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Hand Transplantation Workup

  • Author: Bardia Amirlak, MD; Chief Editor: Ron Shapiro, MD  more...
 
Updated: Mar 05, 2014
 

Laboratory Studies

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.[10]

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Imaging Studies

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.

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Other Tests

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.

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Histologic Findings

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.

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Contributor Information and Disclosures
Author

Bardia Amirlak, MD Assistant Professor of Plastic Surgery, Director of Residency Cosmetic Clinic, Director of Plastic Surgery Global Health Program, University of Texas Southwestern Medical Center at Dallas; Chief of Hand and Peripheral Nerve Surgery, Dallas Veterans Affairs Medical Center

Bardia Amirlak, MD is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, American Society of Reconstructive Transplantation, Kleinert Society

Disclosure: Nothing to disclose.

Coauthor(s)

Gordon R Tobin, MD, FACS Professor of Surgery, Director Emeritus, Executive Faculty, Division of Plastic and Reconstructive Surgery, Associate in Oncology, James Graham Brown Cancer Center, University of Louisville School of Medicine

Gordon R Tobin, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Medical Association, American Society of Plastic Surgeons, Arizona Medical Association, Association of VA Surgeons, Kentucky Medical Association, Pan America Medical Association of Central Florida, Phi Beta Kappa, Plastic Surgery Research Council, Sigma Xi, Society of University Surgeons, Southeastern Society of Plastic and Reconstructive Surgeons, American Association of Clinical Anatomists

Disclosure: Nothing to disclose.

Warren C Breidenbach, III, MD, MSc Professor of Plastic and Reconstructive Surgery, University of Louisville; Director, Kleinert, Kutz and Associates Hand Care Center, PLLC

Disclosure: Nothing to disclose.

Ashley C Campbell, MS Research Assistant, Christine M Kleinert Institute for Hand and Microsurgery

Disclosure: Nothing to disclose.

Vijay S Gorantla, MD, PhD, FRCS Administrative Director, Pittsburgh Hand and CTA Program, Research Assistant Professor of Surgery, Division of Plastic Surgery, University of Pittsburgh Medical Center

Vijay S Gorantla, MD, PhD, FRCS is a member of the following medical societies: American Society of Transplantation, Transplantation Society

Disclosure: Nothing to disclose.

N Ruben Gonzalez, MD Sports Medicine Fellow, Department of Orthopedic Surgery, University of Louisville

N Ruben Gonzalez, MD is a member of the following medical societies: American Society of Transplantation, AO Foundation

Disclosure: Nothing to disclose.

Craig R Lehrman, MD Resident Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Craig R Lehrman, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ron Shapiro, MD Professor of Surgery, Robert J Corry Chair in Transplantation Surgery, Associate Clinical Director, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center

Ron Shapiro, MD is a member of the following medical societies: American Society of Transplantation, American Surgical Association, American College of Surgeons, Transplantation Society, International Pediatric Transplant Association, American Society of Transplant Surgeons, Association for Academic Surgery, Central Surgical Association, Society of University Surgeons

Disclosure: Nothing to disclose.

References
  1. 7th International Symposium on Composite Tissue Allotransplantation. Sept 7-8th 2007. Available at http://cta2007.uklibk.ac.at/page.cfm?vpath=index.

  2. www.handregistry.com (The International Registry on Hand and Composite Tissue Transplantation ). Accessed 7/2/09;

  3. 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].

  4. 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.

  5. 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].

  6. 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].

  7. Amirlak B. Personal communication, Breidenbach W. During hand transplantation. Louisville, Ky: Jewish Hospital Hand Care Center; Nov 30, 2006.

  8. www.handtransplant.com. Available at www.handtransplant.com. Accessed: June 30/08.

  9. 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].

  10. Amirlak B, Gonzalez R, Gorantla V, et al. Creating a hand transplant program. Clin Plast Surg. 2007 Apr. 34(2):279-89, x. [Medline].

  11. Klapheke MM, Marcell C, Taliaferro G, et al. Psychiatric assessment of candidates for hand transplantation. Microsurgery. 2000. 20(8):453-7. [Medline].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. Scheker LR, Hodges A. Brace and rehabilitation after replantation and revascularization. Hand Clin. 2001 Aug. 17(3):473-80. [Medline].

  17. carroll D. A quantitive test of upper extremity function. J Chronic Dis. 1965. 18:479-91.

  18. 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.

  19. Amirlak B, Gorantla V, Gonzalez R, Breidenbach W. Updates on the Three American Hand Transplants. June-2007.

  20. 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].

  21. Amirlak B. Personal communication, Starzl TE and Gorantla V. Seefeld, Austria: 7th International Symposium for Composite Tissue Allotransplantation; Sept 9, 2007.

 
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Cross-section of the mid forearm, demonstrating the relative anatomy of the structures involved in hand transplantation.
Tendons, nerves, and vessels of the recipient limb are dissected and marked.
Immediately after the limb harvest and prior to transportation to the recipient hospital, the limb artery is cannulated and irrigated with chilled University of Wisconsin solution. Irrigation is continuous while the limb is transported.
The donor limb is dissected out simultaneously with the recipient limb in the same room by 2 separate teams in direct communication with each other.
Bone fixation of the ulna and radial bones using small fragment set plates.
The tendons, nerves, and vessels of the donor limb are dissected out on a separate table.
At the end of the transplantation, the skin is closed using staples to facilitate time preservation.
Postoperative use of a crane outrigger device results in optimum therapy results.
Table.
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)  
 
 
 
2009   Pittsburg (1)  
 
 
 
2009 Wroclaw (1)    
 
 
 
2009 Wroclaw (1)    
 
 
 
2010 Pittsburg (1)    
 
 
 
2010   Pittsburg (2)  
 
 
 
2010   Louisville (1)  
 
 
 
Feb 2010 San Antonio (1)    
 
 
 
2010 Wroclaw (1)    
 
 
 
2010   Wroclaw (1)  
 
 
 
2011 Los Angeles (1)    
 
 
 
2011 Atlanta (1)    
 
 
 
2011 Wroclaw (1)    
 
 
 
2011   Mexico City (1)  
 
 
 
2011   Melbourne (1)  
 
 
 
Total patients 30 21 2
 
 
 
Total hands/digits 30 42 2
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