INNOVATION IN COMPOSITE TISSUE TRANSPLANTATION

P. Petruzzo¹, E. Morelon¹, A. Gazarian², J. Kanitakis³, M. Brunet¹, M. Lanzetta⁴, X. Martin¹, J.M. Dubernard¹, L. Badet^1
1Dept Transplantation, Hopital Edouard Herriot, Lyon/FRANCE, ²8. chirurgie De La Main Et Du Membre Supérieur, Polyclinique Orthopédique de Lyon, Lyon/FRANCE, ³Dept Dermatology, Hopital Edouard Herriot, Lyon/FRANCE, ⁴, Italian Institute of Hand Surgery, Monza/ITALY

Body: Introduction
The present study includes five cases of bilateral hand allotransplantation performed in 2000, 2003, 2007, 2008 and 2009 with a period of follow-up ranging from 10 to 1 year.
Methods
The recipients were 33, 21, 27, 29 and 21 years old respectively at the time of transplantation ; 4 men and 1 woman. The causes of amputation were a blast injury (2), an electric injury (1), a crushinjury (1) and a fire (1). The level of amputation was at wrist level bilaterally in 2 recipients, at wrist and distal forearm level in 1 recipient, at mid forearm and third distal forearm in other 2cases.
All the recipients received the same immunosuppressive protocol which included tacrolimus, mycophenolate mofetil, prednisone and, for induction, antithymocyte globulins.
Results
The first two recipients (10 and 7 years of follow-up) experienced two episodes of acute skin rejection grade 2 (Banff CTA score) in the first three months after transplantation and the episodesresolved by increasing oral steroid dose. The third recipient presented 4 episodes on day 16, 271, 635 and 951 (grade 2, except for the third episode, which was grade 3, which regressed usingintravenous steroids and also antithymocyte globulins). The fourth and the fifth recipient experienced only one episode of acute rejection on day 65 and 11 respectively, grade 1-2, resolved byincreasing oral steroid dose and using intravenous steroids respectively. In all cases topical immunosuppressants were used. Although 7 years after transplantation the third recipient developedanti-HLA antibodies class 2, an exhaustive study of all the grafted tissues did not show any sign of chronic rejection in all the recipients. C4d staining of the skin was always negative in all casesof acute rejection episode.
Some complications occurred after the transplantation but they were successfully treated: the first recipient presented transient hyperglycemia and serum sickness in the first month, while the secondrecipient suffered from a thrombosis of the right ulnar artery (POD 1) and an osteomyelitis of left ulna (POD 152); the third patient presented an Epstein Barr virus infection (POD 601) and the fifthpatient developed several vascular complications (thrombosis of right radial artery and left ulnar artery) in the first post-operative period.
All recipients showed recovery of protective and tactile sensitivity and a partial recovery of intrinsic muscles. The first two recipients showed a relevant sensorimotor recovery particularly ofsensibility and activity of intrinsic muscles and a degree of motor coordination. Although both patients present a limited range of motion of their joints and a diminished muscular power, theyperform the majority of daily activities and live a normal social life.
Conclusion
This pilot study demonstrates that bilateral hand transplantation is an acceptable treatment for patients suffering from bilateral hand amputation with a remarkable benefice/risk ratio. A longerfollow-up is required to assess the risk of chronic rejection and dysfunction.

Disclosure: All authors have declared no conflicts of interest.