Major limb replantation: Current status and perspectives

Major limb replantation is a demanding microsurgical procedure aiming to restore form and function after traumatic amputation. Although survival has improved since the 1960s, ischemia, infection, and complex reconstruction continue to limit outcomes. Emerging preservation and reconstructive strategies may help expand indications and improve results.

For this scoping review, MEDLINE, Embase, and the Cochrane Library were searched from inception through December 2024 using predefined MeSH terms related to major limb replantation. Adult case series and reports were included; pediatric cases and long-term follow-up studies were excluded. Screening and data extraction were conducted independently by three reviewers, with consensus resolution of discrepancies.

Ninety-nine publications reported outcomes in 1107 patients with traumatic amputations. The mean age was 31.6 years (range 17-63). Upper-limb replantation represented 88% of cases, most commonly at the forearm and elbow. Mean cold ischemia time was 10 ± 8 h and mean warm ischemia time 4.4 ± 2.3 h. Static cold storage was predominant (72%), while ex vivo dynamic perfusion and ectopic replantation were selectively applied. Overall replantation success was 68%, highest after sharp amputations (85%) and lower following crush (45%) and avulsion (55%) injuries. Vascular complications, infection, and systemic inflammatory response accounted for most failures.

Major limb replantation remains constrained by ischemia-reperfusion injury and surgical complexity. New preservation techniques, adjunctive microsurgery, and optimized perioperative care show potential to improve viability and function. Continued multidisciplinary advancement is essential to strengthen outcomes and accessibility in both civilian and military trauma care.