A multidisciplinary emergency protocol reduces revascularization time in major upper and lower limb replantations

Major limb amputation salvage procedures exhibit an increased risk of failure when revascularization is delayed beyond 360 min. Institutional delays persist as critical barriers, even with advancements in surgical techniques.

Retrospective cohort study (November 2022- December 2024) at Level I Trauma Center. We implemented a systematized emergency protocol featuring: Prehospital activation → Green channel → OR-direct transport Parallel processing → revascularization.

Revascularization time (limb arrival → arterial flow).

30 consecutive amputees (M: F = 21:9; mean age 43.6 ± 14.35 yrs). Included 21 upper limbs (6 wrist, 9 forearm, 6 upper arm) and 9 lower limbs (6 ankle, 3 calf). Revascularization achieved in 142.0 ± 21.17 mins. All cases (100 %) met the ≤180-min golden window. Key timings: Door-to-OR: 19.7 ± 3.2 mins, OR preparation: 20 ± 3.45 mins, Surgery start to revascularization: 102.3 ± 19.8 mins. Limb survival rate reached 96.7 % (29/30). Vascular bridging reconstruction was performed in 17 cases (including 5 cases with emergent anterolateral thigh (ALT) flap arteriovenous bridging). Vascular crisis occurred in 2 cases and was relieved after surgical exploration. The final limb amputation salvage rate was 96.7 % (29/30). One case of ankle-level salvage resulted in postoperative infection and necrosis. At 12-month follow-up, 80 % of upper limbs achieved grasp function (S2-S4 sensibility), and 89 % of lower limbs regained ambulation without prosthesis.

The multidisciplinary emergency protocol significantly reduced ischemia time, with rapid revascularization serving as the critical determinant of high limb amputation salvage rates. The protocol achieved functional limb salvage in 83 % of cases, demonstrating that rapid revascularization correlates with both viability and functional recovery.