INNOVATION IN COMPOSITE TISSUE TRANSPLANTATION

S. Schneeberger¹, G. Pierer², M. Gabl³, M. Ninkovic⁴, T. Hautz⁵, A. Weissenbacher⁶, B. Zelger⁷, W. Loescher⁸, M. Rieger⁹, H. Piza-katzer², R. Margreiter⁴, J. Pratschke¹⁰, G. Brandacher^11
1Department Of Visceral Transplant And Thoracic Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA, ²Dept. Of Plastic Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA, ³Dept. For Trauma Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁴Dept. For General, Transplant And Thoracic Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁵, Center of Operative Medicine, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁶Department Of Visceral, Transplant And Thoracic Surgery, Medical University Innsbruck, Innsbruck/AUSTRIA, ⁷Department Of Pathology, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁸Dept. Of Neurology, Innsbruck Medical University, Innsbruck/AUSTRIA, ⁹Dept. Of Radiology, Innsbruck Medical University, Innsbruck/AUSTRIA, ¹⁰Visceral, Transplant And Thoracic Surgery, Medical University Innsbruck, Innsbruck/AUSTRIA, ¹¹Department Of Visceral, Transplant And Thoracic Surgery, Innsbruck Medical University, Innsbruck/AUSTRIA

Body: Introduction: Three bilateral and one unilateral hand/forearm transplantations have been performed in Innsbruck over the last decade. The outcome with emphasis on function, immunosuppression (IS),histomorphology and graft vascular changes at 10/7/4 and 0.5 years after transplantation is described here. Methods: Four patients received a bilateral hand (n=2), a bilateral forearm (n=1) or aunilateral hand transplant between March 2000 and June 2009. Induction therapy with ATG (n=2) or alemtuzumab (n=2) was followed by tacrolimus, prednisolon ± MMF (n=3) or tacrolimus andMMF (n=1) maintenance IS. Later, sirolimus/everolimus was added to the therapeutic regime under simultaneous withdrawal (n=2) or dose reduction (n=1) of tacrolimus (n=1) or MMF (n=1). Steroids wereentirely avoided in one and withdrawn in two patients. Evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, CT-angio, electrophysiological studies and somatosensory evokedpotentials were performed at regular intervals. Results: Range of motion reached up to 70% of normal with a grip strength of 10 (pos.2) and 7.3 (pos.5), 6.9 and 7.1kg (both pos.2) 4.7 and 4.3 (bothpos.4) and 2.2 (pos.5) on the right and left side (bilateral transplants), respectively. Hand function correlated with the time after transplantation and amputation level and remained stable afteryear 5. Intrinsic hand muscle function recovery and discriminative sensation were observed after hand but not forearm transplantation. Hot and cold sensation was observed in all patients. Sideeffects of IS included CMV infection, fungal infection, hypertension, hyperglycemia, transient creatinine increase and headache. All side effects required treatment, but non were life-threatening.Three, six, four and one rejection episode were successfully treated with steroids, anti-CD25, anti-CD52 antibodies and/or intensified maintenance IS. Skin histology at current shows no or mildperivascular predominantly CD3-pos lymphocytic infiltrates without signs of progression. Vessels are patent without signs for luminal narrowing or intimal proliferation. Conclusions: The overallfunctional outcome and patient satisfaction after bilateral hand, bilateral forearm and unilateral hand transplantation are highly encouraging. After immunological challenging early postoperativecourses, all patients are now free of rejection with moderate levels of IS.

Disclosure: All authors have declared no conflicts of interest.