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.

Unilateral arm transplant 28 years after amputation: fourteen-month result.

Hand transplantation now represents a therapeutic alternative for amputees. Arm transplantation poses a serious challenge regarding many respects of the reconstructive procedure. To the end of 2010, only seven such procedures had been performed in four patients. The goal of this article was to present the preliminary results of an arm transplant in a 30-year-old male patient at 14 months. The patient sustained an amputation at the elbow-joint level as a 2-year-old child. The procedure was performed in October 2010. His postoperative course was complicated by one rejection episode (BANFF grade II), and a de novo cytomegalovirus infection. At this early stage, the patient is doing well regaining function. He can flex at the elbow joint, move his fingers, and experience protective sensitivity reaching the palm. The patient is satisfied with his transplantation.

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.

[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.

[Tests for evaluating various methods of bone fixation in digital replantation]. / Próba oceny róznych metod zespolenia kostnego replantowanych palców.

Clinical results comparing different methods of bony fixation in 50 replanted digits in a series of 41 patients over a 13 year period are presented. The analysis was restricted only to replantantions involving sharp amputations of the proximal phalanx in order to restrict this study to a relatively homogenous group of patients. Evaluated techniques included: single and crossed Kirschner wire, intraosseous wire with or without Kirschner wire support, intramedullary splintage and intramedullary screws. Angulation deformities and delayed union were most common in cases treated with Kirschner wire technique. Nonunion was noted in 1 case (2%) stabilized with a single Kirschner wire. Angulation deformities were noted in 6 cases (12%). No such complications were noted in cases treated with intramedullary splintage and intramedullary screws. The best stabilizing effect and the most rapid union was noted in cases treated with intramedullary screws.

[Finger lengthening by the modified Gillies method]. / Wydluzanie palców reki modyfikacja metody Gilliesa.

Four thumbs and six fingers in 7 patients were lengthened by inserting bone graft harvested from the iliac crest into divided stump of proximal phalanx or first metacarpal. All grafts healed without complications. The operation is indicated in patients who do not accept toe-to-hand procedure. No signs of graft resorption were observed during follow-up.