The Experts below are selected from a list of 360 Experts worldwide ranked by ideXlab platform
Stefan Schneeberger - One of the best experts on this subject based on the ideXlab platform.
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20 year follow up of two cases of bilateral Hand Transplantation
The New England Journal of Medicine, 2020Co-Authors: Stefan Schneeberger, Annemarie Weissenbacher, Palmina Petruzzo, Jean Kanitakis, Theresa Hautz, Emmanuel Morelon, Franka Messner, Laurence Bernardon, Christian Seulin, Valeria BerchtoldAbstract:20-Year Follow-up of Two Patients with Bilateral Hand Transplants This letter reports the 20-year results in two men who underwent bilateral Hand Transplantation. Each of the patients can perform a...
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functional and psychosocial outcomes of Hand Transplantation compared with prosthetic fitting in below elbow amputees a multicenter cohort study
PLOS ONE, 2016Co-Authors: S. Salminger, A. Sturma, Stefan Schneeberger, Marina Ninkovic, Martin Kumnig, Gerhard Pierer, Aidan D Roche, Laura A Hruby, Tatjana Paternostrosluga, M GablAbstract:Background Hand-Transplantation and improvements in the field of prostheses opened new frontiers in restoring Hand function in below-elbow amputees. Both concepts aim at restoring reliable Hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing Hand function and quality-of-life of people with transplanted versus prosthetic Hands. Methods Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). Results Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic Hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in “role-physical” (p = 0.006), “vitality” (p = 0.008), “role-emotional” (p = 0.035) and “mental-health” (p = 0.003). Conclusions The indications for Hand Transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient’s best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for alloTransplantation must still be restrictive, the best being bilateral amputees.
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antibody mediated rejection in Hand Transplantation
Transplant International, 2014Co-Authors: Annemarie Weissenbacher, Bettina Zelger, Gerald Brandacher, Bernhard Zelger, Theresa Hautz, Verena Mayr, Johann Pratschke, Stefan SchneebergerAbstract:Summary Clinical relevance of antibody-mediated rejection (ABMR) in vascularized composite alloTransplantation (VCA) has not been defined. We herein describe a novel type of donor-specific antibody (DSA) and B-cell-associated rejection in Hand Transplantation. In 2003, a bilateral forearm Transplantation was performed on a 42-year-old male patient. In 2012, the patient presented with edematous Hands and forearms without skin lesions. Punch skin biopsies revealed rejection grade Banff II. Immunohistochemical analysis identified large aggregates of CD20 + lymphocytes with an architecture resembling lymph nodes. De novo DSA was found at a high level. Steroid treatment was ineffective, but administration of rituximab resulted in complete remission of clinical symptoms, evaporation of B-cell aggregates, and disappearance of DSA. We herein report the first case of what we suggest is an ABMR in VCA occurring at 9 years after forearm Transplantation. Rituximab therapy successfully reversed the event.
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immunosuppression and monitoring of rejection in Hand Transplantation
Techniques in Hand & Upper Extremity Surgery, 2013Co-Authors: Stefan Schneeberger, Saami Khalifian, Gerald BrandacherAbstract:Advances in vascularized composite alloTransplantation over the last decade have achieved significant milestones in basic science and translational research, as well as clinically with highly encouraging functional and immunologic outcomes. However, certain immunologic challenges remain. In particular, although tolerance has been induced to nearly all components of a Hand allograft in experimental models, the skin component may still be subject to acute rejection episodes. Currently, conventional immunosuppressive protocols have been successful at preventing allograft loss; however, they have not prevented episodes of acute skin rejection. Furthermore, the profound side effect profile of the life-long, high-dose, multidrug immunosuppression regimen that is necessary to maintain a viable graft alters the risk to benefit ratio of this non-life-saving procedure. Therefore, there must be a concerted effort in the scientific community to develop novel protocols to either minimize immunosuppression or to induce tolerance to the allograft to promote the widespread application of this life-changing procedure.
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minimizing immunosuppression in Hand Transplantation
Expert Review of Clinical Immunology, 2012Co-Authors: Gerald Brandacher, Stefan Schneeberger, W Andrew P LeeAbstract:Hand Transplantation, despite all initial skepticism, has developed from myth to reality over the past decade and has shown highly encouraging immunological and functional outcomes. However, the requirement of life-long, multidrug immunosuppression bearing the risk of serious side effects still remains the limiting factor for widespread clinical application of this novel reconstructive modality. Recent advances in immunosuppressive drug development and the design of novel cell-based therapeutic strategies that take into consideration the unique immunological and biological aspects of vascularized composite allografts have shown favorable results with regard to minimization of immunosuppressive medication and tolerance induction in both translational animal studies and first clinical trials in reconstructive Transplantation. This review provides an overview of the current available conventional treatment protocols and novel immunosuppression minimization concepts for Hand Transplantation, which ultimately ...
Warren C. Breidenbach - One of the best experts on this subject based on the ideXlab platform.
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A Methodology for Determining Standard of Care Status for a New Surgical Procedure: Hand Transplantation.
Plastic and Reconstructive Surgery, 2016Co-Authors: Warren C. Breidenbach, Edward A. Meister, Giles W. Becker, Venkata Sundeep Kumar Gorantla, Tolga Turker, L. Scott LevinAbstract:BACKGROUND: Hand alloTransplantation was initially criticized as unethical and unlikely to succeed. The results proved to be better than anticipated, now raising the issue of whether Hand Transplantation is the standard of care. The purpose of this article is to outline a reasonable methodology for determining whether a surgical procedure is the standard of care, and then to apply that methodology to Hand Transplantation. METHODS: Publications on ethics and definitions of medical (not legal) standard of care were reviewed. All Hand Transplantations completed in the United States were evaluated regarding their status as experimental, standard of care, or both. Then, the stakeholders, physicians, public insurers, and regulators were examined to determine whether they accepted Hand Transplantation as the standard of care. Utility and incremental cost-utility ratio were determined. Hand Transplantation was considered the standard of care when stakeholders were using, insuring, and regulating the procedure. RESULTS: The public expresses a desire for Hand Transplantation. A minority of surgeons consider the procedure the standard of care. Ethical committees, institutional review boards, and scholarly articles deem the procedure ethical. A series of institutions have carried out the procedure with a record of successes. Some institutions perform the surgical procedure as the standard of care. Scholarly work demonstrates beneficial outcomes. Some commercial and federal government insurers are willing to cover the cost of the procedure. Utility determination justifies the procedure. There are no incremental cost-utility ratio analysis studies that justify the procedure. CONCLUSION: Hand Transplantation is moving from acceptance as an ethical surgical experiment to the standard of care.
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the history and evolution of Hand Transplantation
Hand Clinics, 2011Co-Authors: Abtin Foroohar, Warren C. Breidenbach, Scott L Levin, River M Elliott, Tae Won Benjamin Kim, Abraham ShakedAbstract:As part of the rapidly expanding vascularized composite alloTransplantation (VCA), Hand Transplantation combines the technical rigors of Hand surgery and microsurgery with the complex multidisciplinary care that defines modern solid organ Transplantation. Although Hand Transplantation and solid organ Transplantation share a common history characterized by important advances in immunosuppression and surgical technique, Hand Transplantation has not yet been performed on a scale approaching that of solid organ transplants. The technical demands of Hand Transplantation, enhanced donor antigen burden of the Hand allograft, and complex psychosocial issues pertaining to the recipient account for much of the discrepancy between these 2 related fields. Despite these unique challenges, Hand Transplantation remains a viable option today for Hand amputees and the standard of care for bilateral upper extremity amputees. The early struggles and breakthroughs of Hand Transplantation’s past have shaped and formed its current state.
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world experience after more than a decade of clinical Hand Transplantation update from the louisville Hand transplant program
Hand Clinics, 2011Co-Authors: Christina L Kaufman, Warren C. BreidenbachAbstract:In the last 12 years, the Louisville CTA program has screened more than 600 interested Hand transplant candidates and has transplanted 6 patients with 7 Hand allografts. The program is a collaborative effort between the surgeons and staff of Kleinert, Kutz and Associates, Jewish Hospital and St. Mary's Healthcare, the Christine M. Kleinert Institute, and the University of Louisville. The functional outcome and long-term results of clinical Hand Transplantation have exceeded initial expectations both within the program and in the community at large. This report summarizes the successes and challenges of the Louisville CTA experience in composite tissue alloTransplantation.
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chronically deafferented sensory cortex recovers a grossly typical organization after allogenic Hand Transplantation
Current Biology, 2008Co-Authors: Scott H Frey, Sergei V Bogdanov, Jolinda Smith, Scott Watrous, Warren C. BreidenbachAbstract:Amputation induces substantial reorganization of the body part somatotopy in primary sensory cortex (S1 complex, hereafter S1) [1, 2], and these effects of deafferentiation increase with time [3]. Determining whether these changes are reversible is critical for understanding the potential to recover from deafferenting injuries. Earlier BOLD fMRI data demonstrate increased S1 activity in response to stimulation of an allogenically transplanted Hand [4]. Here, we report the first evidence that the representation of a transplanted Hand can actually recapture the pre-amputation S1 Hand territory. A 54-year-old male received a unilateral Hand transplant 35 years after traumatic amputation of his right Hand. Despite limited sensation, palmar tactile stimulation delivered 4 months post-transplant evoked contralateral S1 responses that were indistinguishable in location and amplitude from those detected in healthy matched controls. We find no evidence for persistent intrusion of representations of the face within the representation of the transplanted Hand, although such intrusions are commonly reported in amputees [5, 6]. Our results suggest that even decades after complete deafferentiation, restoring afferent input to S1 leads to re-establishment of the gross Hand representation within its original territory. Unexpectedly, large ipsilateral S1 responses accompanied sensory stimulation of the patient's intact Hand. These may reflect a change in interhemispheric inhibition that could contribute to maintaining latent Hand representations during the period of amputation.
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Hand Transplantation in the united states experience with 3 patients
Surgery, 2008Co-Authors: Kadiyala V Ravindra, Joseph F Buell, Christina L Kaufman, Brenda Blair, Michael R Marvin, R Nagubandi, Warren C. BreidenbachAbstract:Background Composite tissue alloTransplantation (CTA) is a newly emerging field of Transplantation that involves the simultaneous transfer of multiple tissues with differing antigenicity. Hand Transplantation, the most widely recognized form of CTA, aims to improve function and the quality of life of upper limb amputees. Methods In 1999, an institutional review board-approved Hand Transplantation protocol was implemented at the Jewish Hospital, University of Louisville. Suitable patients were evaluated and underwent Hand Transplantation. The surgical technique was akin to that used in limb reimplantation, and the immunosuppression protocol used was similar to renal Transplantation. Results Between 1999 and 2006, 3 patients underwent Hand Transplantation at our center. Although episodes of acute rejection were seen in all patients during the early postoperative period, only 1 immunologic event occurred after the first year. Graft function improved with time period. Carroll test scores were superior to those recorded with a prosthesis at the end of 1 year. Additionally, recovery of protective sensation was seen in all 3 patients and limited discriminatory sensation in 2. Complications related to immunosuppression have included cytomegalovirus infection in 2 patients, diabetes in 1, hyperlipidemia in 2, and osteonecrosis in 1. At a follow-up of 8, 6, and 1 year(s), all the recipients are healthy and have returned to a productive life. Conclusions The long-term success reported here should encourage wider application of the CTA in general and Hand Transplantation in particular. Methods of minimizing long-term immunosuppression need to be pursued.
W Andrew P Lee - One of the best experts on this subject based on the ideXlab platform.
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the ethics of Hand Transplantation a systematic review
Journal of Hand Surgery (European Volume), 2018Co-Authors: Carisa M Cooney, Jaimie T. Shores, Gerald Brandacher, Charalampos Siotos, Jeffrey W Aston, Ricardo J Bello, Stella M Seal, Damon S Cooney, W Andrew P LeeAbstract:Purpose We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) alloTransplantation and how these concerns have changed over time. Methods We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE alloTransplantation. Inclusion criteria were papers that were on the topic of UE alloTransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. Results We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0–7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. Conclusions Upper extremity Transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. Clinical relevance Because UE Transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.
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Hand Transplantation evolution of a personal outlook
Journal of Hand Surgery (European Volume), 2017Co-Authors: W Andrew P LeeAbstract:The field of vascularized composite alloTransplantation—combining advances in reconstructive surgery, Transplantation, and immunology—offers great promise for patients with heretofore unsolvable problems. In the last 30 years, Hand Transplantation has progressed through the phases of being a research subject, a controversial clinical procedure, a more widely accepted and expanding field, and now a promising endeavor undergoing refined indications. Although many lessons have been learned, few procedures in the author's experience have been as life-transformative in restoring the body image, motor and sensory functions, activities of daily living, and personal autonomy as successful Hand Transplantation.
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surgical and logistical aspects of donor limb procurement in Hand and upper extremity Transplantation
Vascularized Composite Allotransplantation, 2014Co-Authors: Omar Hausien, Jaimie T. Shores, W Andrew P Lee, Edward W Swanson, James Abraham, James P Higgins, Gerald BrandacherAbstract:Hand and upper extremity Transplantation offers a promising reconstructive solution for select patients lacking a functional upper limb. For such an endeavor, it is imperative that multiple medical and surgical specialties and teams work in concert to achieve a common goal. Sixteen years from the first successful Hand Transplantation, the number of centers performing or planning to perform Hand Transplantation worldwide has increased considerably. This procedure may become the standard of care for properly selected patients in the not-too-distant future. To facilitate this transition, unified protocols are required. In this manuscript, we focus on the donor limb procurement process, including the sequence of events, logistics, and inter-specialty team interaction. Through review of the current literature, we acknowledge and address possible variations, and provide an illustrative overview of the operation. It is important that all members involved in this procedure, including the Organ Procurement Organiz...
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minimizing immunosuppression in Hand Transplantation
Expert Review of Clinical Immunology, 2012Co-Authors: Gerald Brandacher, Stefan Schneeberger, W Andrew P LeeAbstract:Hand Transplantation, despite all initial skepticism, has developed from myth to reality over the past decade and has shown highly encouraging immunological and functional outcomes. However, the requirement of life-long, multidrug immunosuppression bearing the risk of serious side effects still remains the limiting factor for widespread clinical application of this novel reconstructive modality. Recent advances in immunosuppressive drug development and the design of novel cell-based therapeutic strategies that take into consideration the unique immunological and biological aspects of vascularized composite allografts have shown favorable results with regard to minimization of immunosuppressive medication and tolerance induction in both translational animal studies and first clinical trials in reconstructive Transplantation. This review provides an overview of the current available conventional treatment protocols and novel immunosuppression minimization concepts for Hand Transplantation, which ultimately ...
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technical aspects of the recipient operation in Hand Transplantation
Journal of Reconstructive Microsurgery, 2012Co-Authors: Kodi Azari, Jaimie T. Shores, Vijay S. Gorantla, Gerald Brandacher, S Schneeberger, Joseph E Imbriglia, Robert J Goitz, Marshall L Balk, W Andrew P LeeAbstract:The goal of Hand alloTransplantation is to achieve graft survival and useful long-term function. To achieve these goals, precise surgical technique is of critical importance. The key surgical steps and sequence of events in Hand alloTransplantation are similar to major upper extremity replantations, but are modified to accommodate major conceptual differences that exist between the two procedures.
Gerald Brandacher - One of the best experts on this subject based on the ideXlab platform.
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clinical significance of alloantibodies in Hand Transplantation a multicenter study
Transplantation, 2019Co-Authors: Erik Berglund, Gerald Brandacher, Jonas Wadstrom, Christina L Kaufman, Dorota Kaminska, Mette Andersen Ljungdahl, Darko Bogdanovic, David Berglund, Jan Kowalski, Simon G TalbotAbstract:Background.Donor-specific antibodies (DSAs) have a strong negative correlation with long-term survival in solid organ Transplantation. Although the clinical significance of DSA and antibody-mediated rejection (AMR) in upper extremity Transplantation (UET) remains to be established, a growing number
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the ethics of Hand Transplantation a systematic review
Journal of Hand Surgery (European Volume), 2018Co-Authors: Carisa M Cooney, Jaimie T. Shores, Gerald Brandacher, Charalampos Siotos, Jeffrey W Aston, Ricardo J Bello, Stella M Seal, Damon S Cooney, W Andrew P LeeAbstract:Purpose We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) alloTransplantation and how these concerns have changed over time. Methods We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE alloTransplantation. Inclusion criteria were papers that were on the topic of UE alloTransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. Results We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0–7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. Conclusions Upper extremity Transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. Clinical relevance Because UE Transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.
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benefits and limitations of belatacept in 4 Hand transplanted patients
American Journal of Transplantation, 2017Co-Authors: Johanna Grahammer, Annemarie Weissenbacher, Bettina Zelger, C Boesmueller, Marina Ninkovic, A Muhlbacher, Ines Peschel, Gerald BrandacherAbstract:Belatacept (CTLA4Ig) is an emerging treatment in kidney Transplantation. Lack of nephrotoxicity and possibly an inhibitory effect on the development of donor specific antibodies (DSA) make it an interesting agent in Hand Transplantation. In order to reduce CNI immunosuppression and preserve kidney function, we have added belatacept to the therapeutic regimen of 4 Hand transplanted patients at month 4, at 6, 9, and 13 years after Hand/forearm Transplantation. Patients received 5mg/kg belatacept every 2 weeks, the dosing interval was extended to 4 weeks after 5 applications. Belatacept was initially well tolerated in all cases. Two patients were weaned to a low-dose tacrolimus monotherapy together with monthly belatacept applications. One patient is on belatacept with lowered tacrolimus and sirolimus through levels. A fourth patient had significant levels of DSAs at time of conversion and progressed to a severe necrotizing rejection early despite an unaltered baseline immunosuppression. Finger skin necrosis and histological signs of severe chronic allograft vasculopathy eventually led to amputation of the graft. Implementation of belatacept can be beneficial in Hand Transplantation. However, our findings indicated both potential but also caution and reflection of the immunological state at the time of conversion. This article is protected by copyright. All rights reserved.
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surgical and logistical aspects of donor limb procurement in Hand and upper extremity Transplantation
Vascularized Composite Allotransplantation, 2014Co-Authors: Omar Hausien, Jaimie T. Shores, W Andrew P Lee, Edward W Swanson, James Abraham, James P Higgins, Gerald BrandacherAbstract:Hand and upper extremity Transplantation offers a promising reconstructive solution for select patients lacking a functional upper limb. For such an endeavor, it is imperative that multiple medical and surgical specialties and teams work in concert to achieve a common goal. Sixteen years from the first successful Hand Transplantation, the number of centers performing or planning to perform Hand Transplantation worldwide has increased considerably. This procedure may become the standard of care for properly selected patients in the not-too-distant future. To facilitate this transition, unified protocols are required. In this manuscript, we focus on the donor limb procurement process, including the sequence of events, logistics, and inter-specialty team interaction. Through review of the current literature, we acknowledge and address possible variations, and provide an illustrative overview of the operation. It is important that all members involved in this procedure, including the Organ Procurement Organiz...
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case series on defense mechanisms in patients for reconstructive Hand Transplantation consideration on transplant defense concept
Annals of Transplantation, 2014Co-Authors: Martin Kumnig, Gerald Brandacher, Sheila G Jowsey, Elisa Moreno, Kodi Azari, Gerhard RumpoldAbstract:BACKGROUND The technical demands of reconstructive Hand Transplantation (RHT) and need for complex multidisciplinary care have led to intense research efforts to improve patient care and outcomes. However, RHT is an extraordinary life event which carries the potential for long-term consequences including psychological distress, which invokes coping and defense mechanisms. MATERIAL/METHODS Little is known about the relationship between psychological defense mechanisms and health outcomes in RHT patients. In an effort to elucidate this relationship, we studied seven RHT patients who underwent standardized psychological assessment either pre- or post Transplantation. RESULTS No single defense concept was identified as common to all patients, which we suspect was due in part to the varied mechanisms of Hand loss. All seven patients demonstrated diverse psychological reactions to RHT. The self-reported defense styles were associated with psychological adjustment. The patients who reported defenses that distorted reality described less adaptive functioning and psychological well-being. CONCLUSIONS These preliminary findings reveal the varied psychological mechanisms invoked in RHT patients. An assessment of defense mechanisms should be part of multicenter evaluation protocols that address unique psychosocial aspects of RHT in large samples, in order to better guide psychological management.
Vijay S. Gorantla - One of the best experts on this subject based on the ideXlab platform.
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technical aspects of the recipient operation in Hand Transplantation
Journal of Reconstructive Microsurgery, 2012Co-Authors: Kodi Azari, Jaimie T. Shores, Vijay S. Gorantla, Gerald Brandacher, S Schneeberger, Joseph E Imbriglia, Robert J Goitz, Marshall L Balk, W Andrew P LeeAbstract:The goal of Hand alloTransplantation is to achieve graft survival and useful long-term function. To achieve these goals, precise surgical technique is of critical importance. The key surgical steps and sequence of events in Hand alloTransplantation are similar to major upper extremity replantations, but are modified to accommodate major conceptual differences that exist between the two procedures.
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surgical and technical aspects of Hand Transplantation is it just another replant
Hand Clinics, 2011Co-Authors: Tristan L Hartzell, Jaimie T. Shores, Vijay S. Gorantla, Joseph E Imbriglia, Robert J Goitz, Marshall L Balk, Prosper Benhaim, Scott Mitchell, Roee Rubinstein, Stefan SchneebergerAbstract:The ultimate goal of Hand alloTransplantation is to achieve graft survival and useful long-term function. To achieve these goals, selection of the appropriate patient, detailed preoperative planning, and precise surgical technique are of paramount importance. Transplantation should be reserved for motivated consenting adults in good general heath, who are psychologically stable and have failed a trial of prosthetic use. While the key surgical steps of Transplantation are similar to those of replantation, there are major differences. This article describes the steps in Hand alloTransplantation, and the importance of patient selection as well as preoperative and postoperative care.
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Composite tissue alloTransplantation: Hand Transplantation and beyond.
The Journal of the American Academy of Orthopaedic Surgeons, 2010Co-Authors: Jaimie T. Shores, Stefan Schneeberger, Vijay S. Gorantla, Andrew W.p. LeeAbstract:Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation, making composite tissue alloTransplantation with novel and less potent immunosuppressive regimens a possibility. Hand Transplantation has been the most frequently performed human composite tissue alloTransplantation, with more than 50 upper extremity-based transplants done worldwide. Further research is needed regarding immunomodulating protocols, and careful oversight and individualized screening procedures will be required as patients seeking improved quality of life through human composite tissue alloTransplantation come to accept a certain level of risk in these experimental procedures. Still, composite tissue alloTransplantation offers to advance transplant medicine and reconstructive surgery.
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immunosuppression and rejection in human Hand Transplantation
International Symposium on Composite Tissue Allotransplantation, 2009Co-Authors: Stefan Schneeberger, Vijay S. Gorantla, Theresa Hautz, Raimund Margreiter, Benson J Pulikkottil, W P LeeAbstract:Avoidance or at least minimization of maintenance immunosuppression represents the key step for promoting wider applicability of reconstructive Transplantation. Understanding the mechanisms of composite tissue allograft rejection is essential in working toward that goal. We herein review the current knowledge on acute rejection in reconstructive Transplantation and discuss findings in the light of novel immunosuppressive and immunomodulatory strategies.
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atypical acute rejection after Hand Transplantation
American Journal of Transplantation, 2008Co-Authors: Marco Lanzetta, Stefan Schneeberger, Vijay S. Gorantla, R P Van Riet, P Vereecken, C Van Holder, Sandrine Rorive, Myriam Remmelink, Le A MoineAbstract: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.
