A detailed comparison of the functional outcome after midforearm replantations versus midforearm transplantation.

OBJECTIVES: The functional outcome after midforearm transplantation (HT) is believed to be similar to the outcome after replantation. However, the few existing reports comparing functional outcomes are based on amputations at the level of the distal forearm. This report provides a comparative analysis of the functional results after midforearm replantation (HR) versus HT. MATERIALS AND METHODS: Transplantation of a dominant right forearm performed in a 32-year-old man was compared to the outcomes after five dominant (right) forearm replantations (four men and one woman) in patients ranging from 22 to 38 years of age. Cold ischemia time ranged from 6 to 12.5 hours in all cases. We used similar operative technique and rehabilitation protocol. At 26 (+/-2) months after replantation/transplantation, we recorded, bony union (x-ray), arterial flow (ultrasonography), range of motion, grip strength, sensation (2 PD Weisensten's filaments), quality of life (DASH, 30-150 points), general evaluation of function according to Chen's or the IRHCTT scoring system. RESULTS: A complication of wound infection was observed in one HR patient; Marginal skin necrosis accompanied by prolonged wound healing, in one HT patient. Unification of bones was achieved faster after forearm replantation when compared with transplantation. Grip strength was 17% greater after replantation, but ranges of motion were comparable in both groups. Sensitivity was superior after forearm transplantation (2 PD 15 mm) and overall patient satisfaction was comparable (90 points of DASH questionnaire for HR versus 108 points for HT patients). None of the patients returned to their previous occupations. CONCLUSION: The functional outcome after HT was comparable, and in some respects superior, to the outcome after replantation performed at the midforearm level.

Mild rejection episode evoked by modification of immunosuppressive protocol observed in a patient with forearm transplantation: case report.

Skin is the most immunogenic component of a composite tissue allograft (CTA). Clinicopathologic monitoring of the skin seems to be the most reliable method to detect rejection in CTA patients. The symptoms in cases demonstrating full-blown rejection are clear, contrary to those of just mild rejection. The aim of the study was to present the symptoms of mild rejection observed in a midforearm transplant patient at 20 months postoperative. The 32-year-old man underwent right dominant forearm transplantation at 12 years after a traumatic amputation. During the first 20 months, the course was uneventful, with no signs of impaired function. Immunotherapy at 20 months consisted of: Cellcept (2 g/d), prednisolone (10 mg/d), tacrolimus (7 mg/d; level C(0) of 13 ng/mL), An attempt was made to modify therapy by diminishing the tacrolimus dose to 4 mg/d (C(0)-8 ng/mL). After 10 days postimplementation of the new regimen, are hardly visible macullopapular erythematous rash appeared on the palmar and dorsal sides of the hand as well as the skin of the forearm. There was a slight red swelling of the nail bed margins. No deterioration of hand function was observed. The patient was immediately admitted to the hospital; despite unclear clinical and pathomorphological symptoms, we diagnosed a mild rejection (grade I). The therapy consisted of methylprednisolone (500 mg three times daily for 3 consecutive days) and 5 days of topical application of immunosuppressant ointments (tacrolimus and Protopic) with maintenance of the previously applied oral tacrolimus doses. After 5 days of treatment, the symptoms subsided. This approach utilized the advantage of the unique possibility to treat rejection locally, consistent with current awareness that skin is the primary target of hand rejection. However, topical application of immunosuppressants has not been extensively investigated. The manifestations of rejection in CTA patients may be heterogeneous and difficult to diagnose.

[Intramedullary fixation within bones of the hand: 20 years of experience]. / Szynowanie sródszpikowe kosci reki--20 lat doswiadczen.

Intramedullary fixation within bones of the hand has been used for treatment of 313 fractures in 169 patients after serious trauma or replantation between 1978 and 1998. Kirschner wires or Steinmann pins were introduced at the fracture site and anchored within both metaphyses. The method was used in various types of fractures, comminuted ones and bone defects included. In all cases fracture healed between 4 and 8 weeks. No deep infection occurred, in 2 patients the implants had to be removed because of their migration. The method is technically undemanding and allows for immediate postoperative rehabilitation. Total range of motion exceeded by 15% results achieved in patients treated with temporary immobilization of the hand.

Recurrent primary well-differentiated intrascrotal liposarcoma: case report and review of the literature.

Lipoma-like liposarcomas of the scrotal wall are very rarely reported neoplasms in the surgical and histopathological literature. We treated a well-differentiated liposarcoma of the inside wall of the scrotum in a 62-year-old man. Following local excision, the tumor recurred after three months, and a funiculoorchidectomy was performed. Today, 24 months following secondary surgery, the patient is completely asymptomatic and there is no evidence of tumor recurrence either on physical examination, ultrasonography or abdominal and pelvic computed tomography. In this paper we present the case and a review of the relevant literature.

[Rehabilitation after upper extremity replantation at the wrist level -- own experience]. / Wlasne doswiadczenia w zakresie usprawniania konczyn po replantacji na wysokosci nadgarstka.

An amputation at the wrist level (the level with the best prognosis) has been characterized. Rehabilitation protocol after replantation at the wrist level developed on the ground of 328 replantations done in the Center over 25 years has been presented. Its essential quality is an early initiation of active movements (second postoperative day) and resistive movements on 10-14 days after surgery. The differences between currently used protocols have been emphasized. Excellent and good results were achieved in 65% of cases according to Chen's criteria.

[Salvage surgery for severely mutilated hand: report of 2 cases]. / Oszczedzajace operacje w przypadkach rozleglych obrazen reki--opis dwóch przypadków.

Immediate, one stage reconstruction is an optimal mode of treatment for severely mutilated hand. This might be feasible only with the use of tissues destined for amputation. Two cases are reported. The first patient had a thumb reconstruction with transfer of the index finger. The second one had metacarpal reconstruction with little finger structures. Both patients resumed previous occupation.