Hand transplantation and vascularized composite tissue allografts in orthopaedics and traumatology

Vascularized Composite Allotransplantation of the Hand: A Systematic Review of Eligibility Criteria

BACKGROUND

Hand transplantation (HT) has emerged as an intervention of last resort for those who endured amputation or irreparable loss of upper extremity function. However, because of the considerable effort required for allograft management and the risks of lifelong immunosuppression, patient eligibility is critical to treatment success. Thus, the objective of this article is to investigate the reported eligibility criteria of HT centers globally.

METHODS

A systematic review of the HT literature was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, using PubMed, Cochrane, Ovid/Medline, and Scopus. Program Web sites and clinicaltrials.gov entries were included where available.

RESULTS

A total of 354 articles were reviewed, 101 of which met inclusion criteria. Furthermore, 10 patient-facing Web sites and 11 clinical trials were included. The most reported criteria related to the capacity to manage the allograft posttransplantation, including access to follow-up, insurance coverage, psychological stability, and history of medical compliance. Other factors related to the impact of immunosuppression, such as active pregnancy and patient immune status, were less emphasized.

CONCLUSIONS

Because of the novelty of the field, eligibility criteria continue to evolve. While there is consensus on certain eligibility factors, other criteria diverge between programs, and very few factors were considered absolute contraindications. As the popularity of the field continues to grow, we encourage the development of consensus evidence-based eligibility criteria.

Microvascular reconstructive techniques in orthopaedic traumatology

Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology.

Regulation of cell-based therapeutic products intended for human applications in the EU

AIMS

Recent developments in the field of cell-based therapeutic products (CBTPs) have forced the EU to revise its legislation on therapeutic products by enacting several new legal instruments. In this study, we investigate how CBTPs are regulated and what determines their regulatory classification. Furthermore, we compare the regulatory burden between CBTPs in different product categories.

MATERIALS & METHODS

Product categories covering CBTPs were identified and characteristics critical for the regulatory classification of a CBTP were determined in each category. The effect of the critical characteristics on the classification was evaluated by constructing a decision tree that covers all possible combinations of the critical characteristics. Differences in the regulatory burden between CBTPs were evaluated by comparing regulations crucial for placing a therapeutic product on the EU market between the product categories.

RESULTS

Regulation of CBTPs has been divided between the main product categories of the EU legal framework for therapeutic products on the basis of the characteristics of the cells that the CBTPs contain. The regulatory burden is lowest for CBTPs regulated as blood, cells or tissues, and highest for CBTPs regulated as medicinal products.

CONCLUSION

CBTPs exist in all product categories of the EU legal framework for therapeutic products. However, the current framework does not cover all possible CBTPs. Furthermore, our results indicate that the regulatory burden of a CBTP is related to the risk it may pose to the health and safety of recipients.