State of Orthotics & Prosthetics: 2022 and Beyond

The State of Orthotics & Prosthetics: 2022 and Beyond

O&P Is on a

Trajectory

The orthotics and prosthetics (O&P) profession is growing in the U.S. Approximately $4.3 billion1 is spent in the U.S. each year for prescription-based O&P products and services through O&P clinics. The profession is characterized by stable, recurring revenues, primarily resulting from new patients, as well as the need for periodic replacement and modification of O&P devices.

The demand for O&P services will continue to grow. As a result of several trends, including the aging of the U.S. population, there will be an increase in the prevalence of disease-related disability and demand for new and advanced devices.

The typical replacement time for prosthetic devices is three to five years, while the typical replacement time for orthotic devices varies depending on the device. Approximately $1.8 billion1 is spent in the U.S. each year by providers of O&P patient care services for the O&P products, components, devices, and supplies used in their businesses.

Hanger, Inc.

Headquartered in Austin, Texas, Hanger, Inc. is the largest national provider of O&P products and services. According to SEC records, Hanger now operates 789 patient care clinics and 115 satellite locations in 47 states and the District of Columbia, as of Dec. 31, 2021.2 The most recent annual report indicates its Patient Care segment currently accounts for approximately 24% of the market for patients in acute, post-acute, and patient care clinic settings.2

Hanger, Inc. was purchased on July 28, 2022, by Patient Square Capital, a dedicated healthcare investment firm, for approximately $1.25 billion.

Net revenues were $312.4 million for the three months ended Dec. 31, 2021, compared to $277.3 million for the same period in 2020, reflecting growth of 12.6%

Net income was $14.0 million for the three months ended Dec. 31, 2021, compared to $16.1 million for the same period in 2020. Income from operations was $24.9 million for the quarter compared to $29.1 million for the same period in 2020, a decline of 14.6%

EBITDA was $37.2 million

O&P Is on a Growth Trajectory

Other Market Leaders

The next two largest single providers of O&P services in the U.S. are Össur and the U.S. Department of Veterans Affairs (VA), which operate 81 and 79 O&P clinics, respectively, according to public records.

After Hanger and the VA, the top 10 practices have an average of less than 1% of the market each.

The market of patient care services for O&P in the U.S. is fragmented. This is characterized by O&P practices that are both regional and local independently operated. Össur and Ottobock are two O&P manufacturers that have substantial international patient care services operations.

The Orthotic & Prosthetic Group of America (OPGA) is the largest community of independent O&P practices and supplier partners in the U.S., representing nearly 1,300 locations.

Reimbursement

The principal reimbursement sources for O&P services are:

• Commercial private payers and other nongovernmental organizations, which consist of individuals, rehabilitation providers, commercial insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), hospitals, vocational rehabilitation centers, workers’ compensation programs, third-party administrators, and similar sources.

• Medicare, a federally funded health insurance program providing health insurance coverage for persons aged 65 or older and certain persons with disabilities.

• Medicaid, a health insurance program jointly funded by federal and state governments providing health insurance coverage for certain persons requiring financial assistance, regardless of age, which may supplement Medicare benefits for persons aged 65 or older requiring financial assistance.

• The VA, through its Veterans Health Administration, is the country’s largest integrated healthcare network. It features 1,255 healthcare facilities that serve nine million enrolled Veterans each year.

O&P Is on a Growth Trajectory

O&P practices often sign contracts with thirdparty payers, allowing them to provide their services to referred patients, as well as to be reimbursed. Contracts like these usually have stated terms of between one to three years. These contracts, however, may be terminated without cause with a 60- to 90-day notice by either party. If the practice has not met certain licensing/certification standards, or Medicare/ Medicaid requirements, this notice could be reduced to 30 days.

Reimbursement for services, negotiated with the third party, is usually based on fee schedules. Market condition, geographic area, and number of people covered play a role in these negotiations. Commercial contracts are usually proportional to the Medicare fee schedule, relating to the product or service provided.

Government reimbursement, comprised of Medicare, Medicaid, and the VA, account for most O&P practices’ net revenues. Max reimbursement levels are set by these payers for O&P services and products.

Medicare prices are adjusted each year based on the Consumer Price Index for All Urban Consumers (CPI-U) unless Congress acts to change or eliminate the adjustment. Further adjustments are made based on the productivity adjustment (or the multi-factor productivity adjustment), an efficiency factor that helps determine final rate adjustments each year. Adjustments for 2019, 2020, 2021, and 2022 were 2.3%, 0.9%, 0.2%, and 5.1%, respectively.

The industry has no assurance that future adjustments will not reduce reimbursements for O&P services and products from these sources. The O&P profession is subject to various Medicare compliance audits, including Recovery Audit Contractor (RAC) audits, Comprehensive Error Rate Testing (CERT) audits, Targeted Probe and Educate (TPE) audits, Supplemental Medical Review Contractor (SMRC) audits, and Unified Program Integrity Contractor (UPIC) audits.

TPE audits are generally pre-payment audits, while RAC, CERT, and SMRC audits are generally post-payment. UPIC audits can be both pre- and post-payment audits, though the majority currently are pre-payment. TPE audits replaced the previous Medicare Administrative Contractor audits.

Adverse post-payment audit determinations generally require practices to reimburse Medicare for payments previously made, while adverse pre-payment audit determinations usually result in payment denial. Practices can request a redetermination or appeal in these cases if they believe the adverse determination is unwarranted, which can take an extensive period to resolve (as long as six years or more).

fueling demand and growth for the wider O&P market are advancements in robotic prosthetics. In the U.S., an increase in trauma cases and rates of diabetes is leading to increased numbers of amputations.

growing target population and focus on restoring the mobility and independence of amputees will drive the growth of the robotic prosthetics market in the U.S. during the forecast period,” according to a senior analyst at Technavio.

market

CONCENTRATED

of the KEY DRIVERS for this market will be the growing

population and focus

restoring mobility and independence of amputees4

O&P Demand, Forecasting, and Statistics

the KEY

market

be

population

restoring mobility and independence of amputees4

North America O&P market was valued at $2.4 billion USD in 2021 and is expected to grow at a compound annual growth rate (CAGR) of 3.8% during the forecast period, to reach an expected value of $3.1 billion in 2028.4

N.A. Prosthetics & Orthotics Market

N.A. Prosthetics & Orthotics Market

Orthotics Prosthetics

The O&P market is forecasted to be driven by the uptick of cases of sports- and automobilerelated injuries, amputations related to diabetes complications, and the increase of a specific bone cancer, osteosarcoma. At the onset of the COVID-19 pandemic, multiple agencies and organizations took action.

For instance, an open letter dated March 19, 2020, was written by the National Association for the Advancement of Orthotics & Prosthetics (NAAOP) and addressed to the state governors of all 50 states. NAAOP opined that O&P services were essential health benefits that patients would need access to during the pandemic.

According to the American Physical Therapy Association (APTA), the annual sports injury rate

in the U.S. was around 8.7 million5 in 2018. This, along with greatly increased rates of amputation due to road accidents, is anticipated to drive the O&P demand and growth over the forecast period.

The increase of osteosarcoma cases is also a factor in the demand for O&P products. According to the National Cancer Institute, they estimated around 3,450 new cases of bone and joint cancer in 2018, resulting in 1,590 deaths globally. Each year, according to the American Cancer Society, about 1,000 new cases of osteosarcoma are diagnosed in the U.S. with about half of the cases being in children and teens.6

Prosthetics

O&P Demand, Forecasting, and Statistics

COVID-19 and the Market

As with many providers throughout the healthcare continuum, the COVID-19 pandemic impacted the O&P market, causing slowed growth between 2019 and 2020, even as practitioners adopted telehealth technology. Additionally, companies such as Össur saw a decrease in sales for bracing and supports due a reduction in sporting events. With pandemic-related restrictions lifting, the market is now primed for accelerated growth.

Pandemic Impact

The market growth declined to 3.05% from 2019 to 2020 compared to 4.0% from 2018 to 2019.

Post- COVID Outlook

Orthopedic clinics began offering online video appointments while most physical operations are expected to resume by the year-end, which will propel the market growth over in next few years.

According to Össur, COVID-19 pandemic differently impacted the prosthetics & orthotics market. The demand for prosthetics solutions became stable due to servicing the existing amputee population with maintenance.

The bracing and supports sales of Össur declined by 15% to $257 million in 2020 due to lesser sports activity and cancellation of elective surgeries.

During the first quarter of 2021, the market saw a gradual recovery in demand and sales of prosthetics as restrictions eased up and norms relaxed which is expected to positively impact the market.

prosthetics and orthotics market impact: marginal growth of 3% from 2019 to 2020

O&P Demand, Forecasting, and Statistics

Revenue Breakdown

Orthotics held a dominant share of the O&P profession with over 74% of the global market in 2020.7

According to this same report, upper limb orthotics attributed the largest share due to various benefits, in terms of movement, such as pain reduction and quick recovery.

Due to factors such as an increase of spinal injuries, unhealthy lifestyle choices, and rising target population, spinal orthotics are forecasted to have the fastest growth rate between 2021 and 2028.

Global Prosthetics & Orthotics Market share, by type, 2020 (%)

Orthotics Prosthetics

Grand View Research4

An increase in disability rate is expected to drive the growth of prosthetics in the coming years. According to a report published by the Rehabilitation Research and Training Center on Disability Statistics and Demographics in 2018, the percentage of people with disabilities in the U.S. increased from around 11.9% in 2010 to 12.9% in 2017, resulting in a rising demand for prosthetics.8

Even though prosthetics only represent about a quarter of the O&P market, this market segment is large and growing. Approximately 500,000 people are living with major limb loss in the U.S. Approximately 50% of those with limb loss are due to disease, 47% is due to trauma, and 3% is due to other causes. With 350,000 people with major limb loss using a prosthesis, prosthetics in total makes up approximately 50% of the prescription O&P market.9

Prosthetics: Large and Growing Addressable Market

Approximately 500,000 People Living with Major Limb Loss in the U.S.

Approximately 350,000 people with major limb loss utilize a prosthesis +90% are lower extremity

Typically have a 3 5 year replacement cycle (70% recurring revenue)

total approximately 50% of the prescription O&P market

Source: Hanger, Inc.9

Diverse Disease State Mix Drives Demand

Workforce Demand Data and Projections

The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) reports there are about 3,500 separate and unique certified prosthetists.10 Based on this information, let’s assume about 6,000 people with a new transtibial or transfemoral limb loss received a prosthesis for the first time (i.e., preparatory) through Medicare this year.

If Medicare is the sample population, then one can project the total population at about 19,000 new individuals who received an initial prosthesis represented by a preparatory base code.

Therefore, each certified prosthetist has only 0.44 new patient billable events per month, or 5.3 per year. This demand does not take into account the existing population with limb loss who need ongoing care and replacement devices.

All nonpreparatory base code utilizations reveal that Medicare paid for about 30,000 lower-limb devices. Projected to the total population, there were about 100,000 devices provided across all payer types.

Therefore, each certified prosthetist had only 2.35 existing patient billable events per month, or 28.2 per year.

Given this, it can be estimated that each certified prosthetist has 2.79 billable new device events per month.

Employment of orthotists and prosthetists grew 22% from 2016 to 2021, much faster than the average for all occupations. However, because it is a small occupation, the fast growth might result in only about 1,700 new jobs over the next five-year period. There is an expected shortage of 4.2% by 2030, based on population growth alone.

Workforce Demand Data and Projections

The rate increases by 0.40% annually, so that by 2030, a 9.5% shortage may exist if no new O&P schools were to be opened.

A 2014 analysis from Dobson-DaVanzo estimated that by 2025, there will be a 60% higher demand for O&P professionals than the available supply of certified providers.10 Noncertified professionals such as technicians and assistants, for example, will be able to assist in continuing to meet demand.

The composition of the profession will most likely approach drastic change as off-the-shelf products are continually provided by doctors, therapists, and supply chains without certified credentials, as well as credentialed supply struggles to meet demand.

15 states grant licensure for orthotists and prosthetists, and two additional states have regulatory requirements that professionals be certified by either ABC or the Board of Certification/Accreditation (BOC).

The remaining 35 states, as well as the District of Columbia, do not require certification or state licensure to perform O&P services. However, Medicare reimbursement eligibility will only apply to custom-fabricated products provided by state licensed orthotists and prosthetists or ABC/BOC-certified professionals practicing in non-licensure states.

Graduation rates of certified providers, as well as the attrition rates of providers leaving the profession, are the main drivers of the supply change. The attrition rate considers retirement as well as movement away from standard patient care (promotions, retail, academia, etc.).

The Dobson-DaVanzo study estimates, “that the attrition rate will surpass the graduation rates and result in a declining supply of certified providers in the O&P profession overall across the study period.” 10

Though not required in every state, certified or state-licensed orthotists and prosthetists will be able to present knowledge and training that may appeal to more employers.

Staffing bottom line: The demand for clinicians exceeds the supply of qualified personnel.

Labor Statistics

The following statistics are from the Occupational Employment and Wages report for Orthotists and Prosthetists from the U.S. Bureau of Labor Statistics11.

and

Workforce Demand Data and Projections

Workforce Demand Data and Projections

Workforce Demand Data and Projections

Source: U.S. Bureau of Labor Statistics11

The location quotient is the ratio of the area concentration of occupational employment to the national average concentration. A location quotient greater than one indicates the occupation has a higher share of employment than average, and a location quotient less than one indicates the occupation is less prevalent in the area than average.

Government Regulation Issues and Concerns

The operations of O&P practices are subject to a variety of federal, state, and local governmental regulations. Failure to comply with applicable governmental regulations may result in significant penalties, including exclusion from the Medicare and Medicaid programs.

Violations of fraud and abuse laws are punishable by criminal and/or civil sanctions, including False Claims Act (FCA) liability, imprisonment, and exclusion from participation in federal healthcare programs such as Medicare, Medicaid, VA health programs, and the Department of Defense’s TRICARE program (formerly known as CHAMPUS).

Laws include, but are not limited to, federal and state anti-kickback laws, false claims, physician self-referral, and federal criminal healthcare fraud laws. Failure to adhere to any requirements, even unintentionally, could result in altered O&P practice operations and possible refunds to government authority. Refunds can be grand, which may lead to implementation of massive penalties.

Practices might successfully defend against such actions for violation of these laws or regulations; however, this could result in significant legal expenses and divert management’s attention from business operations.

Anti-Kickback Laws

O&P operations are subject to federal and state anti-kickback laws. The federal AntiKickback Statute (Section 1128B(b) of the Social Security Act) prohibits “persons or entities from knowingly and willfully soliciting, offering, receiving, or paying any remuneration in any form (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind, in return for, or to induce, the referral of persons eligible for benefits under a federal healthcare program (including Medicare,

Medicaid, the VA health programs, and TRICARE), or the ordering, purchasing, leasing, or arranging for, or the recommendation of purchasing, leasing, or ordering of, items or services that may be paid for, in whole or in part, by a federal healthcare program.”1

This statute may possibly be violated when even a single purpose, and not necessarily the main purpose, of remuneration is to induce referrals or other business. The Office of Inspector General of the Department of Health and Human Services, recognizing the broadness of the Anti-Kickback Statute, implemented regulations that can offer protection from scrutiny under this statute.

Known as Safe Harbors, they describe actions that may be protected under the Anti-Kickback Statute, given that all requirements have been met. For instance, if a business was offering a discount to healthcare providers and contracting with physicians or other bodies that could refer business that would be billed to federal healthcare programs, as long as this discount is disclosed and reflected properly on claims, the Safe Harbors would cover this.

An arrangement is not necessarily considered illegal if it fails to qualify for Safe Harbor protection. All aspects of the arrangement would need to be analyzed to determine improper intent to pay/reimbursement for referrals. If arrangements do not fully satisfy Safe Harbors, this may just result in raised surveillance from government authorities.

Some states’ anti-kickback laws can vary in scope and may apply whether there is involvement from federal healthcare programs. State anti-kickback laws may extend similar antikickback prohibitions to other payers, including commercial payers. These state laws do not always contain the same safe harbors as the federal regulatory scheme.

Government Regulation Issues and Concerns

Frequently O&P operations and business arrangements include, for example, discount programs or other financial arrangements with individuals and entities, such as lease arrangements with hospitals and certain participation agreements. Therefore, operations and business arrangements are required to comply with the anti-kickback laws.

Self-Referral Laws (the “Stark Law”)

Practices are subject to federal and state physician self-referral laws. The Stark Law (Section 1877 of the Social Security Act) prohibits a physician from referring Medicare beneficiaries to an entity for “designated health services” (durable medical equipment, O&P supplies, etc.) if the physician or the physician’s immediate family member has a financial relationship with the entity.

Financial relationships include ownership/ investment interests and compensation arrangements. Entities that supply these health services to a prohibited referral cannot present a claim or bill for these services. Refunding payments, civil monetary penalties, FCA litigation, and being exempt from Medicare or Medicaid programs are all possible outcomes for violating the Stark Law.

O&P practices are also subject to federal and state laws forbidding individuals or entities from knowingly presenting claims for reimbursement to third-parties that are fraudulent, items/ services not provided as claimed, or contain misleading information.

Also, prosecutors and so-called “qui tam” relators (whistleblowers) may claim that a regulatory violation or wrongfully retained overpayment may be the basis of False Claims

Government Regulation Issues and Concerns

Act litigation. Successful relators can receive a share of the recovery in a False Claims Act case ranging from 15% to 30% depending on whether the government “intervenes” in the case. Penalties in a False Claims Act case may include double or triple damages, plus penalties ranging from $11,665 to $23,331 per claim.

Certification or Licensure Requirements

Clinicians and/or certain operating units may be subject to certification or licensure requirements under the laws of some states. Most states do not require separate licensure for clinicians. However, several states currently require clinicians to be certified by an organization such as ABC or BOC

Failure to comply with state licensure requirements could result in suspension or termination of licensure, civil penalties, termination of Medicare and Medicaid agreements, and repayment of amounts received from Medicare and Medicaid for services and supplies furnished by an unlicensed individual or entity.

The Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act (HIPAA) implemented standards for privacy and specifications concerning use and disclosure of protected health information (PHI) by health plans, clearinghouses, and providers that transfer PHI electronically in connection with certain standard transactions known as “Covered Entities.”

It is required by HIPAA for Covered Entities to protect the confidentiality of PHI by adhering to security standards and implementation specifications. Also, Covered Entities must utilize standardized formats and data elements if certain administrative and financial transfers are made electronically.

Civil monetary penalties can be imposed by HIPAA for noncompliance. Criminal penalties can be enacted for entities knowingly violating privacy standards, violating standards under false pretense, or the intent to sell, transfer, or use PHI for commercial gain. Covered entities’ business associates also must adhere to HIPAA guidelines.

Practices have business associates and are business associates to other Covered Entities. These requirements have had a significant effect on the way practices handle health data and communicate with payers. In addition, state confidentiality and privacy laws may impose civil and/or criminal penalties for certain unauthorized or other uses or disclosures of PHI.

Current and Future Research Initiatives

As practitioners continue to provide evidence to the value of prescribing and providing O&P to patients, practitioners continue to further scientific research. Research from the Amputee Coalition was recently released. The Limb Loss and Preservation Registry (LLPR) seeks to develop a national collaborative warehouse for data on people who have lost limbs and may or may not have access to prosthetics.

The 2021-2022 Amputee Coalition Survey

The Amputee Coalition has shared the results of the largest survey to date of people with limb loss and limb difference (PwLL/LD). This is the first survey of its kind to address the community’s physical and mental health priorities and challenges often faced when accessing care. These findings will assist the Amputee Coalition with raising awareness and informing priorities to improve the quality of care that PwLL/LD receive.

Key Takeaways From the Survey12:

• Identifying the need for pain management as well as improved sleep being a major mental health priority.

Defining the Needs of the Limb Loss/Limb Difference Community

mission of the Amputee Coalition

reach out to and empower people affected

limb loss to achieve their full potential.

• The need for age-appropriate solutions, as depending on the age of the PwLL/LD, the needs changed as well.

only way to

• Physical health affects mental health, and vice versa.

Amputee Coalition Community Survey Results

this goal

with PwLL/LD

the first steps

• There’s a need for increased resources to help PwLL/LD understand the Americans with Disabilities Act (ADA) and navigating health insurance.

Largest Survey of People with LL/LD, with more than 1,700 Participants

Identified Top Priorities of the LL/LD Community

health priorities:

health priorities:

Current and Future Research Initiatives

Outcomes & Limb Loss and Preservation Registry

According to the Mayo Clinic, “the goal of the registry is to bring together validated, detailed medical information so that it can be analyzed and applied to evidence-based treatment to make a better future for patients with limb loss.”13

Whether it is because of a traumatic injury, disease, or congenital amputation, there are over 2 million people in the U.S. that have lost a limb, and that number continues to grow.

Registry data is being collected on:

• Amputations and hospitalizations

• Prosthetic fittings and providers

• Patient-reported outcomes

• Patient function

OPGA supports the development of the LLPR and encourages any practitioner or practice to participate. For additional information on the program or to participate, visit www.vgm.com/opgalimb-loss-preservation-registry

Associations and Organizations in O&P

American Orthotic & Prosthetic Association (AOPA)

A trusted partner, advocating for and serving the orthotic and prosthetic community, the American Orthotic & Prosthetic Association (AOPA) fosters relationships with decision makers, provides education, supports research, and advances equality to strengthen the orthotic and prosthetic profession and improve the lives of its patients.

Since 1917, AOPA has been the largest nonprofit organization consisting of more than 2,000 patient care facilities and suppliers that together manufacture, distribute, design, fabricate, fit, and provide clinical care for patients using orthopedic braces and prostheses (artificial limbs).To learn more about AOPA, visit aopanet.org.

The Orthotic and Prosthetic Group of America (OPGA)

The Orthotic and Prosthetic Group of America (OPGA) works to advance the independent orthotic and prosthetic profession— and helps you advance within it. OPGA is the largest network of independent O&P facilities in the nation. Representing nearly 1,300 locations, OPGA offers services that help each facility operate more efficiently and increase profitability.

OPGA offers constantly evolving, professional business services to sustain your company’s competitive advantage—administered by knowledgeable associates who truly care about your success.

For over 25 years, OPGA has provided savings and solutions to independent O&P practitioners. OPGA members can take advantage of exclusive OPGA member services, such as audit protection, insurance and surety bonds, referral source data, continuing education webinars, practice management software, outcomes program, payer relations, and so much more. To learn more about OPGA, visit opga.com.

Associations and Organizations in O&P

NAAOP

The NAAOP is a nonprofit that promotes public policy that is in the interest of an O&P patient. Founded in 1987, the nonprofit trade association has helped shape healthcare legislation and regulation through governmental advocacy and education efforts. Members of the NAAOP advocate for better evidence, better education of practitioners, greater and better technology for the O&P consumer, and greater access to care. For more information about NAAOP, visit naaop.us

Orthotic & Prosthetic Alliance (O&P Alliance)

The Orthotic and Prosthetic Alliance (O&P Alliance) is a coalition of five of the leading groups that represent the O&P profession, including: the American Academy of Orthotists and Prosthetists (AAOP); the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC); the American Orthotic & Prosthetic Association (AOPA); the Board of Certification/Accreditation (BOC), and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP). The O&P Alliance represents the scientific, research, professional, business, and quality improvement aspects of the O&P field. The O&P Alliance advocates for state and federal policies that improve the practice of O&P and quality of services provided to patients. For more information, visit oandpalliance.org.

About the Author

Mark J. Higley is the vice president of regulatory affairs for VGM Group, Inc. His responsibilities include corporate business development, market research, and industry analysis. His projects include analysis of governmental, regulatory, and compliance issues affecting the home care and DME industry, including healthcare policy, government reimbursement, market demographics, benchmarking and trends, and other current home care provider concerns. Mark received his MBA in marketing research from the University of Iowa and earned undergraduate degrees in finance and economics. Prior to his 1998 employment with VGM, Mark held a variety of executive positions with the Arena Football League in Chicago, Illinois, and as a financial analyst with Deere & Company in Moline, Illinois.

References

1. Hanger, Inc. Hanger Annual Report 2022 Form 10-K (NYSE:HNGR). Washington, D.C.: s.n., 2022.

2. Hanger, Inc. Hanger Reports Final 2021 Financial Results. businesswire.com. [Online] February 28, 2022. https://www.businesswire.com/news/home/20220228005631/en/Hanger-Reports-Final-2021Financial-Results

3. Technavio. Robotic Prosthetics Market in the U.S. 2018-2022. Elmhurst : Technavio, 2022.

4. Grand View Research. Prosthetics & Orthotics Market Size, Share & Trends Analysis Report By Type (Orthotics, Prosthetics), By Region (North America, APAC), And Segment Forecasts, 20212028. San Francisco : Grand View Research, 2022. GVR-2-68038-553-3.

5. American Physical Therapy Association. Sports and Recreation-Related Injuries Top 8.6 Million Annually. PT in Motion News. 2017.

6. American Cancer Society. About Osteosarcoma . cancer.org. [Online] October 8, 2020. https:// www.cancer.org/cancer/osteosarcoma/about/key-statistics.html.

7. Vision Research Reports. Prosthetics & Orthotics Market to Record 6.2% CAGR Through 2030. Pune : Vision Research Reports, 2022.

8. Kraus, L., Lauer, E., Coleman, R., and Houtenville, A. (2018). 2017 Disability Statistics Annual Report. Durham, NH: University of New Hampshire.

9. Hanger, Inc. Investor Presentation. Austin: Hanger, Inc., 2019.

10. Dobson DaVanzo & Associates, LLC. Projecting the Adequacy of Workforce Supply to Meet Patient Demand: Analysis of the Orthotics and Prosthetics (O&P) Profession. Vienna : Dobson DaVanzo & Associates, LLC, 2015.

11. U.S. Bureau of Labor Statistics. Occupational Employment and Wages, May 2021. U.S. Bureau of Labor Statistics. [Online] May 2021. https://www.bls.gov/oes/current/oes292091.htm.

12. Amputee Coalition. Amputee Coalition Releases Limb Loss Community Needs Survey Findings. Thrive. [Online] 2022. https://blog.amputee-coalition.org/press-release/press-release-amputeecoalition-releases-limb-loss-community-needs-survey-findings/.

13. Kaufman, Kenton R. Limb Loss and Preservation Registry. Mayo Clinic. [Online] 2022. https:// www.mayo.edu/research/labs/motion-analysis/research/limb-loss-preservation-registry