Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.
Elbow fracture-dislocations destabilize the elbow, preventing functional rehabilitation. If left untreated, they commonly result in functional compromise and poor outcomes. The "terrible triad" injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. Surgical treatment to restore stable elbow range of motion has evolved in the past few decades based on increased understanding of elbow biomechanics and the anatomy of these injuries. This article highlights current concepts in the treatment of these complicated injuries.
The purpose of this article is to share our institution's experience in optimizing the suitability of composite donor tissue for use in hand transplantation. The centerpiece of this process includes procurement techniques, preservation and timing issues, and anatomical matching. Recovery of the donor hand must proceed in an efficient, organized, and expedient manner. Proper timing of the donor operation not only ensures the quality of donor tissue and outcome for the hand recipient, but also allows surgeons recovering other organs to obtain high quality tissue for those recipients. Timing remains a critical factor in preserving tissue after removal from the donor. We will also consider the factors of temperature and preservation solution during transport.
BackgroundPenetrating injuries to the hand can compromise important anatomic structures, and persisting foreign objects may become a source of infection. Foreign body intrusions into the hand are among the most common injuries to the upper extremity seen in the Emergency Department. Radiolucent organic objects, as well as a few higher density inorganic materials such as plastic, present a diagnostic challenge and are routinely missed using standard radiography. While the literature describes the use of high-frequency ultrasound as an adjunct to conventional diagnostics, to our knowledge, no formal algorithm has been published.Case presentationWe describe a case of incomplete wooden splinter removal, presenting as a late midpalmar abscess five months after the initial injury, and requiring two subsequent surgical explorations for definitive treatment. This case has led us to implement a formal diagnostic pathway including high-frequency ultrasound at our institution. We contrast this presentation with a subsequent case involving a much smaller wooden palmar foreign body that was easily identified under ultrasound and removed without sequelae.ConclusionMany hand injuries are caused by low density, radiolucent foreign bodies. These objects can easily escape traditional evaluation in the emergency room including standard radiography. We present an algorithm implementing high frequency ultrasound to minimize the risk of missing radiolucent penetrating foreign objects in the hand.
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