INNOVATION IN COMPOSITE TISSUE TRANSPLANTATION

P. Petruzzo¹, M. Lanzetta², J.M. Dubernard¹, P. Cavadas³, R. Margreiter⁴, F. Schuind⁵, W. Breidenbach⁶, J. Jableki⁷, S. Schneeberger⁴, C. Kaufman⁶, L. Landin^3
1Dept Transplantation, Hopital Edouard Herriot, Lyon/FRANCE, ², Italian Institute of Hand Surgery, Monza/ITALY, ³Pedro Cavadas Foundation, “La Fe” University Hospital, Valencia/SPAIN, ⁴Department Of Visceral Transplant And Thoracic Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁵Dept Of Orthopaedics And Traumatology, Erasme University Hospital, Bruxelles/BELGIUM, ⁶, Christine M Kleinert Institute for Hand and Microsurgery, Louisville/KY/UNITED STATES OF AMERICA, ⁷Dept Replantation Of Limbs, St Hedwig's Hospital, Tzbenica/POLAND

Body: Introduction
Since May 2002 all groups performing hand transplantations have supplied information to the International Registry on Hand and Composite Tissue Transplantation.
Methods
From September 1998 to February 2010 forty-two patients (forty males and three females) underwent 60 upper extremity transplantations (23 unilateral and 16 bilateral hand/forearm transplantations, 2bilateral arm transplantations, one thumb transplantation). The level of amputation was at level of wrist (40%), distal forearm (17%), mid forearm (20%), proximal forearm (17%) and elbow (6%). Timesince hand loss ranged from two months to 30 years.
Patient average age was 33.8 years. Follow-up period ranged from 6 months to 11 years.
Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, rapamycin and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was administeredin some patients.
Results
Acute rejection episodes occurred at least once in all recipient: 46% of them experienced one episode, 32% two episodes, 15% three episodes and 7% four episodes. Rejection was completely reversiblein all compliant patients when promptly treated. The therapy for acute rejection episodes ranged from topical immunosuppressant drugs and increase in oral steroid dose to intravenous bolus ofsteroids and polyclonal antibodies. Although any team did not report any case of chronic rejection, a hand graft was lost to intimal hyperplasia (275 days after transplantation)
Side-effects included opportunistic infections and metabolic complications correlated to the immunosuppressive therapy (one patient developed an end-stage renal disease needing dialysis); one case ofbasal cell carcinoma of nose and one case of post-transplant proliferative disease. Other complications included 2 cases of arterial thrombosis, one case of venous drainage impairment with graftloss, one case of venous thrombosis and one case of multiple arteriovenous fistulae.
The Registry has performed a functional score system. All patients developed protective sensibility, 90% of them developed tactile sensibility and 72% also a discriminative sensibility. Motorrecovery enabled patients to perform most daily routine activities; 90% of the unilateral hand grafted patients and 50% of the bilateral hand grafted patients returned to work. The majority ofrecipients reported an improvement of their quality of life, which is considered very important as patient satisfaction and well-being are mandatory goals of hand transplantation.
Only one patient who underwent simultaneous face and bilateral hand transplantation died for septic shock. Except for the Chinese patients, three graft losses were reported: the first handtransplantation due to the non-compliance to the immunosuppressive therapy (15 months after transplantation), a hand graft to intimal hyperplasia (275 days after transplantation) and another handgraft due to venous troubles (45 days after transplantation). In 2009 it was reported that 7 Chinese recipients have lost their grafts. In all cases the cause was non-compliance to theimmunosuppressive therapy due to abstention from therapy, long distance from the transplantation centre, and unreported episodes of acute rejection.
Conclusion
Hand transplantation is a good therapeutic alternative to hand amputated patients. Compliance with immunosuppressive therapy as well as careful evaluation of the recipient before and aftertransplantation is mandatory for long-term graft survival.

Disclosure: All authors have declared no conflicts of interest.