Vascularized Composite Allotransplantation: Alternatives and Catch-22s.

Technical success has been achieved in several forms of vascularized composite allotransplantation, including hand, face, penis, and lower extremity. However, the risks of lifelong immunosuppression have limited these procedures to a select group of patients for whom nontransplant alternatives have resulted in unsatisfactory outcomes. Recent reports of facial allograft failure, and subsequent reconstruction using autologous tissues, have reinforced the idea that a surgical contingency plan must be in place in case this devastating complication occurs. Interestingly, backup plans in the setting of vascularized composite allotransplantation consist of the nontransplant alternatives that were deemed suboptimal in the first place. Moreover, these options may have been exhausted before transplantation, and may therefore be limited in the case of allograft loss or reamputation. In this article, the authors describe the surgical and nonsurgical alternatives to hand, face, penis, and lower extremity transplantation. In addition, the authors explore the ethical implications of approaching vascularized composite allotransplantation as a "last resort" or as a "high-risk, improved-outcome" procedure, focusing on whether nontransplant options eventually preclude vascularized composite allotransplantation, or whether vascularized composite allotransplantation limits future nontransplant reconstruction.

Primary Central Nervous System Posttransplant Lymphoproliferative Disease in a Bilateral Transfemoral Lower Extremity Transplantation Recipient.

Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous group of clinical and pathological entities characterized by malignant lymphoid cell proliferation occurring after solid organ transplantation, with frequent extranodal involvement. Central nervous system (CNS) involvement occurs in 7-15% of the cases and it is a significant negative prognostic factor. A case of primary CNS (PCNS) PTLD in the first bilateral lower limb transplant recipient is presented.

Bilateral transfemoral lower extremity transplantation: result at 1 year.

Upper limb transplantation has become a treatment option for upper limb amputees with good midterm results. Lower extremity transplantation has never been considered for fear of poor results. The authors present a bilateral transfemoral transplantation of lower extremities performed to a 22-year patient at 12 months of follow-up. The donor was a full HLA-mismatched female multiorgan donor. CMV status was D-/R-. A primary CMV infection coincident with an acute rejection occurred at 3 months and responded to treatment. At 1 year, the Tinel's sign is at malleolar level, there is active knee extension and active plantar flexion of the foot. The patient is walking between parallel bars. Further substantial improvements are expected with longer rehabilitation and follow-up.

The case for lower extremity allotransplantation.

BACKGROUND: Despite generally excellent success with vascularized composite allotransplantation at many body sites over the past two decades, vascularized composite allotransplantation as a treatment modality for lower extremity amputees has not yet been fully embraced. METHODS: The authors summarize the anticipated benefits of lower limb allotransplantation, and reference the likely controversies relevant to this restorative therapeutic modality. RESULT: Based on evidence culled from both upper extremity and lower extremity transplant experience to date, the authors posit that allotransplantation for lower limb amputees may be a reasonable pursuit. CONCLUSION: The authors advocate for the renewed consideration of lower extremity allotransplantation.

Eighteen-year follow-up after rotationplasty for a grade IIIC open fracture of the distal femur.

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49 years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up.

The transplant of the white man's leg: a novel representation of Cosma and Damians miracle.

The history of the miracle performed by the patron saints of medicine Cosma and Damian is well known: physicians and historians have dealt with this subject on many occasions, giving rise to a large range of literature. The Author brings up the problem again, on the ground of a novel Spanish painting which has never previously been taken into consideration from a medical point of view but which reserves some surprises and offers a possible psychological consideration of the matter.

Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation.

The advent of microsurgery has allowed the replantation of traumatically amputated limbs. Replantation of a severed limb to the contralateral stump in bilateral traumatic amputation, however, is rarer, and criticisms include a prolonged hospital stay and complications. A 54-year-old man was caught in a paper-pulping machine and suffered bilateral lower limb amputation rendering his left lower leg unsalvageable. The right lower leg, after debridement however, was suitable for replantation to the left stump. This replantation was performed successfully. The patient was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. At 11-year follow-up the patient has a preference for his replanted leg in contrast to his contralateral prosthesis and has suffered no long-term complications. In addition, from a psychological perspective, he has experienced restoration of perceived body length with the cross-leg replantation.

Composite tissue transplantation: a rapidly advancing field.

Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. It is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed through 30 hand transplantation, 3 facial reconstructions, and vascularized knee, esophageal, and tracheal allografts. A major drawback for CTA is the requirement for lifelong immunosuppression. The toxicity of these agents has limited the widespread application of CTA. Methods to reduce or eliminate the requirement for immunosuppression and promote CTA acceptance would represent a significant step forward in the field. Multiple studies suggest that mixed chimerism established by bone marrow transplantation promotes tolerance resulting in allograft acceptance. This overview focuses on the history and the exponentially expanding applications of the new frontier in CTA transplantation: immunology associated with CTA; preclinical animal models of CTA; clinical experience with CTA; and advances in mixed chimerism-induced tolerance in CTA. Additionally, some important hurdles that must be overcome in using bone marrow chimerism to induce tolerance to CTA are also discussed.

The first leg transplant for the treatment of a cancer by Saints Cosmas and Damian.

The most renowned of all medically inclined saints must have been St. Cosmas and St. Damian. They became the special patrons of surgery, due to their miraculous operations. On one occasion, they amputated a cancerous leg and replaced it with another, taken from a Moor who had just died. This dramatic cure was meat and drink for artists, and has been portrayed many times.

[Heterotopic replantation after bilateral lower leg amputation]. / Heterotope Replantation nach bilateraler Unterschenkelamputation.

INTRODUCTION: Replantation is an established procedure in reconstructive surgery. In a bilateral lower leg amputation attempts should be made to rescue at least one extremity, if the patients' vital conditions are stable. PATIENT AND METHOD: We report on a patient who has suffered a bilateral lower leg amputation. Due to the complex injuries the left leg was heterotopically (cross-over) replanted to the right leg. At the left leg an above knee stump was created. In a second operation a soft tissue defect at the replanted extremity was covered by a free microvascular latissimus dorsi muscle flap. In addition, the tibial nerve was reconstructed. Thirteen months later the patient is able to walk with a prosthesis for his left leg and complete weight bearing of the replanted extremity. DISCUSSION: Indication for replantation depends on accompanying injuries and vital functions of the patient. Compared to a simple amputation a lower leg replantation prolongs hospital stay, delays mobilisation of the patient, and increases the necessary secondary procedures. However, after replantation functional outcome is mostly better than with prosthetic fitting, especially if reconstruction of sensation in the weight-bearing area is successful. Thus, in a bilateral amputation movement and stability, as well as quality of life, are improved by a replanted extremity.

[Rotation grafts]. / Die Umdrehplastiken.

Nowadays rotationplasty is well established as an acceptable procedure for limb salvage in patients who have a malignant tumor in the femur or tibia. The main indication is that it is the alternative to amputation. Rotationplasty should be used in very young children because of the growth-dependent complications that can be expected after tumor resection. The different types of rotationplasty, the operative technique, prosthetic care, and the results of 104 patients are shown.

Donor leukocyte migration following extremity transplantation in an experimental model.

In an effort to further define the immunologic mechanisms leading to acute composite-tissue allograft rejection, the migratory patterns of donor leukocytes were evaluated. Using a rat model, 52 orthotopic vascularized hindlimb transplants were performed in strains representing major histocompatibility mismatches. In order to evaluate the effect of allogeneic skin on limb rejection, all donor skin was removed in a second group of allografts. Recipient lymphoid organs were examined during the week following transplantation for antigen-presenting cells using a donor-specific class II monoclonal antibody. Donor leukocytes, with dendritic cell morphology, were identified in recipient spleen and lymph nodes draining the allograft. Significantly higher numbers of donor leukocytes were present during postoperative days 1 through 4 for both groups. Association of these important passenger leukocytes with host T-lymphocytes may represent the site of initiation of the immune response.