Early causes of failure in hand and macroreplantations: A multicenter retrospective analysis of 43 cases

Macroreplantation is a rare yet technically challenging procedure performed following traumatic amputations. Despite advances in surgery, early failure rates remain high. The aim of this study was to identify predictors of early failure after macroreplantation.

We conducted a multicenter retrospective analysis of 43 macroamputations (from metacarpal level to proximal humerus) that were treated with replantation at four level-1 trauma centers in France between 2008 and 2024. Patients were classified into two groups: a failure group (defined as secondary amputation within six weeks) and a survival group. Pre-, intra- and postoperative data were collected and analyzed.

Early failure occurred in 20 cases (47%) at a mean of 8 days post-replantation. Overall, 74% of patients experienced one or more postoperative complications, primarily vascular in nature. In the multivariate analysis, predictors for limb survival were: surgeon's expertise level four (highly specialized; adjusted OR = 15.8) and the administration of gentamicin as part of the antibiotic prophylaxis (adjusted OR = 7.42). Smoking was independently associated with an increased risk of failure (adjusted OR = 0.10). Severe wound contamination was not significantly associated with failure (adjusted OR = 0.48).

Early failure in macroreplantation is significantly associated with smoking, suboptimal antibiotic prophylaxis, and limited surgical expertise. We advocate early, aggressive debridement; the use of broad-spectrum antibiotics; and the systematic involvement of senior microsurgeons in these rare, high-stakes cases.

4, retrospective study.