Outcomes of the first 2 American hand transplants at 8 and 6 years posttransplant.

PURPOSE: The feasibility of hand allotransplantation has been demonstrated. The purpose of the article is to report the (1) functional return, (2) psychosocial outcomes, (3) clinical and histological assessment for rejection, (4) complications, and (5) graft survival in the 2 American hand transplant recipients. METHODS: We present 2 patients 106 and 81 months, respectively, after unilateral transplantation of an allogeneic hand and forearm. We analyzed clinical course, number of rejection episodes, adverse events, function of the allograft, and quality of life. Clinical laboratory results, biopsy histology, and patient clinical examinations were used to compare the clinical course. Standard hand function tests were used to evaluate function. Psychological interviews were used to assess acceptance and quality of life. RESULTS: Our patients have allograft survival with improvements in intrinsic muscle activity, total active motion and return of functional grip, pinch strength, and sensibility. Rejection episodes were restricted primarily to the first 6 months after transplantation, and all responded to treatment. The major posttransplantation complications were a cytomegalovirus infection in patient 1 and osteonecrosis of the hip requiring both hips to be replaced, 1 at year 4 and the other at year 6, as well as transient immunosuppression-related diabetes in patient 2. Recently we have weaned both patients off maintenance steroids. Current Carroll scores are fair for patient 1 (72/99) and fair for patient 2 (55/99), although patient 2 has not had good recovery of intrinsic function. Both patients are back at work and report an excellent quality of life at nearly 9 and 7 years, respectively, after transplantation. CONCLUSIONS: Our intermediate long-term results of hand transplants have demonstrated functional return similar to that of replants. Graft survival and quality of life after hand transplantation has far exceeded initial expectations. We conclude that allogeneic hand transplant is feasible and holds promise as a treatment modality for catastrophic upper extremity loss. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A modified model of hindlimb osteomyocutaneous flap for the study of tolerance to composite tissue allografts.

Composite tissue allotransplantation (CTA) is the new frontier in transplantation. More than 25 hand allograft transplants have been performed worldwide, and the feasibility has been well established. The classical experimental model of CTA involves rat orthotopic hindlimb transplantation, a time-consuming procedure associated with high mortality and morbidity. We describe a rat heterotopic osteomyocutaneous flap that serves as a nonfunctional CTA, allowing the study of tolerance induction to a highly antigenic vascularized allograft of bone, muscle, and skin while minimizing the morbidity and mortality of full hind limb transplantation. In the present studies, we explored whether establishing chimerism by nonmyeloablative conditioning would induce tolerance to CTA. When compared with the classic hind limb transplantation model, these results demonstrate that our heterotopic hind limb flap is less morbid and as an effective experimental model for the study of CTA tolerance.

Transplantation of the hand, face, and composite structures: evolution and current status.

This article reviews the world experience in the newly emerging field of composite tissue allotransplantation. These allografts contain multiple tissues that are usually musculoskeletal structures with a skin or epithelial surface, such as hand, facial structures, larynx, tongue, ear, knee/femur, abdominal wall, and penis. They represent a new transplantation field, with only a 10-year experience and just over 50 clinical cases. This review of the 10-year world experience found uniform technical success, immunologic biology, and immunosuppression regimens very similar to solid organ transplants, and success strongly correlated with adherence to guidelines for psychiatric screening, thorough preparation of patient and families, intense postoperative monitoring, and assurance of medication access. All failures reported have been caused by lapses in these parameters. This early experience shows a great potential for application of these new procedures to the most challenging reconstructive needs.

Creating a hand transplant program.

Successful hand transplantation depends upon an extensive, well-coordinated system with resources and experience in both upper extremity and transplant surgery. This description of such a system is drawn from the experience of the Louisville, Kentucky, Hand Transplant Program, which achieved the world's first successful hand transplant in January 1999, and which is the only United States program to date. The personnel and components of this system are outlined, with a detailed description of the roles, responsibilities, and interaction between components. This system ensures optimal management throughout recipient selection, psychiatric screening, education and preparation, donor limb retrieval, transplant surgery, immunosuppression administration and monitoring, and post-transplant rehabilitation therapy. The lessons learned from the experience of the Louisville team, and the experiences of the other teams world-wide, are presented to guide organization of future teams participating in this pioneering endeavor.

The use of tissue flaps as an adjunct to pelvic surgery.

BACKGROUND: The clinical problems of advanced malignancy with invasion of cancers into adjacent organs or structures, fistulizing complications from radiation therapy, postoperative infections, and delayed postoperative healing continue to challenge pelvic surgeons, regardless of subspecialty. The use of autologous muscle and myocutaneous flaps has been applied to the management and prevention of these clinical problems and found to be most helpful. METHODS: Records of patients undergoing abdominopelvic procedures in a single unit during the 15-year period from 1990 to 2005 were reviewed, and patients undergoing autologous tissue flaps were reviewed with respect to indications, complications, and outcomes. RESULTS: Thirty-four patients underwent 35 autologous muscle or myocutaneous flaps for the following indications: large anticipated defects in primary or reoperative cancer surgery (13 patients); malignant, traumatic, inflammatory, or radiation-induced fistulae (12 patients); excision of (an) adjacent organ(s) with need for reconstruction (7 patients); and chronic nonhealing pelvic wounds (2 patients). Wound complications occurred in 41% of patients; however, primary healing of flaps occurred in 88% of patients. CONCLUSIONS: The use of autologous tissue flaps in select patients can be a useful adjunct in pelvic surgery in dealing with a wide variety of problems, specifically in filling large defects, providing vascularized tissue for fistula closure, and avoiding delayed wound healing commonly seen after high-dose radiation.

A position statement in support of hand transplantation.

The scientific basis for human trials of hand transplantation was both experimental and clinical. Prolonged survival of limb transplants was achieved in small and large animals by using novel immunosuppressive drugs. Further, all tissue components of the hand (skin, muscle, tendon, nerve, bone, and joint) were individually transplanted with success in humans. After appropriate institutional review of the ethics, experimental data, treatment protocol, and informed consent, clinical trials were approved. Thirteen hands have been transplanted onto 10 recipients, with resultant low morbidity and no mortality. With the exception of one recipient who requested amputation after the second year, results of hand transplantation have been highly successful. Functional return mirrored that seen after hand replantation. The limbs were progressively integrated into activities of daily living and professional tasks. The hand and patient survival rate exceeds the initial results of any previously transplanted organ. This success strongly supports continuation of these human trials.

Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping.

Postoperative groin lymphoceles that fail to resolve spontaneously or with interventional therapy present a formidable problem that is associated with a high degree of morbidity. Numerous interventional methods and operative techniques have been described to treat these fluid collections, yet recurrence rates remain high. The use of lymphatic mapping has gained widespread use in the treatment of cutaneous malignancies and breast cancer and has been proven effective in delineating the course of lymphatic channels. We present here a series of 17 consecutive patients with 19 problematic groin lymphoceles who were treated with the assistance of intraoperative lymphatic mapping using isosulfan blue dye. To date there have been no recurrences and minimal morbidity associated with the technique and prescribed postoperative treatment regimen.