation in the NHS. Although based on a small cohort of 19 patients and retrospective utility data, the results remained robust, and surgical cost estimates—sourced from 11 patients—were validated by clinicians as representative. Clinical Relevance Statement: TMR surgery offers a clinically and economically superior option for managing chronic postamputation pain. Wider adoption within the NHS could reduce dependence on pharmacological therapies and improve long-term patient outcomes. Risk Assessment and Research Ethics Procedures: As this study followed an NHS trial, detailed risk assessment and research ethics procedures were deemed unnecessary. ( J Prosthet Orthot. 2026;XX:XX–XX)