Perioperative Ischemic Injury and Fibrotic Degeneration of Muscle in a Forearm Allograft

Abstract

Allografts of the forearm are still uncommon in the field of composite tissue allograft transplantation. In November 2007, a right-hand allograft and a left-hand/full-length forearm allograft were transplanted in a 30-year-old man who lost both hands and the vision in his left eye due to an explosion. The patient underwent alemtuzumab and steroid induction therapy. Tacrolimus, mycophenolate mofetil, and low doses of steroids were given to prevent rejection. The allografts were rejected 3 times, but these episodes were controlled successfully. The immunosuppressive regimen was switched from tacrolimus to sirolimus because of increased serum creatinine. The left allograft showed a flexion contracture due to muscle fibrosis that was conjectured to be associated with a perioperative ischemic injury and permitted only a Moberg-type key pinch. In contrast, an excellent grade of function was observed in the right allograft. The Disabilities of the Shoulder, Arm, and Hand score improved from 70.83 to 36.6 and intrinsic musculature returned to both allografts. The patient was able to work 2 years after transplantation. This is the first report of an ischemic injury related to the successful allotransplantation of a composite tissue.

Factors Influencing Acute Rejection of Human Hand Allografts

“…12Y14 Similarly, HHAs may show impaired function after long periods of cold ischemia. 8 The IS therapies that are used to prevent rejection after HAT are similar to those used after SOT. 15 Recommendations for maintenance therapy include the use of a calcineurin inhibitor (CNI) and an antiproliferative agent, usually accompanied by steroids.…”

“…4,20Y22 However, such approaches have succeeded only partially, 22 and tapering IS therapy is a reported cause of AR in both SOT and HAT. 8,10,23 Human leukocyte antigen (HLA) matching is known to be important in the prevention of AR in SOT, 24 although HLA matching in kidney allograft transplantation (KAT) has diminished in recent years. 25 This factor may also be important in HAT.…”

Alloimmune and Infectious Complications in Hand/Face Transplantation

“…Fungal infection has been described in the allograft's skin of two recipients of HAs. One had received high doses of IS due to resistant AR episodes, while the other one was having his therapy adjusted [42,43]. Both cases responded well to medical treatment.…”

Surgical and Logistical Aspects of Donor Limb Procurement in Hand and Upper Extremity Transplantation

“…17 Although no current clinical studies exist with regards to maximal ischemic time, minimization is advocated. 19 Whereas grafts that do not include a large muscle mass (very distal forearm or wrist level hand transplants) might by fairly tolerant to ischemia this is particularly important in more proximal transplantations given the sensitivity of the muscle tissue to ischemia. 1 It is the preference of the senior authors to set the upper limit of expected cold ischemia time to 8-10 hours, which should be obtainable.…”