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Summary The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English, French, or German were reviewed systematically, with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty-eight patients were reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (±19.04) points on the DASH score after HAT (P = 0.005). Lower DASH scores (P = 0.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow-up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty-two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.

Nonunion and avascular necrosis of the proximal pole of the scaphoid remain one of the most difficult problems in wrist reconstructive surgery. A number of interpositional vascularized bone grafts have been proposed for scaphoid nonunion, in order to promote faster union at the contact site with both fragments. However, once the proximal pole has undergone avascular changes and is completely necrotic, there is no alternative other than to remove it. At present, more radical operations have been advocated in these cases, such as proximal row carpectomy or intercarpal arthrodesis. We present a case where the necrotic proximal pole of the scaphoid was removed and replaced with a remodeled osteochondral-free vascularized graft from the rib based on the inferior and superior intercostal arteries, branches of the internal mammary artery. © 2009 Wiley-Liss, Inc. Microsurgery 2009.

Since May 2002 all groups performing hand transplantations have supplied detailed information to the International Registry on Hand and Composite Tissue Transplantation. This inaugural report provides a review of all hand transplants performed to date.Between September 1998 and September 2004, 18 male patients underwent 24 hand/forearm/digit transplantations (11 monolateral and 4 bilateral hand transplantations, 2 bilateral forearm transplantations, and 1 thumb transplantation). The level of amputation was mostly at the distal forearm or wrist. The average age of the patient was 32 years. Time since hand loss ranged from 2 months to 22 years. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, rapamycin, and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was administered in some patients. Follow-up period ranged from 17 to 70 months.Patient survival was 100%. Graft survival was 100% at 1 and 2 years. Two cases of graft failure at a later date were caused by severe inflammation and progressive rejection in a noncompliant patient. Acute rejection episodes occurred in 12 patients within the first year. Rejection was reversible in all compliant patients. Side effects included opportunistic infections and metabolic complications. No life-threatening complications or malignancies were reported. All patients had achieved protective sensation, and 17 patients also achieved discriminative sensation. Extrinsic and intrinsic muscle recovery enabled patients to perform most daily activities.Despite the enormous antigen load associated with composite tissue allograft, hand transplantation became a clinical reality with immunosuppression comparable to transplantation of solid organs.

Studies in animals and humans suggest that sympathetic activity exerts a stiffening influence on large and middle-sized artery walls. We sought to obtain further evidence on this issue by measuring radial artery distensibility in an allotransplanted and thus denervated hand using the contralateral artery as control. In 2 men, blood pressure was measured by a semiautomatic device (Dinamap). Diastolic diameter, systo-diastolic diameter excursion (ultrasound Wall Track system), and distensibility (Reneman formula) of both radial arteries were measured at a level corresponding to 4 cm below the suture of the transplanted hand 40 days after surgery and every 4 weeks for the next 6 months. After surgery, systo-diastolic diameter excursion and distensibility were much greater in the transplanted radial artery than in the contralateral vessel, reaching values similar to the contralateral ones after 4 months, when signs of reinnervation of the transplanted hands had appeared. Radial deinnervation was accompanied by an increased arterial distensibility, which provides further evidence of the sympathetic stiffening effect on arterial wall in humans.

Hand transplantation may become an important procedure for upper limb functional restoration. To date, 18 patients have been undergone 24 hand operations in the world. Initial results are extremely promising; the functional results are apparently superior to those obtained with prostheses. We report on the combined French and Italian experience of six patients (eight hands), which is based on a jointly devised protocol and represents the largest available clinical series. Six male patients aged 43, 33, 35, 32, 33, and 22 years received either a single right hand–dominant transplantation (four cases) or a simultaneous double hand transplantation (two cases). The time since the amputation ranged from 3 to 22 years. The level of transplantation was at the wrist in five cases (six hands) and at the distal forearm in two cases (two hands). Cold ischemia averaged 11.5 hours. Three patients simultaneously received additional full-thickness skin taken from the donor and transplanted onto their left hip area. This skin served as a source for biopsies and as an additional area to monitor rejection (distant sentinel skin graft). The immunosuppressive protocol included polyclonal antibodies (three patients) or monoclonal anti-CD 25 antibody (three patients), tacrolimus, mycophenolate mofetil, and prednisolone. No surgical complications occurred. Skin rejection occurred at least once in all patients at a mean of 40 days postoperatively. Three patients recovered protective and some discriminative sensation in their palm and fingers. Two patients are recovering sensation, but are still in the early phases of the regenerative process, due to the short time since the transplantation. One patient was not compliant with the immunosuppressive therapy, and underwent uncontrolled rejection and reamputation.

Objective of this study was to analyze fifteen months after surgery the sensorimotor recovery of the first human double hand transplantation.As for any organ transplantation the success of composite tissue allografts such as a double hand allograft depends on prevention of rejection and its functional recovery.The recipient was a 33-year-old man with bilateral amputation. Surgery included procurement of the upper extremities from a multiorgan cadaveric donor, preparation of the graft and recipient's stumps; then, bone fixation, arterial and venous anastomoses, nerve sutures, joining of tendons and muscles and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Immunosuppressive protocol included tacrolimus, prednisone and mycophenolate mofetil and, for induction, antithymocyte globulins and then CD25 monoclonal antibody were added. Sensorimotor recovery tests and functional magnetic resonance imaging (fMRI) were performed to assess functional return and cortical reorganization. All the results were classified according to Ipsen's classification.No surgical complications occurred. Two episodes of skin acute rejection characterized by maculopapular lesions were completely reversed increasing steroid dose within 10 days. By fifteen months the sensorimotor recovery was encouraging and the life quality improved. fMRI showed that cortical hand representation progressively shifted from lateral to medial region in the motor cortex.Even though at present this double hand allograft, treated using a conventional immunosuppression, allowed to obtain results at least as good as those achieved in replanted upper extremities, longer follow-up will be necessary to demonstrate the final functional restoration.

Hand transplantation is a model of composite tissue allografting ( a A ) . The immunological issues in CTA are extremely complex, as different tissues are involved, each of which has to be considered both individually and as a part of a unit while each has a different time and intensity of rejection. Cartilage, ligaments and fat present low antigenicity, and consequently they lead to a weak rejection; bone, muscles, nerves and vessels show a moderate rejection profile in spite of various degrees of immunogenicity; skin, a complex immunological structure, is the component that develops the most severe rejection, because of the abundance of dentritic cells within epidermis and dermis. Finally, bone marrow, a source of immunocompetent cells, is a major target for rejection, but also a source of contaminating donor T cells that could induce a graft-versus-host disease in a strongly immunosuppressed recipient, and a source of stem cells that might contribute to the development of a microchimerism. Limb transplantation, the most common experimental model of CTA, has met with varying degrees of success; however, results have improved with the introduction of new immunosuppressants, especially tacrolimus and mycophenolic acid [l-71. In humans few cases of isolated muscle [8], bone, joint [9, lo], nerve [ l l ] or vascular allografts [12] have been reported. The first vascularized human hand transplantation was performed on 23 September 1998 in Lyon, and it is described in the present report [13].

A new sutureless technique to successfully anastomose the abdominal aorta of rats (1.3 mm in diameter) by using a fully biodegradable, laser-activated protein solder is presented. A total of 90 rats were divided into two groups randomly. In group one, the anastomoses were performed by using conventional microsuturing technique, whereas in group two, the anastomoses were performed by using a new laser welding technique. In addition, each of the two groups were divided into five subgroups and evaluated at different follow-up periods (10 minutes, 1 hour, 1 day, 1 week, and 6 weeks). At these intervals, the anastomoses were evaluated for patency and tensile strength. Three anastomoses in each subgroup were processed for light and electron microscopy. All anastomoses were found to be patent. The mean clamp time of the anastomoses performed with conventional suturing was 20.6 minutes compared with 7.2 minutes for the laser-activated welded anastomoses (p < 0.001). The strain measurements showed a stronger mechanical bond of the sutured anastomoses in the initial phase. However, at 6 weeks the tensile strength of the laser-welded anastomoses was higher compared with the conventional suture technique. Histologic evaluations revealed a near complete resorption of the solder after 6 weeks. The junction site of the vessel ends cannot be determined on the luminal side of the artery. In conclusion, a resorbable protein used as a solder, activated by a diode laser, can provide a reliable, safe, and rapid arterial anastomosis, which could be performed by any microsurgeon faster than conventional suturing after a short learning curve.

Ulnar nerve lesions around the elbow often carry an unfavorable prognosis due to insufficient sensory and intrinsic muscle recovery. We present a series of 7 cases in which restoration of ulnar innervated intrinsic muscles of the hand and of skin sensibility was achieved. This was accomplished by a distal connection of the anterior interosseous nerve and the superficial sensory palmar branch of the median nerve to the motor and sensory components of the ulnar nerve at Guyon's canal. The length of the follow-up period ranged from 1 to 3.5 years. Results were graded by the Highet-Zachary scale. Good motor and sensory recovery was obtained in 6 cases; only return of protective sensation occurred in the remaining case.

Using the technique of radioactive 51Cr-labeled biological microspheres, this study evaluated arterial blood flow following small vessel anastomosis by CO2 laser welding and a dissolvable stent in the lumen. A total of 30 Sprague-Dawley rats were divided into two groups. Group A: 11 rats had their femoral arteries ligated on one side. The contralateral side served as a control, with the artery transected and repaired using conventional microsuturing. Group B: 19 rats had their femoral arteries transected and repaired using CO2 laser welding and an intraluminal dissolvable stent technique. The contralateral side was again used as a control using conventional microsuturing. At 1 hr postoperatively, 51Cr-labeled biological microspheres were injected centripetally into the left common carotid artery and the legs and thighs immediately harvested for measurement of radioactivity. All repaired arteries were patent (30/30 in the microsuturing group and 19/19 in the stented welding group), with no detectable stenosis or dilation at the repaired site. Statistical analysis showed that tissue radioactivity (cpm/g) in the ligated group (3,972 +/- 384 in thighs and 3,142 +/- 742 in legs) was significantly lower than in the microsuturing group (7,132 +/- 1,723 in thighs and 6,557 +/- 1,469 in legs) (P 0.05) and legs (6,386 +/- 1,703 and 6,288 +/- 1,757, respectively; P > 0.05). This study provided evidence that the dissolvable stent placed intraluminally does not impair blood circulation and that when coupled with CO2 laser welding offers a high-quality alternative to conventional small vessel anastomosis.

This study evaluates the use of sutureless laser welding for vasovasostomy. In 14 rodents, the left vas deferens underwent vasovasostomy using an albumin-based solder applied to the adventitia of the vas deferens. The solder contained the dye, indocyanine green, to allow selective absorption and denaturation by a fiber-coupled 800-nm diode laser. The right vas deferens served as a control, receiving conventional layered microsurgical repair. We used a removable 4/0 nylon stent and microclamps to appose the vas deferens during repair, with no need for stay sutures. The mean time to perform laser solder repair (23.5 min) and conventional repair (23.3 min) were not significantly different (P = 0.91). However, examination after 8 weeks showed that granuloma formation (G) and patency (P) rates for the conventional suture technique (G, 14%; P, 93%) were significantly better than observed for the laser solder technique (G, 57%; P, 50%). © 1998 Wiley-Liss, Inc. MICROSURGERY 18:414–418, 1998

In thumb reconstruction, the wrap-around free flap has many advantages; however, delayed wound healing, pain, and skin ulcerations at the donor site can be a problem. In 5 patients, a free lateral forearm fasciocutaneous flap was successfully used for immediate resurfacing of the donor defect of the big toe during wrap-around procedures. This flap was selected after preliminary anatomic studies that showed that it could be safely raised if based on the anterior terminal division of the posterior radial collateral artery. The average follow-up period was 2 years. The time required for healing of the great-toe defect was less than 1 month. All patients were satisfied with the outcome of the procedure. The skin of this flap is very pliable and thin, and the subcutaneous tissue is about half the thickness of that of the lateral arm flap. This technique is especially indicated for closure of moderate to big skin defects at the great-toe level, whenever a larger than usual amount of skin is required, during wrap-around procedures for thumb reconstruction.

To assess the efficacy, role, and limitations of diagnostic ultrasound in the hand and wrist, the results of 98 examinations performed for a variety of surgical conditions were retrospectively analyzed. Ultrasound was shown to be reliable in evaluating radiolucent foreign body, tendon rupture versus tendon adhesion, tendinitis, peritendinitis, and ganglion cyst (specificity, 1; positive predictive value, 1). A correct suggestion of soft tissue mass histology was offered in six of eight operated cases. Tumor size and extent was accurately assessed in all but one case. The observed limitation of ultrasound was a small false negative rate in each category, which related to a variety of factors, including operator dependence, resolution threshold in the submillimeter range, image degradation due to postoperative edema, a narrow field of view, and one instance of indiscrete tumor margination. More work is needed to determine the role (if any) of ultrasound in the evaluation of peripheral nerve, triangular fibrocartilage, dorsal carpal ligament, and bone pathology.

When using microvascular polytetrafluoroethylene (PTFE) vascular grafts, the best results in terms of patency rate and neoendothelialization are obtained with prostheses with thin walls and long fibril length (i.e., 90 μm). A complete internal neoendothelial lining is usually achieved at 12 weeks after implantation. Clinically, this period can be too long. In this study, 1-mm internal diameter PTFE prostheses with optimal physical characteristics were pretreated with basic fibroblast growth factor in fibrin glue, a potent endothelial cell mitogen, and chemoattractant. Rate, speed, extent, quality, and origin of neoendothelium were compared with two control groups, using Evans Blue dye, immunohistochemical localization of factor VIII von Willebrand factor protein, and scanning electron microscopy. Prostheses (8 mm long) were implanted in the infrarenal rat aorta and harvested after 3 weeks. In treated grafts, the amount of endothelial regeneration was greater than in untreated grafts (75% of the internal surface compared with 30%). However, patency rate in the experimental group was lower than in the control groups. This study provides new data on neoendothelial regeneration in small-diameter PTFE grafts. © 1998 Wiley-Liss, Inc.

Fibre-optic technology combined with confocality produces a microscope capable of optical thin sectioning. In this original study, tibial nerves have been stained in a rat model with a vital dye, 4-(4-diethylaminostyryl)-N-methylpyridinium iodide, and analysed by fibre-optic confocal microscopy to produce detailed images of nerve ultrastructure. Schwann cells, nodes of Ranvier and longitudinal myelinated sheaths enclosing axons were clearly visible. Single axons appeared as brightly staining longitudinal structures. This allowed easy tracing of multiple signal axons within the nerve tissue. An accurate measurement of internodal lengths was easily accomplished. This technique is comparable to current histological techniques, but does not require biopsy, thin sectioning or tissue fixing. This study offers a standard for further in vivo microscopy, including the possibility of monitoring the progression of nerve regeneration following microsurgical neurorraphy.

The 3M Precise Microvascular Anastomotic System has had an experimental long-term testing for the first time in polytetrafluoroethylene (PTFE) 1-mm diameter arterial grafts. The grafts were placed in the infrarenal aorta of 48 rats. At different time intervals (2 weeks, 16 weeks and 1 year), each section containing a graft and its pair of anastomotic devices was removed and processed for light and scanning electron microscopy, with the aid of a newly-designed device. Eighty-three percent of the mechanically anastomosed grafts were found to be patent. Only 14.8 percent of the grafts harvested at 16 weeks or 1 year showed neo-endothelial lining on the inner surface of the graft. A constant finding of this study was the marked atrophy of the aortic media within the devices, that was progressively evident from 2 weeks to 1 year. A network of capillaries within the graft walls was present at 16 weeks. In one case, a large capillary was found to traverse the graft wall and to reach the luminal surface, suggesting that transmural capillaries may contribute to the formation of neo-intima in 1-mm PTFE grafts.

The 3M Precise Microvascular Anastomotic System has been tested experimentally in long-term studies of arteries of 1 mm in diameter for the first time. The device was placed, using a newly described technique, in the infrarenal aorta of 25 rats. At different intervals (2 weeks, 16 weeks, and 1 year), the section containing the 3M Precise Microvascular Anastomotic System was removed and processed for light microscopy and scanning electron microscopy. All the anastomoses were found to be patent. Using a new device to process the material, both light microscopy and scanning electron microscopy at 2 weeks showed a perfect reparative process at the junction site and the presence of a continuous endothelial layer. Media atrophy was responsible for wall thinning within the device. At 16 weeks, the atrophy of the media was even more marked, reducing the vessel wall thickness within the device to one-third of normal. At 1 year, this atrophy of the media was complete; smooth muscle cells disappeared and were replaced by fibrous tissue. Adventitia was not present over the long term within the device. The continuous endothelial layer, however, was still viable. These long-term results suggest that scar tissue forms within the device, while a continuous endothelial layer remains viable internal to this.

We present a case in which an open wound involving the ulnar collateral ligament of the metacarpophalangeal joint of the little finger was treated by ligament reconstruction using a strip of Dacron material, nerve grafting and coverage by a posterior interosseous artery pedicled flap. At a long term follow-up of 4 years, the joint was stable and had a full range of movement.

Human cytomegalovirus (HCMV) infection is the major viral complication in solid organ transplant recipients. Seronegative recipents (R-) of organs from seropositive donors (D+) appear to be at higher risk of developing symptomatic HCMV infection. To what extent systemic life-threatening complications can be risked for non-life-saving transplant procedures? A case report describing successful treatment of repeated episodes of active HCMV infection in a D+R- hand recipient in the absence of HCMV-specific T-cell immunity is presented. In the attempt to save both the patient and the transplanted hand, a preemptive treatment strategy was adopted with the aim to boost the constitution of the virus-specific T-cell immune response and simultaneously avoid onset of disease. Careful monitoring of HCMV load in blood and HCMV-specific T-cell immunity guided administration of repeated courses of antiviral treatment and avoided emergence of HCMV-related symptoms. Following establishment of HCMV-specific CD4+ and CD8+ T-cell response, preemptive treatment was no longer required due to sustained HCMV disappearance from blood. The patient is now well, and his hand too. In conclusion, evaluation of virus-specific T-cell immunity is of crucial importance in D+R- transplant recipients and careful monitoring of HCMV-specific T cell mediated response should always parallel monitoring of HCMV load in transplant recipients.

Skin rejection after hand transplantation is characterized by a maculopapular erythematous rash that may be diffuse, patchy or focal, and distributed over forearms and dorsum of the hands. This 'classical' pattern of rejection usually spares the skin of the palm and does not affect the nails. Herein, we report the experience on four cases presenting with an 'atypical' pattern of rejection that is novel in involving the palmar skin and the nails. All patients were young and exposed to repetitive and persistent mechanical stress of the palm. Characteristic features of rejection included a desquamative rash associated with dry skin, red papules, scaling and lichenification localized to the palm. Skin lesions were associated with nail dystrophy, degeneration, deformation or loss. Histology of the skin and nail bed revealed a lymphocytic infiltrate with predominance of T cells (CD3+, CD4+ and CD8+), with small numbers of B cells (CD20+ and CD79a+) and a low number of Forkhead transcription factor 3 (FOXP3)-positive cells in one patient. The lesions persisted over weeks to months, responded poorly to steroid treatment and were managed with antithymocyte globulin (ATG; Thymoglobulin, Genzyme, Cambridge, MA), alemtuzumab and/or intensified maintenance immunosuppression.

Human hand transplantation became a reality on 23 September 1998 when the first successful case was performed, with long-term transplant survival and promising functional recovery [1]. Twenty-four hand transplantations have been performed until the writing of this book (12 unilateral and 6 bilateral). However, there remains considerable debate over the ethical consequences of hand allotransplantation, and many questions must be answered before it becomes a routine procedure.

The first hand transplantation was performed in Lyon, France, on 23 September 1998 by an international team of surgeons. Since then, hand transplantation programmes have been launched in the United States, China, Italy, Austria and Belgium. Since 1998, 11 patients have received a single hand transplant, four a double hand transplant and two a double forearm transplant.

A complete range of instruments to face any possible situation during a hand transplantation procedure is mandatory. The material and instruments needed for hand transplantation should be carefully selected and prepared in advance. Their division into practical and readyto-use sets is essential in a scenario where wasting time must be minimised. Our list of instruments and materials as well as the additional items to be used in the operating theatre is as follows: Surgical instruments trays Suture stitches tray One table with sterile sheets Two tables, one of which prepared with a tray for harvesting an iliac crest bone graft Two squared tables: one for the osteosynthesis set; one for the harvested limb (including iced solution) Operating microscope with videocamera and monitor Portable image intensifier.

Patients suffering from intestinal failure and total-parenteral-nutrition-derived complications can be treated with either intestinal or multivisceral abdominal transplantation. These operations have greatly increased in number in the last decade (more than 1,000 reported cases) because of the improved survival rate due to advances in surgical technique, better immunosuppressive regime, donor selection and recipient care [1]. However, there are cases where achieving primary closure of the abdominal wall at the end of the surgical procedure is very difficult. Patients requiring intestinal transplantation have often previously undergone intestinal resection, with loss of the small-bowel domain. Their abdominal wall structure may be severely altered because of laparotomies, enterocutaneous fistulae, infections and tumours.

Since May 2002 all groups performing hand transplantations have supplied detailed information to the International Registry on Hand and Composite Tissue Transplantation. This report provides a review of all hand transplants performed to date. From September 1998 to February 2006 eighteen male patients underwent 24 hand/forearm/digit transplantations (eleven unilateral and four bilateral hand transplantations, two bilateral forearm transplantations, one thumb transplantation). The level of amputation was mostly at the distal forearm or wrist. Patient average age was 32. Time since hand loss ranged from 2 months to 22 years. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, rapamycin and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was administered in some patients. Follow-up period ranged from 34 to 85 months. Patient survival was 100%. Graft survival was 100% at 1 and 2 years. Two cases of graft failure at a later date occurred and were caused by severe inflammation and progressive rejection in a non-compliant patient. In addition, 6 hands were lost due to a rejection process as the Chinese recipients did not take their immunosuppressive treatment. These failures were communicated in January 2006. Acute rejection episodes occurred in 12 patients within the first year. Rejection was completely reversible in all compliant patients. Side-effects included opportunistic infections and metabolic complications. No life-threatening complications or malignancies were reported. As it would have been very difficult to analyse transplantation functional results in a standardized way, the Registry has performed a functional score system. All patients had achieved protective sensation and in 17 of them also discriminative sensation. Extrinsic and intrinsic muscle recovery enabled patients to perform most daily activities and 90% of the recipients returned to work, and improved manual skills allowed them not only to resume their previous jobs but also, in some cases, to find more suitable employment. Fifteen recipients reported an improvement of their quality of life and we evaluated as a very important point as patient satisfaction and well-being are mandatory goals of hand transplantation.

The complete withdrawal of immunosuppressive therapy after hind-limb transplantation across a strong histocompatibility barrier (Brown-Norway to Lewis) included a low-dose combination of FK506, mycophenolate mofetil (MMF), and prednisone. MMF and prednisone were tapered and withdrawn between weeks 2 and 7. From weeks 8 to 24, Group 1 animals (n = 23) had FK506 tapered; for those in Group 2 (n = 11) the dose of FK506 was not changed. At week 24, FK506 was stopped. The six limb grafts in Group 1 (26%) that achieved the 1-year end-point uneventfully showed chimerism by bone marrow and skin grafting supporting the presence of donor-specific tolerance. Rejection, which was common during tapering of FK506, was reversed by salvage therapy. All limbs were rejected postwithdrawal in Group 2. This study showed that tapering of FK506 combined with salvage therapy may allow long-term survival of some transplanted limbs after complete withdrawal of immunosuppressive therapy despite a complete MHC barrier.

Functional recovery of transplanted hand can be evaluated clinically but until now there has been no direct assessment of muscle control. In October 2000 we transplanted the right hand of a brain-dead man aged 43 onto a man aged 35 who had lost his right dominant hand 22 years before. Starting from day 205 after the transplant, multi-channel surface electromyographic (EMG) signals were recorded from intrinsic muscles of the transplanted hand in order to assess their degree of reinnervation. Eleven months post-operatively, the first motor unit action potential train was detected from the abductor digiti minimi. One month later, also the abductor pollicis brevis and the opponens pollicis muscles showed motor unit activity, while, after 15 and 24 months, the first dorsal interosseous and the first lumbricalis muscles, respectively, showed activation of their first motor units. An increase in the number of active motor units was observed after the first signs of reinnervation, although the process was rather slow. In sustained maximal contractions, the motor unit discharge rate decreased from (mean +/- S.D.) 34.0+/-6.7 pps to 23.4+/-5.1 pps in 60 s for the abductor digiti minimi, although the subject was verbally encouraged to maintain a maximal activation. Moreover, the subject was able to perform basic control tasks involving voluntary modulation of motor unit discharge rate. With a visual feedback, he could increase discharge rate of the abductor digiti minimi approximately linearly over time, from 13.4+/-6.7 pps to 32.5+/-11.2 pps in 60 s. In conclusion, we showed reinnervation of single motor units in a transplanted hand after 22 years of denervation. Moreover, voluntary modulation of discharge rates of these motor units could be performed since the first sign of reinnervation.

Composite tissue allograft has become a clinical reality: hands, vascularized femoral diaphyses, abdominal walls, a larynx have all been transplanted throughout the world. Conventional immunosuppressive protocol has shown to be sufficient and effective. Rejection has been prevented in most cases and when it did occur it was successfully reversed. Skin has been confirmed as the principal target of acute and chronic rejection. There has been no mortality or early graft losses and, particularly in hand transplantation, the survival graft rate is 91% with a follow-up period ranging from 6 months to 61 months. The side effects of immunosuppression are limited and include primarily transient hyperglycemia, an increase in creatinine values and some opportunistic infections (i.e. cytomegalovirus infection). Nerve regeneration and cortical reorganization have been demonstrated in hand transplantation. Functional results have been encouraging particularly for hand and larynx transplantation. Appropriate indications and patient selection, based particularly on patient motivation and compliance, are essential requirements for composite tissue allograft success.

We present a new method for the treatment of painful neuromas of the palmar cutaneous branch of the median nerve. A preliminary cadaver study was done to investigate the extraneural and intraneural course of the palmar cutaneous branch of the median nerve with respect to the main trunk of the median nerve. Seven patients presented with a painful neuroma following previous surgery on the palmar aspect of the wrist. The neuroma was dissected and excised by stripping the whole of the palmar cutaneous branch from the main trunk of the median nerve. In all cases complete relief from pain and discomfort was achieved. The resulting area of numbness in the palm did not represent a significant problem.

Diffusible factors from the distal stumps of transected peripheral nerves exert a neurotropic effect on regenerating nerves in vivo (specificity). This morphological study was designed to investigate the existence of tissue specificity in peripheral nerve fiber regeneration through a graft of vein filled with fresh skeletal muscle. This tubulization technique demonstrated experimental and clinical results similar to those obtained with traditional autologous nerve grafts. Specifically, we used Y-shaped grafts to assess the orientation pattern of regenerating axons in the distal stump tissue. Animal models were divided into four experimental groups. The proximal part of the Y-shaped conduit was sutured to a severed tibial nerve in all experiments. The two distal stumps were sutured to different targets: group A to two intact nerves (tibial and peroneal), group B to an intact nerve and an unvascularized tendon, group C to an intact nerve and a vascularized tendon, and group D to a nerve graft and an unvascularized tendon. Morphological evaluation by light and electron microscopy was conducted in the distal forks of the Y-shaped tube. Data showed that almost all regenerating nerve fibers spontaneously oriented towards the nerve tissue (attached or not to the peripheral innervation field), showing a good morphological pattern of regeneration in both the early and late phases of regeneration. When the distal choice was represented by a tendon (vascularized or not), very few nerve fibers were detected in the corresponding distal fork of the Y-shaped graft. These results show that, using the muscle-vein-combined grafting technique, regenerating axons are able to correctly grow and orientate within the basement membranes of the graft guided by the neurotropic lure of the distal nerve stump. © 2000 Wiley-Liss, Inc. MICROSURGERY 20:65–71 2000

In this study, a unilateral epigastric free flap was raised in 12 rabbits. After the arterial portion of the flap (the superficial femoral artery) was replaced by a 1-cm-long polytetrafluoroethylene graft with an internal diameter of 1 mm, the flap was revascularized by two conventional microvascular end-to-end anastomoses (graft to artery and vein to vein). At 3 weeks, all flaps were raised again and the patency of the polytetrafluoroethylene grafts was checked. All grafts, including the proximal and distal anastomoses, were harvested and processed for light and electron microscopy. All grafts remained patient, and all flaps survived the period of 3 weeks. At reexploration, the graft was completely covered with connective tissue. Light and scanning electron microscopy evaluation showed that the internal surface of the graft was covered by a fibrin layer, and that the ingrowth of neoendothelium had just started from both anastomotic sites. The use of small-diameter polytetrafluoroethylene grafts in a rabbit free-flap model was demonstrated to be a reliable alternative for pedicle elongation.

Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. The authors describe the case of a patient who sustained a closed rupture of both flexor digitorum profundus and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The present paper highlights the importance of the mechanism of injury and explains its biomechanical basis. The patient was treated by a two-stage reconstruction of the flexor digitorum profundus and regained full flexion and extension of the finger.

In the years 1970–90, 118 procedures were performed on 100 patients with arthritis (osteoarthritis in all but 13) of the carpo-metacarpal joint of the thumb. The patients were aged 17 to 83 years (mean 54.5 years); 75 were females and 25 males; there were 73 right and 45 left hands; 18 patients had bilateral procedures. The average follow up period was 4.3 years, with a range of 1 to 20 years. Sixteen of the 118 procedures were arthrodeses; all these patients had isolated trapezio-metacarpal joint arthritis. Fifteen procedures were trapeziectomies and soft tissue arthroplasties; they were performed for pan-trapezial arthritis in the older age group, or as a secondary procedure for failed previous operations. Eighty-seven of the 118 procedures were silicone partial or total arthroplasties either for pan-trapezial arthritis or isolated trapezio-metacarpal joint arthritis (53 trapezium, 32 metatarso-phalangeal and 2 condyle implants). The overall results were: arthrodesis (68.7% good, 18.8% fair, 12.5% poor); soft tissue arthroplasty (80% good, 6.7% fair, 13.3% poor); silicone total arthroplasty (73.5% good, 15.1% fair, 11.3% poor); silicone hemiarthroplasty (68.8% good, 15.6% fair, 15.6% poor). No silicone synovitis was found in any of the 87 cases of silicone arthroplasties.

The first reported case of multiple aneurysms of both the palmar arch and a proper digital artery is described. A palmar arch aneurysm was excised, and two end-to-end anastomoses were necessary to restore the blood flow. Microsurgical repair was the only possible treatment in this case. The authors believe that the vascular anatomy should always be restored as naturally as possible. No treatment was necessary for the more distal aneurysms.