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Zargaran et al. Plast Aesthet Res 2023;10:10 https://dx.doi.org/10.20517/2347-9264.2022.42 Page 5 of 7

patient for upper extremity amputation. Equally, the healthcare system saw an overall cost of $166 million
[16]
[4]
over a 15-year period . Lifetime costs to an amputee patient can exceed $500,000 . The EQ-5D-5L
questionnaire is a reproducible and informative resource that provides practical insight into the impact on a
patient’s quality of life. The international impact of the EQ-5D and its applicability is a testament to its
wide-ranging benefits and further supports policy makers at national and firm levels in their decision
making to fund the interventions.

Previous articles have already established the reproducible nature of TMR in improving symptoms of NP
and PLP after amputation. However, there has been no work specifically evaluating the interplay between
the chronic pain caused by NP and PLP on quality of life after upper limb amputation. Moreover, while
[17]
recognised by NICE as a key metric , assessing changes in (pain) quality of life is not routinely performed
after upper limb amputation. Our study highlights the efficacy of TMR in improving HRQoL, with 66% of
patients reporting an overall improvement following their intervention. It is important to assess why five
(33.3%) patients reported a decrease in functionality for some domains such as pain, mobility and usual
activities following TMR. We hypothesise that this could be multifactorial. Some reasons may include
individual patient perception towards domains such as pain and anxiety, extent of the initial injury, degree
of amputation and site of injury. Other reasons include non-specific questions such as mobility, which some
patients may have perceived as pertaining to lower limb mobility rather than upper limb, and further could
be a function of other confounding variables as it may sometimes be challenging to discern the changes
patients experience from surgery versus over time. In addition, the retrospective nature of our study gives
rise to the potential impact of recall bias. Patients may not recall the impact that TMR may have had on
their HRQoL, particularly if a number of years have elapsed since their surgery. Our study was conducted in
December 2021 on patients who initially had their TMR operation as far back as October 2013. Amongst the
five patients with a reduction in domain function, three (60%) demonstrated positive improvements in
other domains [Table 1]. Therefore, despite these drawbacks, most patients in our study reported an overall
improvement in their HRQoL following TMR, as evidenced by their Q-5D-5L domain scores and VAS. Our
study provides precedence for further investigation into the HRQoL benefits associated with TMR surgery
for secondary NP/RLP and/or PLP associated with upper limb amputation. Ideally, this should be
performed in the context of a multi-centre randomised control trial.

For this analysis, we used a numerical (pain) rating scale (NRS) which was simple, reproducible, and easily
understood (by patients and researchers) to perform surveys over the telephone. This was necessary because
of the restrictions on face-to-face contact during the COVID-19 pandemic. However, we accept that further
work could be done to evaluate the complexity of the questionnaires we administered, their reproducibility
and error rate to create a better framework for future trials.

Funding for TMR surgery in the UK is currently determined on a local level. Since there are no OPCS codes
for this procedure, the codes for a number of different procedures (e.g., nerve repair, nerve transfers, free
tissue transfer) are often put together to cover the cost of the TMR procedures. However, the absence of any
uniformity of what constitutes a TMR procedure may contribute to further inequities in healthcare
provision in the future. As a first step towards reducing these inequities, we have tried to quantify the size of
the improvements in quality of life produced by TMR surgery after upper limb amputation. Based on our
analysis, we believe that there is sufficient evidence to inform any future Health Technology Assessments
and Appraisal, and this may enable NICE to make recommendations on the future (national) provision for
TMR surgery. However, the complex nature of the surgery (especially in the upper limb) means that it is
likely to need that such care will only ever be possible on a tertiary or quaternary basis.