The first upper limb replantation in a 12-year-old pediatric patient was reported by Malt and Mckhann [1] in 1962, and the first successful replantation surgery for lower limb amputation was achieved in Korea in 1976 [2]. Since then, replantation surgery for traumatic amputation has been actively performed in Korea [3-7]. In clinical practice, this surgery should be performed within a so-called “golden time” for successful limb reattachment. However, it remains challenging to meet time deadlines, as patients at major trauma centers often present with severe injuries to the head, chest, and abdomen [8-10]. Furthermore, if the trauma is life-threatening, all situations must be excluded and revision amputation must be expedited.

Generally, revision amputation requires less time than replantation and can reduce hospitalization time, but the resulting patient cosmetic satisfaction is very low. Replantation surgery is more difficult to perform, but good success rates are currently being reported with the development of microsurgery [11]. Successful replantation can provide very high satisfaction to patients in terms of functional and cosmetic results, although the length of hospitalization and hospitalization costs are relatively high compared to revision amputation [12].

To our knowledge, there are no reports regarding patient characteristics and medical costs in the domestic environment for patients treated for traumatic amputation from a single center in the Republic of Korea. Such data are crucial for making surgical decisions and comparing outcomes, but obtaining it remains challenging due to the scarcity of cases. Therefore, in this study, we analyze and report medical costs based on the epidemiology and treatment methods of patients with traumatic limb amputations who visited a level 1 trauma center in Korea.

From November 2015 to December 2021, we conducted a retrospective investigation among 57 patients, excluding 11 patients who were transferred to the regional trauma center of Pusan National University Hospital due to traumatic limb amputation or incomplete amputation, and two patients who died in the emergency room. Exclusion criteria were pediatric patients under 18 years of age and soft tissue amputations such as fingertip amputations. Cases in which amputation was performed due to failure after reattachment were also excluded.

The causes of injury were four rope injuries (7.0%), 10 machine injuries (17.5%), 21 traffic accidents (36.8%), 16 roller machine injuries (25.4%), four expulsions (7.0%), and four others (7.0%) (Table 1). For the treatment of limb amputation, revision amputation or replantation was selected depending on the presence of the amputated limb (stump), degree of contamination, ischemic time, and the pattern of accompanying fractures. Vascular damage was diagnosed using physical examination, angiography, and three-dimensional computed tomography. All patients underwent replantation or stump revision under general anesthesia.

Before surgical replantation, debridement should be performed on the amputated proximal part and the amputated limb and contaminating subjects or foreign bodies fully removed within the shortest time possible. First, fixation was performed using a plate or external fixation device, and depending on the case, bone shortening of an appropriate length was performed. Subsequently, vascular anastomosis and in some cases, a vein graft, was performed. The tendon and nerve were repaired. If possible, neurorrhaphy was performed without a graft. Areas with severe nerve defects were tagged for future nerve grafting. If the wound defect of the severed part was large, negative pressure wound therapy was applied. Later, the soft tissue was reconstructed through skin grafting or flap surgery.

Postoperative management for patients who underwent replantation included assessing blood flow status by observing capillary refill, color, and temperature of the reattached part over an average of 5 to 7 days. Drug treatment for blood circulation improvement (Eglandin 10 mg every day, for 7 days; Mitsubishi Tanabe Pharma, Osaka, Japan) was administered. The severed part was kept at a constant temperature using a Bair Hugger system for 50 minutes with a 10-minute rest.

We investigated injury mechanisms, accompanying injuries, number of surgeries, length of hospital stay, injury severity score (ISS), insurance classification, medical costs, and the financial burden on the guarantor by reviewing each patient’s medical records (Table 1). We analyzed medical costs based on treatment methods. Each patient’s insurance was categorized as national health insurance, car insurance, worker’s compensation insurance, type 1 Medicaid, or uninsured. We analyzed each patient’s financial burden and total cost, which includes insurance financial contribution, separately.

We divided patients into the replantation and amputation groups for analysis. Continuous variables were compared between groups with the Mann-Whitney U-test for nonnormally distributed data and the Fisher exact test for categorical variables. A two-sided p-value of less than 0.05 was considered to indicate statistical significance. All statistical analyses were conducted using Stata ver. 15.1 (Stata Corp., College Station, TX, USA).

Among a total of 57 patients who visited the hospital for limb amputations, the median age was 55 years (range, 25–71 years), with 48 males (84.2%) and nine females (15.7%). Among them, 17 underwent replantation surgery and 40 underwent surgical stump revision surgery after amputation. The mechanisms of injury, accompanying injuries, ISS, frequency of operation, and hospitalizations were compared between groups and are summarized in Table 1.

The median ISS was 16 (interquartile range [IQR], 9–22) with no significant difference between groups. The median ISS of upper extremity injuries was 12 (15 in the replantation group and 10 in the amputation group), with no significant difference between groups (p=0.568). The median ISS of lower extremity injuries was 14 (22 in the replantation group and 14 in the amputation group). Injury severity was higher in the replantation group, but the difference was not significant (p=0.238). The average time of arrival at the emergency room was 80 minutes after injury (IQR, 50–170 minutes). There was no difference in the treatment method according to the injury mechanism, but the frequency of traffic accidents was higher in the amputation group (28.0% vs. 8.7%, p=0.046). The types of injuries included crushing injuries, sharp cuts, and avulsion, with the frequency of crushing injuries higher in the group with revision amputation (54.% vs. 15.7%, p=0.009), while the frequency of avulsion injuries was higher in the replantation surgery group (7.0% vs. 0%, p=0.001). The ratio of upper and lower extremity injuries was 32 upper extremity (56.1%) to 25 lower extremity (43.9%), and of these, replantation surgery was performed in 17 of the 32 upper extremity (53.1%) and 3 of the 25 lower extremity cases (12.0%), with a higher ratio performed on the upper extremity (p=0.002).

A detailed analysis of 32 upper extremity amputees revealed that 14 underwent replantation surgery, while 18 underwent revision amputation. The replantation group underwent the median of five surgeries (IQR, 4–6), significantly more than the amputation group, which underwent the median of two surgeries (IQR, 2–3) (p=0.006). The replantation group also had a significantly longer median hospital stay (58 days; IQR, 25–95 days) compared to the revision amputation group (30 days; IQR, 15–48 days) (p=0.03).

Of the 25 patients with lower extremity injuries, 22 (88.0%) underwent revision amputation procedures, while only three patients (8%) underwent replantation surgery. The median number of surgeries was nine (IQR, 4–20) in the replantation group and three (IQR, 2–4) in the revision amputation group (p=0.027). The median hospitalization period was 98 days (IQR, 83–120 days) for replantation and 51 days (IQR, 39–94 days) for revision amputation, but the difference was not statistically significant (Table 2).

The patients’ medical cost burden was shared by national health insurance (29 patients, 58.8%), workers compensation insurance (15 patients, 26.3%), car insurance (nine patients, 15.7%), type 1 Medicaid (two patients, 3.5%), and uninsured (one patient, 1.8%). The total medical cost (the sum of the patient’s share and the insurance share) was higher for replantation surgery at 38.97 million Korean won (KRW) (IQR, 28,507,275–76,366,021 KRW) than for revision amputation surgery at 24.75 million KRW (IQR, 6,030,381–50,894,746 KRW) for upper extremities but the difference was not significant (p=0.129). Among lower extremity injuries, the difference between 48.11 million KRW (IQR, 46,729,058–92,029,756 KRW) for replantation and 26.50 million KRW (IQR, 21,568,516–62,540,122 KRW) for revision amputation was also not significant (p=0.242). However, the total medical costs of 32 upper extremity injuries covered by national health insurance were 40.05 million KRW (IQR, 28,507,275–76,366,021 KRW) for replantation surgery, and 19.82 million KRW (IQR, 5,457,026–31,586,099 KRW) for revision amputation surgery, a significant difference (p=0.029). There were no differences for other types of insurance in upper extremity injuries.

The actual patient share of costs for upper limb injuries was 4,39 million KRW (IQR, 1,603,930–9,745,988 KRW), and among these, the actual patient share for replantation surgery was higher at 4.96 million KRW (IQR, 2,371,020–10,423,497 KRW) than the 3.56 million KRW (IQR, 1,119.672–8,435,901 KRW) of the revision amputation group but the difference was not significant (p=0.342). In terms of the form of medical expense burden, for using health insurance, the replantation surgery cost was 10.42 million KRW (IQR, 7,573,237–13,283,499 KRW), and the revision amputation cost was 4.54 million KRW (IQR, 1,309,028–9,858,507 KRW) but the difference was not significant (p=0.104). There was no difference between treatment methods for car insurance, industrial accident insurance, the uninsured, and medical benefits type 1.

In an analysis of 25 lower limb injuries, we observed no cost differences. The total medical costs and patients’ actual co-payments for both upper and lower extremity amputations are detailed separately in Table 3.

In this study, most traumatic amputation patients were young adults, and overwhelmingly male, potentially due to injuries associated with labor using machinery or traffic accidents. The proportion of traffic accident patients was especially high, even among patients who underwent amputation surgery immediately after traumatic amputation. The average time to arrive at the emergency room was 65 minutes after injury for replantation surgery and 80 minutes for revision amputation surgery, but the difference was not significant. The ISS was an median of 14 points, with no significant difference between the two groups in this study.

In comparisons between upper limb amputees who underwent prosthetic fitting after revision amputation and those who underwent replantation surgery, most of the replantation group were satisfied with the results. The satisfaction rate of patients who underwent prosthetic fitting after amputation above the elbow was significantly lower at 30%, while about 50% who underwent amputation below the elbow were satisfied [13], probably because prosthesis function was better below the elbow [10]. When considering replantation surgery, it is necessary to consider the surgical risks, costs, treatment time, and complications. While it has been reported that replantation surgery can be considered if the degree of contamination is low and the time elapsed after injury is short, it is better to wear a prosthesis after amputation if those conditions do not apply [11]. Compared to revision amputation, limb replantation requires more surgeries, longer hospital stays, and a longer rehabilitation process, and although it is psychologically and economically painful, there are reports that the quality of life is the same with revision amputation [14]. Therefore, a balance between patient satisfaction and cost-effectiveness needs to be considered when deciding on the surgical method.

In this study, the mean hospital stay was longer for replantation surgery patients at 73.5 days, compared to 68.8 days for amputation surgery. The mean number of surgeries was also higher for replantation surgery at 6.1, compared to 3.1 for revision amputation surgery. Ultimately, differences in the number of surgeries and length of hospital stay are reflected in medical costs. Zhu et al. [15] reported that in a comparison of medical costs among traumatic amputation patients in China, replantation surgery cost about six times more (p<0.001) and required a longer hospital stay than amputation surgery. However, according to a cost-effectiveness study of traumatic amputees in the United States by Yoon et al. [16], replantation surgery was more expensive than revision amputation surgery, but if the additional medical costs that patients can bear in the United States environment are less than 100,000 US dollars, replantation surgery is more cost-effective than revision amputation surgery. In recently published studies of cost-effectiveness related to finger amputation injuries, replantation treatment had greater costs compared to revision amputation [17-19]. The cost-effectiveness of surgery can vary depending on the medical environment of each country, so it is difficult to compare based on cost.

There are several unique considerations in Korean clinics. First, patients generally face a low financial burden due to the existence of various medical payment forms such as health insurance, car insurance, industrial accident benefits, and benefits for foreign nationals. Specifically for upper limb injuries, patients with car insurance and industrial accident insurance bear significantly lower costs, between 1/50 and 1/5 of those borne by those covered solely by health insurance. If osteoplasty is performed, the difference ranges from 1/25 to 1/1.4 times. Second, due to Korean culture, there is a preference to attempt replantation first, even if the chance of success is relatively low. In this study, out of 19 cases where replantation was performed on the upper extremities, seven cases failed and required revision amputation. This high failure rate suggests that cultural factors are significant. Although several studies suggest that a higher ISS implies a higher probability of amputation [20,21], in this study we found no significant difference, which could be explained by cultural aspects.

Unlike finger amputation, limb amputation has very significant functional and aesthetic issues, and often has direct impacts on the patient’s life, so it is difficult to consider cost-effectiveness when deciding on treatments. However, in the insurance environment of Korea, the medical fees are relatively low, and in the case of worker’s compensation or car insurance, the cost to the patient is significantly reduced. Therefore, even though attempting reattachment surgery raises medical costs, it is possible for clinicians to be more proactive in trying reattachment surgery.

The limitations of this study are that we did not investigate cost-effectiveness and patient satisfaction in the context of functional outcomes through retrospective research. In future studies, investigations of patient satisfaction and cost-effectiveness to patients should be conducted. The reliability of statistical analyses was insufficient due to the relatively small number of cost comparisons possible between each trauma’s solidification and coalescence. In addition, the cost calculation was based on medical costs incurred at a single center, and only the cost of initial primary care was calculated, so we were not able to include the costs of additional reoperations, making it difficult to compare overall cost-effectiveness.

The success rate of replantation surgery has recently increased due to the development of microsurgery, but when deciding on a surgical method to treat traumatic limp amputation, factors such as functional recovery, hospitalization period, and medical expenses must be considered. Limb replantation surgery requires more operations, longer hospital stays, and higher medical costs compared to revision amputation surgery. This difference in medical costs was more than twice as large when using health insurance as for other payment methods. These results may be used as reference material when considering characteristics and medical costs as factors when deciding between treatment methods for patients with traumatic limb amputations.