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.

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The results have been evaluated of 29 patients who had wrist denervation for chronic wrist pain between 1979 and 1987. Follow-up ranged from 22 to 86 months (mean 51 months). 17 patients had denervation without a concurrent procedure. Of these, 12% became pain-free and 71% had pain with all activities or had additional surgery; 24% said they were satisfied with their treatment. The results were worse in those who had partial denervation than those who had total denervation. 12 patients had denervation performed concurrently with another pain-relieving procedure. Denervation alone was not reliable in resolving chronic wrist pain.