HAND/PERIPHERAL NERVE

Multilevel Dysvascular Injury of the Hand:

Replantation versus Revision Amputation
Sang Ho Kwak, M.D.
Background: Multilevel dysvascular injury of the hand can be treated with
Sang Hyun Lee, M.D.
replantation or revision amputation. The authors compared both modalities
Seung Joon Rhee, M.D.
regarding functional outcomes, patient-reported outcomes, and required re-
Hyo Seok Jang, M.D. sources, as relevant studies are scarce.
Dong Hee Kim, M.D. Methods: In this retrospective review of consecutive case series (replantation,
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3OY3Hg5ow9MS1l9quIQeQZFKM0+4C9z3NRpGpldFCTTk= on 09/28/2020

Yong Jin Kim, M.D. n = 8; revision amputation, n = 11), clinical results and functional outcomes (in-
Busan, Yangsan, and Changwon-si, cluding grip strength, range of motion, sensory recovery, and grip or pinch abil-
Republic of Korea ity) were assessed. Patient-reported outcomes, required hospital resources, and
treatment cost until 1 year after surgery were compared between both groups.
Results: Six patients used passive prostheses, two used body-powered prosthe-

cpt ses, and three did not use a prosthesis in the revision amputation group. All
patients in the replantation group could grip objects and had restored hands,
with protective sensory recovery and substantial wrist motion, whereas six pa-
tients in the revision amputation group were unable to grip or pinch objects.
Replantation was associated with superior patient-reported outcomes, but re-
quired more hospital resources and treatment costs.
Conclusions: This study suggests that in the treatment of multilevel dysvascular
injury of the hand, the surgical method should be chosen on a case-by-case
basis. For better functional and patient-reported outcomes, replantation is pre-
ferred. Revision amputation can be performed in the absence of sufficient
hospital resources and to reduce treatment cost. These findings can aid in the
preoperative counseling of patients with multilevel dysvascular injury of the
hand. (Plast. Reconstr. Surg. 146: 819, 2020.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

R
eplantation of a completely amputated arm
was first reported in 1966,1 and that of a
thumb in 1968.2 Since then, developments
in microsurgical techniques and instruments
have resulted in better outcomes for upper arm
replantation, and the indications for replantation
are increasing. Thus, attempts at replantation are
being made for conditions previously considered
as contraindications. One such notable contrain-
dication is the multilevel dysvascular injury of the
From the Department of Orthopaedic Surgery, Pusan Na-
tional University Yangsan Hospital; the Department of
Orthopaedic Surgery, Medical Research Institute, Pusan
National University Hospital; the Department of Orthopae-
dic Surgery, Inje University Haeundae Paik Hospital; the
Department of Orthopaedic Surgery, Samsung Changwon
Hospital, Sungkyunkwan University School of Medicine;
and the Centum Institute for Hand and Microsurgery, West
Busan Centum Hospital.
Received for publication August 23, 2019; accepted April
01, 2020.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000007158
hand.3–5 Multilevel dysvascular injury of the hand
is defined as a dysvascular injury of more than
two levels at the same time, involving multiple
digit amputations in many cases. The function
and survival rates were thought to be poor after
replantation.
In an injury in which replantation surgery is
debated, functional outcomes, patient-reported
outcomes, required hospital resources, and the
treatment cost are important factors for decision-
making.6–8 There are only a few pioneering articles
that report findings for replantation and spare-
part surgery for multilevel dysvascular injury of the
hand, and most of the literature is limited to case
reports,3,9–14 except for one case series.15 Although
the studies reported better survival and functional
outcomes than the authors had expected, no stud-
ies directly compared functional outcomes between
replantation and revision amputation followed by
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 819
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 Plastic and Reconstructive Surgery • October 2020
prosthetic rehabilitation. Also, the previous litera-
ture rarely dealt with required hospital resources
and cost for this type of injury. Thus, it was not
determined whether replantation could yield supe-
rior functional or patient-reported outcomes than
revision amputation, and whether the amount of
hospital resources and treatment cost required dif-
fer for each treatment option. In this retrospective
review of a consecutive case series, we performed
replantation or revision amputation for patients
with multilevel dysvascular injury of the hand,
and evaluated the clinical results for both surgical
options. Moreover, we compared the functional
outcomes, patient-reported outcomes, required
hospital resources, and treatment cost associated
with the two surgical options. We hypothesized that
the two groups would have different functional and
patient-reported outcomes. In addition, we wanted
to determine the amount of hospital resources and
treatment costs required for each group.
PATIENTS AND METHODS
After approval of the study protocol by the insti-
tutional review board, we retrospectively reviewed
patients who underwent surgery for multilevel
dysvascular injury of the hand. Between 2006 and
2015, 20 patients underwent surgery at two institu-
tions. Our indications for replantation were (1) at
least two different levels of amputation, (2) clean
guillotine type of injury,16 and (3) short preop-
erative warm ischemia time (<3 hours).15,17–19 In
severe crushing or avulsion type of injury (n = 5),
and massive contamination with organic matter (n
= 3), we did not find any vessels suitable for anas-
tomosis after debridement, including shortening;
therefore, we performed revision amputation. In
cases of prolonged preoperative warm ischemia
time (>6 hours, n = 1) or multiple comorbid dis-
eases (coronary heart disease with diabetes mel-
litus, n = 2), we performed revision amputation
without exploration.20 One patient followed up
for less than 1 year was excluded. Finally, eight
patients (replantation group: patients 1 through
8, seven men and one woman; mean age, 43.8
years) underwent replantation and 11 patients
(revision amputation group: patients 9 through
19; 11 men; mean age, 50.2 years) underwent revi-
sion amputation. The mean follow-up period was
4.2 years (range, 1 to 11 years).
Surgical Technique and Postoperative Care for
Replantation
The amputated parts were prepared and clas-
sified into the following groups depending on
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
the wound locations: wrist-palm-digit (n = 2),
wrist-digit (n = 3), and palm-digit (n = 3).15 Sur-
gery was performed by two orthopedic surgeons,
and according to Tang’s levels of surgical exper-
tise, both surgeons were level 4 (specialist, highly
experienced).21 Under general anesthesia, a
tourniquet was applied to the upper arm. Bone
fixation was usually performed with Kirschner
wires and interosseous wiring technique. If
Kirschner wire fixation was not feasible, we used
plates for fractures of the proximal phalanx,
metacarpal bone, radius, and ulna. Thereafter,
the extensor tendon suture was performed to
stabilize the amputated part. The tourniquet was
released after the ends of proximal arteries were
found. The arterial anastomosis was started from
the proximal segment, as it was easier to observe
the blood volume after replantation, which even-
tually helped in the identification of blood ves-
sels at the next amputated level (Fig. 1). If the
proximal blood flow was not sufficient, anasto-
mosis of adjacent vessels was attempted accord-
ing to the concept of spare-part surgery.15,22 We
tried to repair both digital arteries at each level
to reserve as much flow as possible. After arterial
anastomosis, veins that showed adequate blood
flow were chosen and anastomosed for each digit.
Although flexor tendons with sufficient purchase
were repaired with four-strand core sutures,
flexor tendons in short intermediate segments
(<3.0 cm) were repaired using two-strand core
sutures to minimize soft-tissue injuries.23 If the
flexor tendons were multisegmented in the zone
I and II area, the tendons were just repaired in
a tenodermodesis fashion. If the flexor tendons
were pulled out, no attempt was made. Thereaf-
ter, the median nerve, ulnar nerve, and digital
nerves were repaired without tension.
Desensitization was started 3 weeks after sur-
gery.24 At 6 to 8 weeks, the Kirschner wires were
removed and active wrist and finger exercises
without a splint were allowed. At 10 weeks, the
digits were reexamined, and flexor tendon tenol-
ysis at the palm and wrist level or staged flexor
tendon reconstructions were performed.25 At 12
weeks, strengthening exercise was started and
task-oriented training (including grasping, hold-
ing, moving, and placing objects) was performed
with hand therapists three times per week, up to 6
to 9 months postoperatively.26
Data Review and Outcome Assessment
Data regarding sites of replantation, involved
and surviving digits, amputation level, additional
procedures, radiologic union, type of prosthesis,
 Volume 146, Number 4 • Multilevel Amputation of the Hand
Fig. 1. Left hand of a 23-year-old man (patient 3). The hand was amputated at the wrist, and at the index, middle, ring, and little
fingers following injury by a press machine. After replantation, all fingers survived.
duration of the emergency operation, transfusion
volume, length of hospital stay, and the treatment
cost until 1 year after the injury were reviewed
retrospectively. The treatment cost included the
price of prosthesis, which is presented in U.S. dol-
lars (exchange rate: 1 U.S. dollar = 1100 South
Korean Won). Simple radiographs were reviewed
that were taken at 6 weeks, 12 weeks, 12 months,
and annually after surgery. Two trained nurses
performed the following measurements of physi-
cal function at the last follow-up: ability to grip a
ball or pinch a pencil, grip strength, active range
of motion, and static two-point discrimination.
The Quick Disabilities of the Arm, Shoulder,
and Hand self-reported questionnaire and the
Michigan Hand Outcomes Questionnaire scores,
reported by the patients at the last visit, were used
for the analysis.27,28
Statistical Analysis
The Shapiro-Wilk test was used to assess nor-
mality. According to the result of the normality
test, t test was used for independent normally
distributed continuous variables, and the Mann-
Whitney U test was used for independent non-
normally distributed continuous variables. The
results for continuous variables are presented
either as mean values with standard deviation or
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
as median values with twenty-fifth to seventy-fifth
percentiles and ranges. Statistical significance was
set at p < 0.05.
RESULTS
Clinical Results
In eight patients treated with replantation, a
total of 25 digits from 29 severed digits, includ-
ing intermediate segments, were replanted. All
patients in the replantation group had segmental
nerve and vessel injuries at each level. One digit
was replanted to the adjacent stump in patient 1
(the fourth digit to the third stump). Both digital
arteries were anastomosed at each level, but only
one artery was anastomosed in five sites (patient
1, third and fifth fingers; patient 4, second fin-
ger; patient 8, third and fourth fingers). Among
the surviving digits, only one digital nerve was
repaired at four sites (patient 1, fifth finger;
patient 2, second and third fingers; patient 8,
fourth finger). Nerve reconstruction was not
performed. Four patients (patients 1, 2, 4, and
6) underwent additional débridement of one
digit at the distal or proximal phalanx level. In
the remaining four cases, all injured fingers sur-
vived. All remaining osseous structures showed
bone union at the last follow-up. There was no
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 Plastic and Reconstructive Surgery • October 2020
major systemic complication after the operation.
The antibiotics were changed to vancomycin in
two patients because methicillin-resistant Staphy-
lococcus epidermidis had grown on samples from
the operating room. However, no osteomyelitis
had developed. In 11 patients treated with revi-
sion amputation, six patients used passive (aes-
thetic silicone) prostheses and two patients used
hook-type body-powered prostheses. The other
three patients with metacarpal level amputation
did not use a prosthesis because there was no
prosthesis that could fit the shape of the hand
(Table 1).
Functional Outcomes
In patients treated with replantation, active
finger flexion was usually possible at the meta-
carpophalangeal joint; however, such flexion was
not possible at the interphalangeal joint if pha-
langeal level injuries were combined. The mean
static two-point discrimination was 24.6 mm
(range, 16 to 35 mm) at the finger level, and
36 mm (range, 30 to 45 mm) at the palm level.
Seven patients could grip a ball and pinch a pen-
cil (Fig. 2), but patient 1 could not pinch a pencil
(Fig. 3). The average grip strength in the affected
hand was 53.8 percent (range, 25 to 75 percent)
of that of the contralateral hand. Less sensory
recovery of the finger and less grip strength
were reported in the wrist-palm-digit group. In
11 patients treated with revision amputation, the
ability to grip a ball or pinch a pencil was possible
using a hook-type prosthesis or when two fingers
including the thumb were preserved (Fig. 4).
The follow-up observation revealed that five of
the eight patients in the replantation group and
three of the 11 patients in the revision amputa-
tion group returned to their previous jobs. All
patients in both groups reported cold intoler-
ance as the main discomfort, but this symptom
was not worsened definitely except for patient
6. Particularly in the replantation group, hyper-
esthesia contributed to hand discomfort during
the first 2 years of follow-up and was controlled
by oral nonsteroidal antiinflammatory drugs and
pregabalin (Table 2).
Patient-Reported Outcomes, Hospital Resources
Required, and Treatment Cost
Patients in the replantation group reported
better scores in the patient-reported outcomes
except for pain and satisfaction. However, hospi-
tal resources and cost were significantly higher in
the replantation group (Table 3).
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DISCUSSION
After treating patients with multilevel dysvas-
cular injury of the hand, we found that replanta-
tion saved 21 fingers in 25 replanted digits, and
all patients in the replantation group could grip
objects and had restored hands, with protective
sensory recovery and substantial wrist motion.
However, six patients treated with revision ampu-
tation were not able to grip or pinch objects. The
replantation group had superior patient-reported
outcomes, but required more hospital resources
and treatment cost than the revision amputation
group, followed by passive or body-powered pros-
thetic rehabilitation.
Previous studies reported that replantation
surgery is only indicated in cases with clean
guillotine type of injury and short preoperative
warm ischemia time (<3 or 4 hours).13,15,17,18 As
total presurgery time is defined as the sum of
preoperative warm ischemia time (time from
the onset of trauma to the arrival at the hospital)
and cold ischemia time (the time of preserving
the amputated parts at 4°C in the hospital),17 we
suggested that cold ischemia time should also be
minimized for better outcomes. Some authors
included only young adults in their teens or
twenties,3,12,15 but other reports, including the
current study, reported successful replantation
in middle-aged patients.9,14 Both proximal-to-
distal order and distal-to-proximal order in
digital replantation have been used according
to reports in the literature.9,13–15 Because the
replantation continued over 10 hours, some
authors reported that two or more surgeons
performed the anastomosis to minimize sur-
gical time.10,11,13 However, we showed that one
surgeon could perform the entire replantation
procedure with a survival rate of 84 percent.
Thus, we believe short preoperative warm isch-
emia time and clean guillotine type of injury
are the most important factors for the survival
of replanted digits.
Finger motion after replantation was mostly
limited to the metacarpophalangeal joint. Flexor
tendon adhesion in zone I or II injuries, and pro-
longed immobilization, might cause interphalan-
geal joint stiffness. Satisfactory interphalangeal
joint motion was not achieved even after tendon
reconstruction in one patient, and interphalan-
geal joint stiffness has also been reported regard-
less of the flexor tendon repair technique.10,11,15
Although the interphalangeal joint motion
was not adequate, the flexor tendons in our
cases, which were repaired in a tenodermodesis
 Table 1.  Clinical Results of the Patients
Preoperative
Warm
Ischemia
Time/Cold Replantation No. of
Digits
Age Sex Follow-Up Ischemia Location Survival Amputation Site Amputated Additional Type of
Patient (yr) (M/F) Period (yr) Time (min) (Group) Level Level (Failed) Involved Replanted Surviving Parts Procedure Prosthesis
1 39 M 11 120/55 Wrist, MC, PP, MP DP, PP 5 (1) All 1, 3, and 5 1 and 5 8 FT, ALT flap —
(wrist-palm-digit)
2 42 M 8 150/72 Wrist, MC, PP DP, PP 5 (1) All 1, 2, 3, 1, 2, and 3 6 FT —
(wrist-palm-digit) and 4
3 23 M 7 175/32 Wrist, PP All 5 (0) 2, 3, 4, 2, 3, 4, All 5 FT —
(wrist-digit) and 5 and 5
4 36 M 3 90/68 Wrist, MP PP 3 (1) 1 and 2 1 and 2 1, 3, 4, 3 FT —
(wrist-digit) and 5
5 60 F 5 120/47 Carpal PP All 5 (0) 2, 3, 4, 2, 3, 4, All 5 Two-stage —
(wrist-digit) and 5 and 5 tendon
reconstruction
6 54 M 3 150/65 MC, PP DP, PP 4 (1) All 1, 2, 3, 1, 3, and 4 4 FT —
(palm-digit) and 4
7 42 M 2 135/58 MC, PP All 3 (0) 1 and 2 1 and 2 All 3 FT —
(palm-digit)
8 55 M 2 180/75 MC, DP All 3 (0) 3 and 4 3 and 4 All 3 FT —
(palm-digit)
9 45 M 2 Metacarpal 3, 4, and 5 None 1 and 2 — — —
10 47 M 5 Wrist All None None — — Passive
11 55 M 3 Forearm All None None — — Passive
12 35 M 5 Metacarpal 2, 3, and 4 None 1 and 5 — ALT flap —
Volume 146, Number 4 • Multilevel Amputation of the Hand

13 51 M 3 Forearm All None None — — Body-powered

hook
14 68 M 1 Metacarpal All None None — — Passive
15 60 M 3 Forearm All None None — — Body-powered
hook
16 55 M 4 Metacarpal 3, 4, and 5 None 1 and 2 — Groin flap Passive
17 57 M 5 Metacarpal 2, 3, 4, None 1 — — —
and 5
18 42 M 2 Forearm All None None — — Passive
19 38 M 7 Forearm All None None — — Passive
M, male; F, female; MC, metacarpal; PP, proximal phalanx; MP, middle phalanx; DP, distal phalanx; FT, flexor tenolysis; ALT, anterolateral thigh.
*Replantation, patients 1–8; revision amputation, patients 9–19.

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 Plastic and Reconstructive Surgery • October 2020

Fig. 2. Patient 3 could grasp and pinch objects with the injured hand at the final follow-up.

Fig. 3. Left hand of a 39-year-old man (patient 1). The hand was amputated at the wrist, metacarpal shaft, metacarpophalangeal
joint, and proximal phalanx. After replantation, the thumb and little finger survived. The patient was able to grip an object using
the thumb and the anterolateral thigh flap. (Reprinted from An SJ, Lee SH, Min HS, Kim IH, Kim JI. Replantation for segmental
amputation of the digits and hand: A case report. Arch Reconstr Microsurg. 2016;25:60–64, with permission.)

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 Volume 146, Number 4 • Multilevel Amputation of the Hand

Fig. 4. Left hand of a 55-year-old man (patient 16). The thumb and index finger survived, and the others were amputated because
of severe contamination. The soft-tissue defect at the severed metacarpal shaft was covered with a groin flap. The patient was able
to pinch a pencil using the thumb and index finger.

Table 2.  Functional Outcomes, Payer Status, and Job Status of the Patients
Static
Two-Point
Grip Discrimination
Strength Range of Motion (deg) (mm)
(% Compared Severe
to Unaffected Second Third Fourth Fifth Grip Cold Payer Job
Case Hand) Thumb Finger Finger Finger Finger Wrist Finger Palm or Pinch Intolerance Status Status
1 25 20 — — — 0 40 35 45 Grip − WC No
2 33 30 30 10 — — 40 32 38 Grip, pinch − WC No
3 75 80 50 50 40 50 80 25 35 Grip, pinch − WC Previous
4 71 20 — 60 60 60 70 27 35 Grip, pinch − PI Previous
5 67 50 40 40 40 40 80 22 40 Grip, pinch − NHC Previous
6 45 10 — 35 30 — 60 20 35 Grip, pinch + WC Other
7 55 20 0 50 35 35 80 20 30 Grip, pinch − PI Previous
8 60 80 60 30 30 60 60 16 30 Grip, pinch − WC Previous
9 30 60 50 — — — 60 — — Grip, pinch − WC Previous
10 — — — — — — — — — — − WC No
11 — — — — — — — — — — − WC Other
12 15 60 — — — 100 100 — — Grip, pinch − PI Other
13 20 — — — — — — — — Grip, pinch − WC Previous
14 — — — — — — 90 — — — − WC No
15 25 — — — — — — — — Grip, pinch − WC Previous
16 25 60 20 — — — 60 — — pinch − WC No
17 — 50 — — — — 90 — — — − NHC No
18 — — — — — — — — — — − WC No
19 — — — — — — — — — — − NHC Other
WC, workers’ compensation; PI, private insurance; NHC, national health care; −, without; +, with.
*Replantation, patients 1–8; revision amputation, patients 9–19.

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 Plastic and Reconstructive Surgery • October 2020

Table 3.  Patient-Reported Outcomes, Hospital Resources Used, and Treatment Cost
Replantation Revision Amputation p
No. of patients 8 11
Patient-reported outcome
 Quick DASH* 33.8 ± 13.5 48.3 ± 9.2 0.008†
 Overall MHQ score* 46.3 ± 10.0 32.7 ± 4.8 0.001†
 MHQ component scores
  Overall hand function* 36.8 ± 9.9 24.0 ± 8.6 0.01†
  Activities of daily living (two hands)* 27.7 ± 8.0 18.8 ± 5.4 0.02†
   Work ability* 47.5 ± 22.7 22.7 ± 15.2 0.02†
   Pain* 54.0 ± 13.9 49.3 ± 12.6 0.46
   Aesthetics* 68.7 ± 23.8 36.9 ± 11.6 0.001†
   Satisfaction‡
    Median 52.1 33.3
    IQR 25.0–62.5 25.0–41.7
    Range 20.8–66.7 20.8–62.5 0.209
Hospital resources
 Duration of emergency operation, hr * 14.6 ± 3.6 2.9 ± 0.7 <0.001†
 Transfusion (pack)‡
   Median 4.5 1
   IQR 3.25–5.75 1–1
   Range 2–7 0–2 <0.001†
 Duration of hospital stay, days 24.6 ± 4.8 20.2 ± 3.1 <0.001†
Treatment cost (U.S. dollars)* $13,916.40 ± $2174.20 $4813.10 ± $862.80 <0.001†
DASH, Disabilities of the Arm, Shoulder and Hand; MHQ, Michigan Hand Outcomes Questionnaire; IQR, interquartile range (25th–75th
percentiles).
*t test. Mean ± SD presented.
†Statistically significant.
‡Mann-Whitney U test.

fashion, still helped the achievement of substan-
tial grip strength. However, sensory recovery was
not satisfactory, although it seemed somewhat
protective. Although most of the previous cases
with intact wrists showed two-point discrimina-
tion at approximately 10 mm,10,12,13 cases with
median and ulnar nerve injuries at the wrist level
reported less favorable sensory recovery.9,15 Thus,
we suggested that combined median and ulnar
nerve injuries might make the sensory recovery
worse. Besides, the difference in the number of
segmented parts, nerve repair technique, and
digital replantation order might be the cause of
the poor outcome. In addition, our rehabilita-
tion program did not include multimodal sen-
sory rehabilitation programs, and this lack of
multimodal programs might have partly affected
the poor sensory recovery.29
All patients in this study had only one arm
injured. Although the Quick Disabilities of the
Arm, Shoulder and Hand questionnaire score
measures total function of the uninjured and
injured hands, the score was significantly differ-
ent between both groups. The Michigan Hand
Outcomes Questionnaire component scores were
also significantly different regarding the work
ability and activities of daily living with respect
to the two hands. This was probably because the
ability of the amputated hand was notably limited
even with passive or body-powered prostheses.
The pain component score was higher in the
replantation group than in the revision amputa-
tion group, although this difference was not sta-
tistically significant. This might be because there
were more neurorrhaphy sites in replantation
than in revision amputation, because all injured
sites of the digital nerves could by possible sources
of painful neuroma.
In our study, the most limited hospital
resource seemed to be the duration of the emer-
gency operation. It was difficult for one surgeon
to concentrate throughout the duration of the
microscopic surgery, which lasted for more than
10 hours. Even without taking surgeon fatigue
into account, the physical exertion with respect
to coworkers including nurses, surgical train-
ees, and anesthesiologists should be considered.
Moreover, the schedules of the operating room
are important considerations. Therefore, replan-
tation for multilevel dysvascular injury of the
hand could be conducted only in hospitals with
sufficient room and manpower for prolonged sur-
gery. In the Republic of Korea, 19 trauma centers
(15 Level I trauma centers and four special cen-
ters for replantation) are capable of performing
this type of work currently.30,31 However, the Level
I trauma centers are often busy treating head and
trunk injuries, and the special centers for replan-
tation are not evenly located within the Republic
of Korea. Because of this situation, some patients

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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 146, Number 4 • Multilevel Amputation of the Hand
in our country might not undergo replantation
because of limited hospital resources.
The cost difference was mainly attributable
to the cost of the emergency operation, duration
of hospital stay, and prolonged postoperative
rehabilitation. The law of the Republic of Korea
mandates that the people must be covered by at
least one medical insurance. The patient pays
approximately 30 percent of the treatment cost
(national health care) or nothing (the Korean
workers’ compensation or personal insurance);
however, the price of a prosthesis varies widely.
Eight patients in the revision amputation group
used a prosthesis provided by the Korean work-
ers’ compensation and welfare service. Although
the cost of a passive or body-powered prosthesis is
$227 to $682, the price of a basic externally pow-
ered prosthesis is $5000, and the more maneu-
verable externally powered prosthesis costs up
to $40,000. In addition, the prosthesis should be
changed every 3 to 5 years because of its durabil-
ity. Also, insurance coverage for the prosthesis
is limited as follows: the Korean workers’ com-
pensation, $5000; national health care, $1700;
personal insurance, no coverage. For these rea-
sons, although an externally powered prosthesis
could provide more function, patients declined
to use one. Thus, the cost of the prosthesis, and
the treatment cost, should be considered before
determining treatment options.
Our study has several limitations. First, the
patients were not allocated randomly, and there
was a significant selection bias between groups.
As both groups had different preoperative warm
ischemia times and different injury patterns,
patients who underwent revision amputation
may have suffered more damage in the proxi-
mal stump. This bias might negatively affect the
functional outcomes or patient-reported out-
comes in the revision amputation group. Sec-
ond, the current results are limited to patients
that used passive or body-powered prostheses
because our study did not include patients using
externally powered prosthesis. Third, the price
of a prosthesis and the cost of treatment might
differ in accordance with the health care policy
of each nation; thus, the current results may
be applicable to only our country. Fourth, the
results were obtained using a small sample and
thus may have limited statistical power. Future
studies should minimize selection bias, and com-
pare these surgical options, considering various
health care policies and outcomes with exter-
nally powered prosthesis.
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
CONCLUSIONS
This study suggests that in the treatment of
multilevel dysvascular injury of the hand, the
choice of surgical method should be individual-
ized. For better functional and patient-reported
outcomes, replantation is preferred, although
revision amputation can be performed in the
absence of sufficient hospital resources and treat-
ment cost. The price and function of hand pros-
thesis should also be considered while choosing
a surgical method. These findings can aid in the
preoperative counseling of patients with multi-
level dysvascular injury of the hand.
Sang Hyun Lee, M.D.
Department of Orthopaedic Surgery
Medical Research Institute
Pusan National University Hospital 179, Gudeok-ro
Seo-gu, Busan, Korea 602-739
handsurgeon@naver.com
CODING PERSPECTIVE
Coding perspective provided by Dr.
cpt Raymond Janevicius is intended to
provide coding guidance.
20805 Replantation, forearm (includes ra-
dius and ulna to radial carpal joint),
complete amputation
20808 Replantation, hand (includes hand
through metacarpophalangeal
joints), complete amputation
20816  Replantation, digit, excluding
thumb (includes metacarpopha-
langeal joint to insertion of flexor
sublimis tendon), complete ampu-
tation
20822 Replantation, digit, excluding
thumb (includes distal tip to sub-
limis tendon insertion), complete
amputation
20824 Replantation, thumb (includes
carpometacarpal joint to meta-
­
carpophalangeal joint), complete
­amputation
20827  Replantation, thumb (includes
distal tip to metacarpophalangeal
joint), complete amputation
• Each replantation is reported sepa-
rately. Thus, a replantation through the
distal left forearm with replantations of
827
 Plastic and Reconstructive Surgery • October 2020
the left index, middle, ring, and small
fingers through the proximal phalanges
would be reported using the following
codes:
20805 Forearm
20816-59 Index finger
20816-59 Middle finger
20816-59 Ring finger
20816-59 Small finger
• Use of digital modifiers is often required
by payers, as follows:
20805 Forearm
20816-59-F1 Index finger
20816-59-F2 Middle finger
20816-59-F3 Ring finger
20816-59-F4 Small finger
• The digital modifiers are defined as follows:
FA Left thumb
F1 Left index finger
F2 Left middle finger
F3 Left ring finger
F4 Left small finger
F5 Right thumb
F6 Right index finger
F7 Right middle finger
F8 Right ring finger
F9 Right small finger
• The replantation codes are reported for
“complete amputations.” Per Current
Procedural Terminology, “To report re-
plantation of incomplete hand/digit am-
putation, see specific code[s] for repair of
bone[s], ligament[s], tendon[s], nerve[s],
or blood vessel[s] with modifier 52.”
CODING PRINCIPLE: Each replantation
code includes the following:
• Preparation of amputated part and prox-
imal stump, including debridement and
dissection of vessels and nerves
• Osteosynthesis or arthrodesis
• Microsurgical primary repair of two
­arteries
• Microsurgical primary repair of two veins
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Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
• Microsurgical primary repair of all nerves
lacerated at the amputation site
• Primary repair of all tendons/muscles
lacerated at the amputation site
• Straightforward soft-tissue closure (skin
grafts and flaps are separately reported)
• Intraoperative and postoperative
­monitoring
• Application of splint
• 90 days of postoperative care
Disclosure: Dr. Janevicius (janeviciusray@
comcast.net) is the president of JCC, a firm
specializing in coding consulting services
for surgeons, government agencies, attor-
neys, and other entities.
ACKNOWLEDGMENT
This work was supported by clinical research grant
from Pusan National University Hospital in 2020.
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