Static cold perfusion solutions in clinical limb transplantation: a systematic review

To summarize the application of perfusion solutions in clinical limb transplantation procedures, to analyze the outcomes between using different perfusion solutions, and to provide recommendations for future research.

Our current study was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement. Articles were acquired from multiple databases (EMBASE, PubMed, Web of Science, and Scopus) by using key words or terms such as "perfusion solution," "preservation solution," "allograft," "allotransplantation," "transplantation," "extremity," and "limb." Clinical studies with the description of perfusion solutions for donor limb procurement were included. We evaluated our systematic review compliance by using A Measurement Tool to Assess systematic Reviews 2 criteria and fell in moderate quality. Perfusion solution parameters and outcomes were extracted and analyzed. Data analyses were performed using SPSS version 19.0. This study was conducted without using artificial intelligence tools in accordance with the TITAN Guidelines 2025.

Nineteen clinical studies encompassing 47 patients were enrolled. In clinical practices, the application rate of cold University of Wisconsin (UW), histidine-tryptophan-ketoglutarate (HTK), St. Thomas, and Institute Georges Lopez-1 (IGL-1) solutions for limb preservation was 70.21% (33/47), 14.90% (7/47), 8.51% (4/47), and 6.38% (3/47), respectively. Postoperatively, the occurrence of at least one episode of immunological rejection was reported in 9 studies (7 with UW perfusion, 1 with UW&IGL-1 perfusion, and 1 with HTK perfusion) encompassing 25 patients (25/47, 53.19%). Amputation was reported in one hand transplantation case, and death was reported in one quadruple limb transplantation case.

Despite the predominant use of cold UW solution in clinical limb transplantation, robust comparative evidence demonstrating its superiority over alternative solutions (HTK, St. Thomas, and IGL-1) remains lacking. The current literature suffers from insufficient sample sizes and non-standardized outcome measures, precluding definitive conclusions about optimal perfusion strategies. Only through large-scale, multicenter clinical trials with standardized protocols can we establish evidence-based guidelines for future limb preservation.