Technique for Rapid Hand Transplant Donor Procurement Through the Elbow

Abstract

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Preservation solutions for attenuation of ischemia–reperfusion injury in vascularized composite allotransplantation

“…96 This article did not provide a rationale for the use of HTKS over other solutions. 96 Another case report describes the first bilateral hand transplant in the Netherlands where UWS at 4°C was used. 97 Again, this technique article did not provide a rationale for the selection of UWS over other preservation solutions.…”

“…One hand transplant technique paper from the University of Utah with a series of two bilateral and five unilateral hand transplants describes an SCS preservation technique with the use of three liters of HTKS. 96 This article did not provide a rationale for the use of HTKS over other solutions. 96 Another case report describes the first bilateral hand transplant in the Netherlands where UWS at 4°C was used.…”

Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb

“…Whether UW is appropriate for the preservation of muscle is unknown, with concern about endothelial injury from potassium-induced vasoconstriction (required for cardioplegia of the donor heart) (29). Histidinetryptophan-ketoglutarate (HTK), a low viscosity cardioplegic solution has been used in two bilateral and five unilateral transplants (30) among other solutions such as IGL-1, Celsior, Scot solution and heparinised saline (31). In view of the unique cellular and metabolic features of the allograft, a more scientific approach to selecting and developing preservation solutions is required Despite cooling, the metabolic requirements of tissues does not cease (32).…”

Advanced Amputation Techniques in Orthopedic Surgery: Hand Transplantation

“…19,20 Although amputation could occur at any level, procurement at the elbow has been shown to be the most efficient procedure for amputations below the elbow and will be discussed herein. 20 The donor procurement follows the standard of care techniques of elbow or shoulder disarticulation and transplantation. Briefly, a variety of skin incision patterns may be used, however, a fish mouth incision for elbow disarticulation allows for increased skin if needed for the recipient surgery, a straightforward identification of critical anatomic structures, and rapid procurement.…”

“…However, if complications arise or circumstances preclude simultaneous procurements, the life-saving organ is prioritized. 19,20 Although amputation could occur at any level, procurement at the elbow has been shown to be the most efficient procedure for amputations below the elbow and will be discussed herein. 20 The donor procurement follows the standard of care techniques of elbow or shoulder disarticulation and transplantation.…”