Early causes of failure in hand and macroreplantations: A multicenter retrospective analysis of 43 cases - 30/05/26

Doi : 10.1016/j.hansur.2026.102686

Sofiane Khelfallah ^a, Arnaud Walch ^a,⁎ , Aram Gazarian ^a,^b, Alexandra Forli ^c, Jean-Philippe Giot ^c, Anaïs Delgove ^d, Marie-Laure Abi-Chahla ^d, François Loisel ^e, Isabelle Pluvy ^e, Laurent Mathieu ^a,^f, Thibault Druel ^a

^a Hand and Upper Extremity Surgery Department, Edouard Herriot Hospital, Hospices Civil de Lyon, 5 place d’Arsonval, 69003 Lyon, France

^b Clinique du Parc, 155 boulevard de Stalingrad, 69006 Lyon, France

^c Plastic and Reconstructive Surgery of the Limbs — Hand Surgery Department, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France

^d Hand Surgery Department, François-Xavier Michelet Center, Pellegrin Hospital, Bordeaux University Hospital, place Amélie Raba Léon, 33000 Bordeaux, France

^e Orthopedic, Trauma and Reconstructive Surgery Department, Jean Minjoz Hospital, Besançon University Hospital, 3 boulevard Alexandre Fleming, 25000 Besançon, France

^f Orthopedic, Trauma and Reconstructive Surgery Department, Percy Military Hospital, 2 rue Lieutenant Raoul Batany, 92140 Clamart, France

^⁎ Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 30 May 2026

Abstract

Introduction

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.

Methods

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.

Results

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).

Conclusion

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.