Hand transplantation: current challenges and future prospects

Noor Alolabi,1 Haley Augustine,1 Achilles Thoma1–3 1Division of Plastic Surgery, Department of Surgery, 2Surgical Outcomes Research Centre, 3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada Abstract: Over the last two decades, 113 vascularized composite allotransplantation (VCA) of the hand have been performed in 76 patients globally. The procedure that was once regarded as experimental has certainly emerged as a clinical reality with multiple centers worldwide now performing it. The psychological and physical impact of losing an upper extremity is profound. Amputees face significant challenges contributing to disability and dependence even with activities of daily living. Hand transplantation offers functions with restoring sensation, voluntary motor control, and proprioception, as well as a sense of feeling “whole” again. Along with these benefits, however, transplantation carries a significant risk profile attributed to the complications of life-long immunosuppression and possible rejection. Moreover, the procedure carries a significant financial burden to the health care system. As hand VCA is becoming more widely accepted and performed worldwide, there are still many challenges that will face its rapid growth. This review highlights some of the challenges facing hand VCA including patient selection, effect on quality of life, financial burden, functional outcomes, and complications of immunosuppression. Keywords: hand transplantation, vascularized composite allotransplantatio

Complex elbow Instability: treatment and rehabilitation

Complex elbow instability represent a challenging injury even for expert elbow surgeons. Chronic instability, posttraumatic osteo-arthritis, stiffness and poor functional outcomes are frequent if these injuries are not adequately treated. A correct preoperative evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability tests under fluoroscopy in order to recognize all osseous and ligamentous lesions. The most common patterns of complex elbow instability includes: (1) radial head fractures associated with lateral and medial collateral ligaments lesions; (2) coronoid fractures and lateral collateral ligament lesion; (3) Terrible Triad; (4) fracture-dislocations of the proximal ulna and radius, also referred to as transolecranon fracture-dislocations and Monteggia-like lesions; and (5) humeral shear fractures associated with lateral and medial collateral ligament lesions. The main goals of the treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow throught the repair of soft tissue constraint lesions and (3) to allow early motion. All the patterns of complex elbow instability share the same therapeutic algorithm based on seven main principles: 1) the proximal ulna must be anatomically reduced and fixed; 2) the radial head or humeral shear fracture must be repaired or replaced, 3) bone length, alignment and rotation of ulnar and radial shaft fractures must be recovered; 4) the lateral collateral ligament complex must be repaired to obtain elbow stability; 5) the medial collateral ligament must be repaired if persistent instability is observed after lateral collateral ligament repair; 6) an hinged external fixator must be considered if the elbow remains unstable or the protection of the joint reconstruction is required; 7) re-evaluation of the surgical steps if congruent ulno-humeral and radio-humeral joints have not been achieved. Following the surgical treatment an adequate rehabilitation programme should be started promptly and continued for at least 6 months since a significant improvement of the range of motion occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow