Hand Transplantation Workup
- Author: Bardia Amirlak, MD; Chief Editor: Ron Shapiro, MD more...
A comprehensive tissue-typing department is needed for preoperative anti-HLA alloantibody (HLA-Ab) screening, panel reactive antibody studies, and crossmatching. The recipient should be ABO-typed at the preliminary evaluation and rechecked for ABO antibodies periodically and before the transplant. Preoperative full laboratory studies, such as viral screening, CBC, and metabolic profile should be assessed in the recipient. Postoperative immunosuppressive drug levels should be assessed at regular intervals.
Posteroanterior and lateral radiographs of both upper extremities of the donor and the recipient, including both elbow and wrist joints, are compared prior to transplantation. In the recipient, preoperative CT angiography of the affected limb should also be considered, along with musculoskeletal MRI of forearm stump to assess proximal musculature for atrophy, fibrosis, or contracture.
Electromyography and nerve conduction studies
Neurophysiologic studies, including electromyography nerve conduction velocity (NCV) and compound motor action potential (CMAP) testing, are performed for assessment of re-innervation of the muscles and to monitor the progression of re-innervation and muscle function posttransplant at scheduled visits.
Preoperative psychosocial screening and therapy
A psychiatrist and a transplant social worker are involved in patient selection and psychiatric assessment of patients before and after transplant. Early management may aid the patient's candidacy for transplant and may minimize psychiatric morbidity after surgery.[3, 11]
Preoperative and intraoperative assessment for hand therapy
Preoperatively, the physical therapists (PTs) and occupational therapists (OTs) assess functional needs and take measurements. The therapy team should watch the live video of the procedure to observe the anatomical and surgical details that would determine the extent of functional recovery that the transplanted limb can achieve. Limitations in achieving optimum range of motion and strength can be anticipated based upon the level of recipient tendon atrophy; hence, variations in tenorrhaphy needed to overcome such tendon atrophy can also be evaluated.
Histology of rejection
Composite tissue allotransplantation (CTA) recipients can experience rejection episodes that are mediated by immune mechanisms comparable to those seen in rejections of solid organs. Regular skin biopsies to monitor rejection episodes are done postoperatively and during follow-up visits.
CTA rejection has been systematically examined, and a histological classification was formulated by Schneeberger et al and Cendales et al.[12, 13] CTA rejections initially present as a perivascular infiltrate progressing to involve the dermis. Arteritis can be observed in the medium to large arteries of the subcutis. Myositis can also be present. Perineural involvement without frank neuritis is seen in advanced rejection. The infiltrate is predominantly CD4+ in milder cases and CD8+ in advanced cases.
7th International Symposium on Composite Tissue Allotransplantation. Sept 7-8th 2007. Available at http://cta2007.uklibk.ac.at/page.cfm?vpath=index.
www.handregistry.com (The International Registry on Hand and Composite Tissue Transplantation ). Accessed 7/2/09;
Tobin GR, Breidenbach WC, Klapheke MM, et al. Ethical considerations in the early composite tissue allograft experience: a review of the Louisville Ethics Program. Transplant Proc. 2005 Mar. 37(2):1392-5. [Medline].
Chad R. Gordon, Joseph M. Serletti, Kirby S. Black and Charles W. Hewitt. The Evolution of Composite Tissue Allotransplantation: the Twentieth Century Realization of. Charles W. Hewitt, W. P. Andrew Lee and Chad R. Gordon. Transplantation of Composite Tissue Allografts. Springer US; 2007. 13-25.
Jones JW, Gruber SA, Barker JH, et al. Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team. N Engl J Med. 2000 Aug 17. 343(7):468-73. [Medline].
Tobin GR, Breidenbach WC 3rd, Pidwell DJ, et al. Transplantation of the hand, face, and composite structures: evolution and current status. Clin Plast Surg. 2007 Apr. 34(2):271-8, ix-x. [Medline].
Amirlak B. Personal communication, Breidenbach W. During hand transplantation. Louisville, Ky: Jewish Hospital Hand Care Center; Nov 30, 2006.
www.handtransplant.com. Available at www.handtransplant.com. Accessed: June 30/08.
Lanzetta M, Petruzzo P, Dubernard JM, et al. Second report (1998-2006) of the International Registry of Hand and Composite Tissue Transplantation. Transpl Immunol. 2007 Jul. 18(1):1-6. [Medline].
Amirlak B, Gonzalez R, Gorantla V, et al. Creating a hand transplant program. Clin Plast Surg. 2007 Apr. 34(2):279-89, x. [Medline].
Klapheke MM, Marcell C, Taliaferro G, et al. Psychiatric assessment of candidates for hand transplantation. Microsurgery. 2000. 20(8):453-7. [Medline].
Cendales LC, Kirk AD, Moresi JM, et al. Composite tissue allotransplantation: classification of clinical acute skin rejection. Transplantation. 2006 Feb 15. 81(3):418-22. [Medline].
Schneeberger S, Gorantla VS, van Riet RP, et al. Atypical acute rejection after hand transplantation. Am J Transplant. 2008 Mar. 8(3):688-96. [Medline].
Golshayan D, Pascual M. Drug-minimization or tolerance-promoting strategies in human kidney transplantation: is Campath-1H the way to follow?. Transpl Int. 2006 Nov. 19(11):881-4. [Medline].
Scheker LR, Chesher SP, Netscher DT, et al. Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm replantation. J Hand Surg [Br]. 1995 Oct. 20(5):584-90. [Medline].
Scheker LR, Hodges A. Brace and rehabilitation after replantation and revascularization. Hand Clin. 2001 Aug. 17(3):473-80. [Medline].
carroll D. A quantitive test of upper extremity function. J Chronic Dis. 1965. 18:479-91.
Gonzalez, Ruben N.; Gorantla, Vijay S.; Breidenbach, Warren C. Complications after Hand Transplantation: Preliminary Report of Osteonecrosis in the Second American Patient. Journal of Reconstructive Microsurgery. August 2005. 21(6):425.
Amirlak B, Gorantla V, Gonzalez R, Breidenbach W. Updates on the Three American Hand Transplants. June-2007.
Muramatsu K, Kuriyama R, You-Xin S, et al. Chimerism studies as an approach for the induction of tolerance to extremity allografts. J Plast Reconstr Aesthet Surg. 2008 Sep. 61(9):1009-15. [Medline].
Amirlak B. Personal communication, Starzl TE and Gorantla V. Seefeld, Austria: 7th International Symposium for Composite Tissue Allotransplantation; Sept 9, 2007.
|Date||Single Hand Transplantation||Double Hand Transplantation||Digital Transplantation|
|Sep 1998||Lyon (1)|
|Jan 1999||Louisville (1)|
|Sep 1999||Guangzhou (2)|
|Jan 2000||Nanning (2)||Lyon (1)||Nanning (1)|
|Mar 2000||Innsbruck (1)|
|May 2000||Kuala-Lumpur (1)
Twins - no immunosuppression required
|Sep 2000||Guangzhou (1)|
|Oct 2000||Milan (1)|
|Nov 2000||Nanning (2)|
|Jan 2001||Harbin (1)|
|Feb 2001||Louisville (1)|
|Oct 2001||Milan (1)|
|Jun 2002||Bruxelles (1)|
|Jun 2002||Harbin (1)|
|Jul 2002||Nanjin (1)|
|Oct 2002||Harbin (1)|
|Nov 2002||Milan (1)|
|Feb 2003||Innsbruck (1)|
|Apr 2003||Lyon (1)|
|Feb 2005||Nanjin (1)|
|Jun 2006||Innsbruck (1)|
|Feb 2006||Wroclaw (1)|
|Nov 2006||Louisville (1)|
|Dec 2006||Valencia (1)|
|Feb 2007||Lyon (1)|
|Nov 2007||Valencia (1)|
|Jan 2008||Wroclaw (1)|
|July 2008||Louisville (1)|
|Jul 2008||Munich (1)|
|Nov 2008||Louisville (1)|
|Feb 2009||Pittsburg (1)|
|March 2009||Paris (1)
Simultaneous with face
|July 2009||Lyon (1)|
|Feb 2010||San Antonio (1)|
|2011||Los Angeles (1)|
|2011||Mexico City (1)|