Unilateral hand transplant-results after 41 months.

We present the final results achieved by a young male hand transplant (HTx) recipient. Harvested from a woman. The limb was grafted at the wrist level 7 years postaccident. There were three HLA-A, -B, -DR mismatches and negative T- and B-cell crossmatches. The maintenance immunosuppression consisted of tacrolimus (trough level 10 ng/mL), steroids (5 mg/d), and mycophenolate mofetil (2 g/d). At the 41-months posttransplant follow-up the Semmens-Weinstein's monofilament tests gave positive results for both main hand nerves: ulnar nerve-blue, median-purple, which rated at S3- and S3+, respectively. The grip strength was 5.4 kg. HTx-specific evaluation systems showed the following results: Hand Transplant Score System (HTSS) 93.5; Chen grade I; Tamai score modified by Ipsen 86; DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire 65. Overall, the patient is able to perform with his transplanted hand practically all daily activities, even those requiring a combination of mobility, motor function, and sensation. He works full-time as a cart driver.

Hand transplantation--Polish program.

BACKGROUND: Hand transplantations (HTs) are performed in specialized centers proceeding within a board-accepted transplantation program. In Poland such requirements are met by the Subdepartment or Replantation of Limbs of St. Jadwiga Hospital in Trzebnica. The goal of this study was to present the experience of the Center after 3 years of activity. MATERIAL AND METHODS: On creating the "waiting list of would-be hand recipients," we adhered to the inclusion criteria commonly used by other centers. Among 52 potential candidates seen over a 4-year period, the selection process and inclusion criteria yielded 13 patients who were preliminary candidates for an HT. They proceeded to a formal hospital admission to obtain a detailed evaluation including invasive diagnostic tests. The group consisted of 12 men of age 21-42 years with single dominant hand amputations and 1 woman of 23 years with amputations of both hands. Within this group we performed 3 HTs in 3 men of 32, 42, and 30 years old: 2006 and in 2007 at mid-forearm level and in 2008 at the distal forearm level. The times elapsed from amputation to HT were 14, 6, and 7 years, respectively. RESULTS: The first patient achieved total motion of fingers equal to 63% of that of his unaffected hand. Evaluation using the SF-36 protocol gave a result of 50; by DASH, 95; by CFSS (according to Lanzetta and Petruzzo), 84 (excellent). He had only 1 mild rejection episode. Our second HT failed. The third patient has a good hand function, namely, 80% of the finger motion of the unaffected hand and sensitivity reaching his finger tips. No rejection episodes were observed. CONCLUSION: On the basis of these results, we plan to proceed with the hand transplantation program.

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.

First Polish forearm transplantation: report after 17 months.

INTRODUCTION: The number of hand transplantations is increasing every year prompted by promising results. Still, the number of transplantations performed at the level of midforearm/elbow is relatively small. The aim of the study was to evaluate after 17 months postoperatively the result of the first Polish upper limb transplantation performed at midforearm level. MATERIALS AND METHODS: The transplant recipient was a 32-year-old man, who lost his right, dominant upper limb at the level of midforearm in an accident 14 years prior. After a comprehensive pretransplantation evaluation and informed consent process we transplanted a right forearm matched for size and skin tone from a 47-year-old brain-dead man. The donor's limb amputated at the elbow was irrigated with University of Wisconsin solution. We dissected donor and recipient limbs simultaneously. The cold ischemia time was 10.5 hours. Immunosuppression included Simulect, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tacrolimus, mycophenolic acid, and Encorton. RESULTS: There were no intraoperative or early postoperative complications, except for delayed wound healing. No episodes of rejection were observed. Immunosuppression was well tolerated. In the process of physiotherapy, a continuous passive motions device was applied, as well as special tests to stimulate tactile sensation. After 11 months, Tinel's sign reached the finger pulps innervated by the ulnar nerve and after 12 months, by the median nerve. The monofilament test/Semmens-Weinstein was positive after 17 months: blue for ulnar nerve and purple for median nerve. The sensations proved grade 3+ and grade 3, respectively. The activity of intrinsic muscles was not detectable by electromyography; active range of motion included 63% of the unaffected hand. The extremity excellently matched the contralateral hand for size, color, and skin texture. The patient uses his hand for writing, riding his bike, and a mobile phone. The total Lanzetta' score was excellent (82 points).

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.

[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.

[Treatment of complex fractures within the hand with external fixation]. / Leczenie skomplikowanych zlaman w obrebie reki stabilizacja zewnetrzna.

External fixation with the use of bone cement was employed in treatment for 22 metacarpal and phalangeal fractures in 18 patients. Open fractures prevailed (70%). A frame or "V" construction was used. Metal implants were connected with balls of bone cement. The average hand function loss in cases of metacarpal fractures associated with nerves and tendons lesion was 25%.

[Treatment of intraarticular finger fractures with the help of the traction system of "pins and rubbers" according to Y. Suzuki]. / Leczenie zlaman sródstawowych palców reki za pomoca systemu wyciagowego "druty i gumki" wg Y. Suzuki.

The results of treatment of intraarticular finger fractures by means of Y. Suzuki's pins and rubbers traction system are presented. The system consists of 2-3 thin K-wires and 2 rubber bands, is easy to assemble, effective, and less clumsy then the ones applied previously. It also allows for the reduction of palmar displacement of bony fragments. Sixteen intraarticular fractures have been treated. The average total range of motion of the injured PIP joint was 82 degrees at the average follow-up of 8.5 months.