Objective To minimize maintenance immunosuppression in upper-extremity transplantation to favor the risk-benefit balance of this procedure. Background Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the risks and side effects of multidrug immunosuppression. We present our experience with upper-extremity transplantation under a novel, donor bone marrow (BM) cell-based treatment protocol (“Pittsburgh protocol”). Methods Between March 2009 and September 2010, 5 patients received a bilateral hand (n = 2), a bilateral hand/forearm (n = 1), or a unilateral (n = 2) hand transplant. Patients were treated with alemtuzumab and methylprednisolone for induction, followed by tacrolimus monotherapy. On day 14, patients received an infusion of donor BM cells isolated from 9 vertebral bodies. Comprehensive follow-up included functional evaluation, imaging, and immunomonitoring. Results All patients are maintained on tacrolimus monotherapy with trough levels ranging between 4 and 12 ng/mL. Skin rejections were infrequent and reversible. Patients demonstrated sustained improvements in motor function and sensory return correlating with time after transplantation and level of amputation. Side effects included transient increase in serum creatinine, hyperglycemia managed with oral hypoglycemics, minor wound infection, and hyperuricemia but no infections. Immunomonitoring revealed transient moderate levels of donor-specific antibodies, adequate immunocompetence, and no peripheral blood chimerism. Imaging demonstrated patent vessels with only mild luminal narrowing/occlusion in 1 case. Protocol skin biopsies showed absent or minimal perivascular cellular infiltrates. Conclusions Our data suggest that this BM cell-based treatment protocol is safe, is well tolerated, and allows upper-extremity transplantation using low-dose tacrolimus monotherapy.

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Transection of the transverse carpal ligament (TCL) for carpal tunnel syndrome is commonly performed, yet actual knowledge of TCL morphology is rudimentary and the anatomical terminology is inconsistently used. The purpose of this study was to perform a morphological analysis of the TCL, to redefine the anatomical terminology concerning the TCL and surrounding structures, and to evaluate any correlation between external, measurable hand dimensions, and TCL dimensions. A silicone casting technique and digitization were employed to measure the morphology of the TCL in cadaveric specimens and to construct a three-dimensional TCL model. The TCL was the thickest distally at the midline and ulnar segments and the thickest proximally at the radial segment. External hand dimensions did not significantly correlate with TCL dimensions. The TCL thickness distribution is variable along the radioulnar axis. The thickness of the TCL was 2.1±0.8 mm, ranging from 1.3 to 3.0 mm.

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