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The international registry on hand and composite tissue transplantation
2010
Background. The International Registry on Hand and Composite Tissue Transplantation was founded in May 2002, and the analysis of all cases with follow-up information up to July 2010 is presented here. Methods. From September 1998 to July 2010, 49 hands (17 unilateral and 16 bilateral hand transplantations, including 1 case of bilateral arm transplantation) have been reported, for a total of 33 patients. They were 31 men and 2 women (median age 32 years). Time since hand loss ranged from 2 months to 34 years, and in 46% of cases, the level of amputation was at wrist. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, sirolimus, and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was also used in several cases. Follow-up ranges from 1 month to 11 years. Results. One patient died on day 65. Three patients transplanted in the Western countries have lost their graft, whereas until September 2009, seven hand grafts were removed for noncompliance to the immunosuppressive therapy in China. Eighty-five percent of recipients experienced at least one episode of acute rejection within the first year, and they were reversible when promptly treated. Side effects included opportunistic infections, metabolic complications, and malignancies. All patients developed protective sensibility, 90% of them developed tactile sensibility, and 82.3% also developed a discriminative sensibility. Motor recovery enabled patients to perform most daily activities. Conclusions. Hand transplantation is a complex procedure, and its success is based on patient's compliance and his or her careful evaluation before and after transplantation.
Nassimizadeh M, Nassimizadeh A, Power D. Annals of the Royal College of Surgeons of England 2014; 96(8):571-4, 2014
In September 1998 the world's first hand transplant was performed in Lyon, France. A new era in reconstructive surgery had begun. This case highlighted the potential for composite tissue allotransplantation (CTA). While CTA is not a new technique, it unifies the principles of reconstructive microsurgery and transplant surgery, achieving the goals of absolute correction of a defect with anatomically and physiologically identical tissue with none of the issues of donor site morbidity associated with autologous tissue transfer. The adoption of this technique for non-life threatening conditions to improve quality of life has generated a number of new ethical considerations. Additionally, the prominence of transplanted hands has led to much discussion around the issue of body identity and psychological assessment of potential recipients. This is fundamental to any hand transplantation programme. With the advent of hand transplantation dawning in the UK, we review the many ethical considerations that contribute to this new frontier.
Human hand transplantation: what have we learned?
Transplantation Proceedings, 2004
Hand transplantation may become an important procedure for upper limb functional restoration. To date, 18 patients have been undergone 24 hand operations in the world. Initial results are extremely promising; the functional results are apparently superior to those obtained with prostheses. We report on the combined French and Italian experience of six patients (eight hands), which is based on a jointly devised protocol and represents the largest available clinical series. Six male patients aged 43, 33, 35, 32, 33, and 22 years received either a single right hand-dominant transplantation (four cases) or a simultaneous double hand transplantation (two cases). The time since the amputation ranged from 3 to 22 years. The level of transplantation was at the wrist in five cases (six hands) and at the distal forearm in two cases (two hands). Cold ischemia averaged 11.5 hours. Three patients simultaneously received additional full-thickness skin taken from the donor and transplanted onto their left hip area. This skin served as a source for biopsies and as an additional area to monitor rejection (distant sentinel skin graft). The immunosuppressive protocol included polyclonal antibodies (three patients) or monoclonal anti-CD 25 antibody (three patients), tacrolimus, mycophenolate mofetil, and prednisolone. No surgical complications occurred. Skin rejection occurred at least once in all patients at a mean of 40 days postoperatively. Three patients recovered protective and some discriminative sensation in their palm and fingers. Two patients are recovering sensation, but are still in the early phases of the regenerative process, due to the short time since the transplantation. One patient was not compliant with the immunosuppressive therapy, and underwent uncontrolled rejection and reamputation. A N EFFECTIVE COLLABORATION between a group of international surgeons and physicians led to the first single hand transplantation performed in Lyon on September 23, 1998. The first double hand transplantation was performed in the same location on January 13, 2000, where French and Italian teams simultaneously transplanted the left and the right hands, respectively, to a 33-year-old bilateral amputee at the wrist. Following the Italian Department of Health authorization, the Italian Hand Transplantation Group performed the first hand transplantation in Italy on October 17, 2000, followed by a second operation on October 1, 2001, and a third on November 5, 2002. The French group performed another double hand transplantation on April 30, 2003. These procedures have been carried out using the same operative and postoperative protocols, especially in the area of immunosuppressive therapy. 1-4 With a follow-up ranging from 2 to 41 months, we have collected a significant amount of data for analysis and discussion, mainly in the areas of selection criteria, harvesting and transplantation surgical techniques, immunosuppressive regimens, monitoring of rejection, rehabilitation programs, and functional results and outcomes. In this article we present our combined experience on six cases (four single and two double transplantations-eight hands), which represents the largest series.
Hand Transplantation: The Milan Experience
Polish Journal of Surgery, 2007
The authors describe the most critical aspects of transplantation of the hand. Three successful cases are presented from the Italian Hand Transplantation National Program. The key issues of this new type of surgical reconstruction for major amputations are selection criteria of suitable candidates, technical aspects of surgery, postoperative regime and functional rehabilitation. Other important aspects are staff requisites and organisation of the clinical trial, ethical and legal implications, dealing with the media. The authors comment on the fact that we might be ready to accept that almost anything could come from a cadaver, even if it is not a life-saving organ, to reconstruct missing parts and restore anatomical integrity and, especially, function.
Hand Transplantation: The State-of-the-Art
Journal of Hand Surgery (European Volume), 2007
The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient’s pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.
Transplantation Reviews, 2005
This review provides an overview of the progress made to date in hand transplantation. Working from published data and our own observations, we outline important aspects in this novel field. We believe that hand transplantation poses a therapeutic option for a select group of patients. D