The Case for Lower Extremity Allotransplantation:

A World Update of Progress in Lower Extremity Transplantation: What's Hot and What's Not

ABSTRACT

The field of vascularized composite allotransplantation (VCA) is the new frontier of solid organ transplantation (SOT). VCA spans life-enhancing/life-changing procedures such as upper extremity, craniofacial (including eye), laryngeal, tracheal, abdominal wall, penis, and lower extremity transplants. VCAs such as uterus transplants are life giving unlike any other SOT. Of all VCAs that have shown successful intermediate- to long-term graft survival with functional and immunologic outcomes, lower extremity VCAs have remained largely underexplored. Lower extremity transplantation (LET) can offer patients with improved function compared to the use of conventional prostheses, reducing concerns of phantom limb pain and stump complications, and offer an option for eligible amputees that either fail prosthetic rehabilitation or do not adapt to prosthetics. Nevertheless, these benefits must be carefully weighed against the risks of VCA, which are not trivial, including the adverse effects of lifelong immunosuppression, extremely challenging perioperative care, and delayed nerve regeneration. There have been 5 lower extremity transplants to date, ranging from unilateral or bilateral to quadrimembral, progressively increasing in risk that resulted in fatalities in 3 of the 5 cases, emphasizing the inherent risks. The advantages of LET over prosthetics must be carefully weighed, demanding rigorous candidate selection for optimal outcomes.

Advancements in autologous peripheral nerve transplantation care: a review of strategies and practices to facilitate recovery

Autologous peripheral nerve transplantation, a pioneering technique in nerve injury treatment, has demonstrated remarkable progress. We examine recent nursing strategies and methodologies tailored to various anatomical sites, highlighting their role in postoperative recovery enhancement. Encompassing brachial plexus, upper limb, and lower limb nerve transplantation care, this discussion underscores the importance of personalized rehabilitation plans, interdisciplinary collaboration, and innovative approaches like nerve electrical stimulation and nerve growth factor therapy. Moreover, the exploration extends to effective complication management and prevention strategies, encompassing infection control and pain management. Ultimately, the review concludes by emphasizing the advances achieved in autologous peripheral nerve transplantation care, showcasing the potential to optimize postoperative recovery through tailored and advanced practices.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

Innovations in reconstructive microsurgery: Reconstructive transplantation

In the past 20 years, reconstructive transplantation (RT) has emerged as a viable reconstructive option for carefully selected patients. More than 100 upper extremity and 40 face transplants have been performed worldwide to date. Concomitantly, the portfolio of reconstructive transplantation has been extended by additional procedures such as lower extremities, abdominal wall, neck, uterus, genitourinary, and pediatric transplants. In the present review article, we aim to summarize the current state of knowledge about this exciting field.

Public's Knowledge and Attitudes Toward Vascularized Composite Allotransplantation and Donation

BACKGROUND

The purpose of this survey was to assess the public's knowledge and attitudes toward vascularized composite allotransplantation and donation.

METHODS

Members of the public (n = 5942) were surveyed using a questionnaire that examined their knowledge and attitudes concerning solid organs (kidney, heart, liver, lung, and pancreas) and vascularized composite tissue (hand/upper extremity, lower extremity, abdominal wall, and face) transplantations and donations.

RESULTS

Respondents demonstrated greater (all P < 0.05) knowledge and willingness to donate and/or receive solid organs than vascularized composite tissues. Educational level, accurate knowledge, willingness to donate, and willingness to receive were significant (all P < 0.05) determinants of acceptance to donate and/or receive hand/upper extremity, lower extremity, face, and/or abdominal wall.

CONCLUSION

The public presented less knowledge and willingness to donate and/or receive hand/upper extremity, lower extremity, abdominal wall, and face.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Primary Central Nervous System Posttransplant Lymphoproliferative Disease in a Bilateral Transfemoral Lower Extremity Transplantation Recipient

Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous group of clinical and pathological entities characterized by malignant lymphoid cell proliferation occurring after solid organ transplantation, with frequent extranodal involvement. Central nervous system (CNS) involvement occurs in 7-15% of the cases and it is a significant negative prognostic factor. A case of primary CNS (PCNS) PTLD in the first bilateral lower limb transplant recipient is presented.

Vascularized composite allotransplant in the realm of regenerative plastic surgery

Vascularized composite allotransplant (VCA) has led to new treatment options for patients with severe upper extremity and facial injuries. Although VCA can restore form and function, it exposes the patient to the risks associated with lifelong immunosuppression. Hopefully, ongoing advances in regenerative medicine will someday obviate the need for VCA, but until that time, VCA remains an immediate means of reconstructing otherwise unreconstructable defects. We review the outcomes of hand and face transplants, as well as the recent developments in immunosuppression as it relates to the field of VCA.