Vascularized Composite Hand Allograft Procurement and Preparation for Distal and Proximal Forearm Allotransplantation: A Stepwise Approach

Summary

Here, we present a protocol for procuring and preparing vascularized composite hand allografts during distal or proximal forearm transplantation.

Abstract

Upper limb amputations represent a real medical and surgical challenge. The ideal treatment should restore function, sensation, and body image. At present, neither traditional reconstructions nor prostheses meet all these criteria. However, vascularized composite allografts offer a unique option for restoring form and function satisfactorily despite harmful immunosuppression.

Ideally, donor tissue is procured in excess to repair without tension. The donor upper limb is procured through a fish-mouth incision at the mid-arm level. Then, the brachial artery and vein, median, ulnar, and radial nerve are located and dissected. The biceps, brachioradialis, and triceps muscles are sectioned, and then an osteotomy of the humerus is performed above the elbow. For distal forearm transplantation, the donor upper limb can also be procured below the elbow by disarticulating through the joint.

The brachial artery is cannulated, and the graft is irrigated with a preservative solution. Preparation of the graft then begins with two incisions, anterior and posterior, to raise two lateral skin flaps. A medial skin flap exposes the basilic vein, medial antebrachial cutaneous nerve, medial epicondylar muscles, ulnar nerve, median nerve, brachial artery, and vein. A lateral skin flap, including the cephalic vein, the lateral antebrachial cutaneous nerve, the radial nerve up to its division, the brachioradialis, and the lateral epicondylar muscles, completes graft preparation. In the case of transplantation, cutting guides are attached to the posterior surface of the two forearm bones to perform the osteotomies.

This protocol presents a systematized procedure for procuring and preparing a vascularized forearm composite allograft to ensure optimal results and minimize tissue damage during procurement.

Introduction

Since the first successful hand transplantation by Dubernard in 1998¹, the medical community has done a lot of research and has made progress on upper extremity vascularized composite allotransplantation (VCA). The main advantage is that VCA provides a unique option to restore form and function compared to traditional prosthetics or reconstructions^2,3. Hand VCA is one of the best examples of VCA, comprising many diverse tissues: skin, neurovascular, bone, cartilage, and muscle⁴. To this date, there have been more upper extremity transplants than any other kind of....

Protocol

The Anatomy Laboratory of the Faculty of Medicine of Nice, France, generously provided the specimens and material used for the study. The French National Ethics Committee approved this study (approval number 83.2024), which was conducted following the Helsinki Declaration.

1. Preoperative care

1. On a selected deceased organ donor, position the patient supine with the arm abducted on a hand table.
2. Apply a tourniquet over the upper donor arm, as proximal as possible.
3. Prepare and drape the limb with a pierced sterile drape rolled up distal to the tourniquet.
4. Inflate the tourniquet at 100....

Results

At the end of this protocol, the donor limb should be ready for transplantation on the receiving residual limb. The radius and ulna are sufficiently exposed for the osteosynthesis with a 3.5-mm locking compression plate^14,15,16 or 2.7-mm volar locking distal radius and ulna plates in distal forearm transplant. The brachial or radial and ulnar arteries are dissected depending on the level, allowin.......

Discussion

This protocol presents some critical steps. First, the skin flap incisions are marked. The goal is to properly match the flaps to ensure sufficient tissue to close over the bulky tendon anastomoses without skin surplus, which can lead to bulky skin adaptation. Furthermore, distal tip perfusion of the flaps should be ensured. To help in this surgical planning, three-dimensional (3D) stereophotogrammetry and 3D-printed skin incision guides can be useful, as Hummelink et al.²³ described. The rad.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
11.5” medium premium surgiclip II auto suture vessel clip applier	Covidien
2-0 silk suture	N/A	N/A
Adson forceps	MPM	106-2112A
Bipolar coagulation forceps	Olsen	20-1320I
Custodiol HTK solution for limb perfusion	Essential Pharmaceuticals Inc.		off-label use
Cysto/Bladder irrigation set	Baxter Healthcare Corp.	2C4040
Disposable scalpel #15	Sklar
DLP 3 mm vessel cannula blunt tip	Medtronic Inc	https://www.medline.com/product/Medtronic-DLP-Vessel-Cannulae/Cannulas-Tubing/Z05-PF24250?question=vessel%20cannula
Fine needle cautery	Cormedica
Forceps dilators	WPI	15910
IV stopcock	N/A	N/A
Micro scissors	WPI	504492
Monopolar diathermy	Medtronic Inc	Valleylab
Oscillating saw	GPC Medical	https://www.gpcmedical.com/1015/BTD1138/battery-operated-oscillating-saw.html
Saline solution 0,9%	GenDepot	S0600-101
Sterile Esmarch bandage	N/A	N/A
Sterile indelible ink markers	N/A	N/A
Strabismus scissors	Surtex	102-4109
Surgical marking pen	Cardinal health	212PR
Sutures Ethilon 4.0	Ethicon	1667G
Syringue 10 mL	Agilent	9301-6474
Three sterile procurement plastic bags, and three sterile zip ties	N/A	N/A
Tissue forceps	MPM	106-0511
Vessel loop	Deroyal	30-711