raffinose and Amputation--Traumatic

Long-term survival of animal limb allografts with new immunosuppressant combinations and encouraging results of autologous limb replantations led us to believe that clinical application of hand transplantation in human beings was viable.. On Sept 23, 1998, we transplanted the right distal forearm and hand of a brain-dead man aged 41 years on to a man aged 48 years who had had traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with UW organ preservation solution at 4 degrees C, amputated 5 cm above the elbow, and transported in a cool container. We dissected the donor limb and the recipient's arm simultaneously to identify anatomical structures. Appropriate lengths of viable structures were matched. Transplantation involved bone fixation, arterial and venous anastomoses (ischaemic time 12.5 h), nerve sutures, joining of muscles and tendons, and skin closure. Immunosuppression included antithymocyte globulins, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tacrolimus, mycophenolic acid, and prednisone. Follow-up included routine post-transplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support.. The initial postoperative course was uneventful. No surgical complications were seen. Immunosuppression was well tolerated. Mild clinical and histological signs of cutaneous rejection were seen at weeks 8-9 after surgery. These signs disappeared after prednisone dose was increased (from 20 mg/day to 40 mg/day) and topical application of immunosuppressive creams (tacrolimus, clobetasol). Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress (Tinel's sign) was excellent and reached the wrist crease (20 cm) on day 100 for the median and ulnar nerves, and at least 24 cm to the palm by 6 months when deep pressure, but not light touch sensation, could be felt at the mid palm.. Hand allotransplantation is technically feasible. Currently available immunosuppression seems to prevent acute rejection. If no further episode of rejection occurs, the functional prognosis of this graft should be similar to if not better than that reported in large series of autoreconstruction.

Topics: Adenosine; Allopurinol; Amputation, Traumatic; Feasibility Studies; Follow-Up Studies; Forearm; Glutathione; Graft Rejection; Hand Transplantation; Humans; Immunosuppressive Agents; Insulin; Male; Microsurgery; Middle Aged; Organ Preservation; Organ Preservation Solutions; Organ Transplantation; Physical Therapy Modalities; Raffinose; Time Factors; Transplantation, Homologous

The first hand allograft was performed on September 23, 1998. The right distal forearm and hand of a brain dead donor was transplanted to a 48 year old recipient who had undergone a traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with organ preservation solution (UW) and transported to Lyon in a cool container. Two teams simultaneously dissected the donor's limb and the recipient's stump to identify anatomical structures. Transplantation involved bone fixation, arterial and venous anastomoses, nerve sutures, joining of the muscles and tendons, and skin closure. Immunosuppression consisted of anti-lymphocyte, polyclonal and monoclonal antibodies, tacrolimus, mycophenolic acid, and prednisone. Mild clinical and histological signs of rejection occurred at week 9 after surgery. They disappeared with adjustments of the immunosuppressant doses. Seven months after surgery the patient was in good general condition. Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress is excellent, reaching the fingertips. A longer follow-up is necessary to appreciate the final result. In the absence of further rejection, the functional prognosis of the graft should be similar to that reported after successful autoreconstruction.

Topics: Adenosine; Allopurinol; Amputation, Traumatic; Anastomosis, Surgical; Anti-Inflammatory Agents; Antibodies, Monoclonal; Antilymphocyte Serum; Arteriovenous Shunt, Surgical; Enzyme Inhibitors; Follow-Up Studies; Forearm Injuries; Glutathione; Graft Rejection; Hand; Hand Transplantation; Humans; Immunosuppressive Agents; Insulin; Internal Fixators; Male; Middle Aged; Muscle, Skeletal; Mycophenolic Acid; Organ Preservation Solutions; Physical Therapy Modalities; Prednisone; Raffinose; Tacrolimus; Tendons; Transplantation, Homologous

We report our results using University of Wisconsin (UW) cold storage solution in two cases of major replantation of the upper extremity. We employed a technique of a complete vascular washout with 1000 ml UW solution at 4 degrees Celsius at 120 cm hydrostatic pressure into the artery via a size 18 cannula. The ischaemic time of the amputated limbs were 7 hours and 11 1/4 hours respectively. No fasciotomy was performed upon revascularisation and minimal swelling was observed postoperatively. No post-ischaemic syndrome was encountered following the replantation surgery. With a follow-up of 10 and 16 months respectively, muscle and nerve viability were observed with sensory recovery and motor reinnervation. There was absence of muscle contracture and at subsequent surgical procedures, healthy musculature was present in the replanted limbs. These two clinical cases suggest that the UW solution has a role in extending the duration of tissue preservation and improving the quality of the tissues preserved.

Topics: Adenosine; Allopurinol; Amputation, Traumatic; Anastomosis, Surgical; Arm Injuries; Crush Syndrome; Cryopreservation; Debridement; Follow-Up Studies; Forearm Injuries; Glutathione; Humans; Insulin; Male; Motor Neurons; Nerve Regeneration; Organ Preservation Solutions; Postoperative Complications; Raffinose; Replantation; Wound Healing