RESUMO
As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.
Assuntos
Transplante de Mão/métodos , Adulto , Aloenxertos , Anastomose Cirúrgica , Placas Ósseas , Cadáver , Desenho Assistido por Computador , Dissecação , Feminino , Mãos/irrigação sanguínea , Mãos/inervação , Humanos , OsteotomiaRESUMO
The field of vascularized composite allotransplantation has developed for more than a decade. Investigators are defining patient selection criteria, transplant indications, immunologic regimens, and tolerance. The majority of the current reported hand transplantations have been for treatment of distal forearm or hand amputations. In more proximal amputees, the functional outcome of the transplanted arm has some unique variables that require a different surgical approach. We present a single case of bilateral proximal forearm transplantation in effort to describe the unique technical considerations in this complex procedure. The surgical procedure is described in detail. At 19 months, our patient had 4/5 strength of finger and thumb flexors and protective extensor as well as 4/5 wrist flexors and extensors. Our patient had recovery of sensation. Our patient now lives independently and does her lower extremity prosthesis independently using her hands. These results are expected to continue to improve with more time. In hand transplantation, functional results have been very promising. The described approach of forearm transplantation allows the transfer of the entire functional unit, which should optimize the ultimate outcome for these more proximal injuries.
Assuntos
Braço/transplante , Alotransplante de Tecidos Compostos Vascularizados/métodos , Amputação Cirúrgica , Feminino , Humanos , Seleção de Pacientes , Recuperação de Função Fisiológica , Coleta de Tecidos e Órgãos/métodos , Resultado do TratamentoRESUMO
Mini suture anchors are commonly used in hand surgery involving attachment of soft tissue to bone. There are few data on the biomechanical behavior of these implants under physiologic conditions. Commercially available mini anchors were inserted into the carpal bones of fresh-frozen cadaver wrists. Anchors were divided into threaded and pronged types according to design. The anchors were cyclically loaded. Pronged anchors (1.3 and 2.1 mm) failed at a range of 199 to 5,155 cycles. Threaded anchors (2.5 and 2.8 mm) consistently completed 40,000 cycles without failure. Before failure pronged anchors displaced on average 5.1 mm and threaded anchors displaced on average 0.01 mm. The pronged implants failed because of either prong fatigue or fracture; the threaded anchors remained structurally intact. The larger threaded suture anchors seem to have superior biomechanical properties than smaller pronged anchors.