Background The purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios. Methods The study was conducted from the societal perspective. Decision tree models were created for the reference case (two finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A web-based time trade-off survey was created to determine quality adjusted life years (QALYs) for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and QALYs for revision amputation and replantation were calculated for each decision tree. An incremental cost effectiveness ratio (ICER) was calculated if a treatment was more costly but more effective. Results We had a 64% response rate (n=437). Replantation treatment had greater costs and QALYs compared to revision amputation in all injury scenarios. Replantation of single digit injuries had the highest ICER ($136,400/QALY gained). Replantation of three and four digit amputation injuries had relatively low cost-benefit ratios ($27,100 and $23,800/QALY respectively). Replantation for distal thumb amputation had a relatively low ICER ($26,300/QALY) compared to replantation of non-thumb distal amputations ($60,200/QALY). Conclusions The relative cost per QALY gained with replantation treatment varied greatly among the injury scenarios. Situations in which indications for replantation are debated had higher cost per QALY gained. This study highlights variability in value for replantation among different injury scenarios.

Wilbrand and Saenger 1 studied optic chiasms after unilateral enucleation, noting inferonasal crossing fibers curved anteriorly into the contralateral optic nerve (Wilbrand knee; figure, A). This explains contralateral superotemporal visual field defects (junctional scotomas) with optic nerve lesions at the chiasmal junction. However, Wilbrand knee may be an enucleation artifact.2 The anisotropic light-reflecting properties of myelinated axons permitted imaging of normal human chiasms. Thin sections (25 mm) were illuminated and digitally imaged from 3 incident angles. Each of the images was pseudocolored (red, green, or blue) and merged, revealing an anomalously oriented fiber tract (appearing white) that reversed direction at the optic nerve-chiasm junction, found in inferior (figure, C) but not in superior sections (figure, B), consistent with Wilbrand and Saenger's original description.