Indian Subcontinent's First Proximal Forearm Level Double Upper Extremity Transplantation.

Introduction Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols. Materials and Methods A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime. Discussion Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant "reestablishes" the "donor extremity length," maintains the normal functional length of the donor muscles, and the functional return happens only after the newly transplanted donor muscles are reinnervated over a period of time. Conclusion As the sequence of surgical repair and associated decision making could be quite confusing for this level of transplantation, it is highly advisable to do mock cadaver surgical dissections in order to standardize the procedure and make the team familiar with it.

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient's own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

First two bilateral hand transplantations in India (Part 2): Technical details.

INTRODUCTION: This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream. MATERIALS AND METHODS: The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient. RESULTS: The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines. CONCLUSIONS: Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring.

INTRODUCTION: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'. MATERIALS AND METHODS: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. RESULTS: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately. DISCUSSION: Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well. CONCLUSION: A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

First two bilateral hand transplantations in India (Part 1): From vision to reality.

INTRODUCTION: Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015. MATERIALS AND METHODS: The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services. RESULTS: Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines. CONCLUSIONS: The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome.

INTRODUCTION: This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India. MATERIALS AND METHODS: The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year. RESULTS: Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand. CONCLUSION: Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.