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Cendales LC, Farris AB, Rosales I, Elder D, Gamboa-Dominguez A, Gelb B, Issa F, Ravindra K, Nankivell BJ, Talbot S, Xu XG, Moris D, Drachenberg CB, Kanitakis J, Selim MA. Banff 2022 Vascularized Composite Allotransplantation Meeting Report: Diagnostic criteria for vascular changes. Am J Transplant 2024; 24:716-723. [PMID: 38286355 DOI: 10.1016/j.ajt.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024]
Abstract
As more data become available, the Banff 2007 working classification of skin-containing vascularized composite allograft (VCA) pathology is expected to evolve and develop. This report represents the Banff VCA Working Group's consensus on the first revision of the 2007 scoring system. Prior to the 2022 Banff-CanXadian Society of Transplantation Joint Meeting, 83 clinicians and/or researchers were invited to a virtual meeting to discuss whether the 2007 Banff VCA system called for a revision. Unanimously, it was determined that the vascular changes were to be included in the first revision. Subsequently, 2 international online surveys, each followed by virtual discussions, were launched. The goals were (1) to identify which changes define severe rejection, (2) to grade their importance in the evaluation of severe rejection, and (3) to identify emerging criteria to diagnose rejection. A final hybrid (in-person and virtual) discussion at the Banff/Canadian Society of Transplantation Joint Meeting finalized the terminology, the definition, a scoring system, and a reporting system of the vascular changes. This proposal represents an international consensus on this topic and establishes the first revision of the Banff 2007 working classification of skin-containing vascularized composite allograft pathology.
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Affiliation(s)
- Linda C Cendales
- Department of Surgery, Duke University, Durham, North Carolina, USA.
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Ivy Rosales
- Department of Pathology, Immunopathology Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Armando Gamboa-Dominguez
- Departamento de Patología. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Bruce Gelb
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Fadi Issa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | | | - Simon Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaowei G Xu
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Cinthia B Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jean Kanitakis
- Department of Dermatology, Ed. Herriot Hospital, Lyon, and Dept. of Pathology, Lyon Sud Hospital Center, Pierre Bénite, France
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Noel OF, Dumbrava MG, Daoud D, Kammien AJ, Kauke-Navarro M, Pomahac B, Colen D. Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome. Ann Plast Surg 2024; 92:100-105. [PMID: 37962243 DOI: 10.1097/sap.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT In the past decade, vascularized composite allotransplantation (VCA) has become clinical reality for reconstruction after face and hand trauma. It offers patients the unique opportunity to regain form and function in a way that had only been achieved with traditional reconstruction or with the use of prostheses. On the other hand, prostheses for facial and hand reconstruction have continued to evolve over the years and, in many cases, represent the primary option for patients after hand and face trauma. We compared the cost, associated complications, and long-term outcomes of VCA with prostheses for reconstruction of the face and hand/upper extremity. Ultimately, VCA and prostheses represent 2 different reconstructive options with distinct benefit profiles and associated limitations and should ideally not be perceived as competing choices. Our work adds a valuable component to the general framework guiding the decision to offer VCA or prostheses for reconstruction after face and upper extremity trauma.
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Affiliation(s)
- Olivier F Noel
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | | | - Deborah Daoud
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alexander J Kammien
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Martin Kauke-Navarro
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Bohdan Pomahac
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - David Colen
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
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3
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Toyoda Y, Levin LS. What is needed to ensure long-term sustainability for the field of vascularized composite allotransplantation? Curr Opin Organ Transplant 2023; 28:446-451. [PMID: 37767962 DOI: 10.1097/mot.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
The field of vascularized composite allotransplantation (VCA) has demonstrated remarkable advances since its inception with some excellent long-term results in a variety of graft types. However, unlike solid organ transplantation, it has yet to become mainstream. We therefore discuss strategies on ensuring long-term sustainability by addressing continued clinical developments of VCA to improve the risk-to-benefit balance, importance of public support, improved policy and financial support, and need for a bridge to the future of transplant surgery. There has been headway on all fronts and collaboration among the VCA centers for centralization of data and incorporation of patient voices will be essential for continued progress.
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Affiliation(s)
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Downey MC, Gacki-Smith J, Kuramitsu B, Vanterpool KB, Nordstrom M, Luken M, Langlee W, Riggleman T, Fichter S, Altema W, Jensen SE, Dumanian GA, Cooney CM, Levan ML, Tintle S, Brandacher G, Gordon EJ. Patient definitions of transplant success in upper extremity vascularized composite allotransplantation: A mixed-methods study. SAGE Open Med 2023; 11:20503121231184677. [PMID: 37465724 PMCID: PMC10350745 DOI: 10.1177/20503121231184677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Objective Upper extremity vascularized composite allotransplantation is an innovative treatment option for people with upper extremity amputations. Limited patient-relevant long-term outcomes data about transplant success may impede patients' informed treatment decision-making. We assessed perceptions of what constitutes upper extremity vascularized composite allotransplantation success among individuals with upper extremity amputations. Methods This multisite study entailed interviews and focus groups with individuals with upper extremity amputations and upper extremity vascularized composite allotransplantation candidates, participants, and recipients. We examined perceptions of transplant success and preferences for five upper extremity vascularized composite allotransplantation outcomes. Qualitative data were analyzed using thematic analysis; and quantitative data were analyzed using descriptive statistics. Results In all, 50 individuals participated in interviews (61.7% participation rate), and 37 participated in nine focus groups (75.5% participation rate). Most were White (72%, 73%), had a mean age of 45 and 48 years, and had a unilateral amputation (84%, 59%), respectively. Participants conceptualized upper extremity vascularized composite allotransplantation success as transplant outcomes: (1) restoring function and sensation to enable new activities; (2) accepting the transplanted limb into one's identity and appearance; (3) not having transplant rejection; (4) attaining greater quality of life compared to prosthetics; and (5) ensuring benefits outweigh risks. Participants rated their most important upper extremity vascularized composite allotransplantation outcomes as follows: not having transplant rejection, not developing health complications, grasping objects, feeling touch and temperature, and accepting the upper extremity vascularized composite allotransplantation into your identity. Conclusion Individuals with upper extremity amputations maintain several conceptions of vascularized composite allotransplantation success, spanning functional, psychosocial, clinical, and quality of life outcomes. Providers should address patients' conceptions of success to improve informed consent discussions and outcomes reporting for upper extremity vascularized composite allotransplantation.
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Affiliation(s)
- Max C Downey
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brianna Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen B Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Michelle Luken
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Whitney Langlee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tiffany Riggleman
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Shannon Fichter
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Withney Altema
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Sally E Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Scott Tintle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Guo J, Qin C, Li X, Zhuang X. The Flow Cytometric Analysis of Peripheral Blood Lymphocytes and Expression of HLA II Molecules in Lymphocyte During Acute Rejection After Renal Transplantation. J Inflamm Res 2023; 16:2607-2613. [PMID: 37360623 PMCID: PMC10289173 DOI: 10.2147/jir.s410341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
Objective To investigate the changes in the proportion of peripheral blood lymphocytes and the expression of HLA II molecules in lymphocytes during acute rejection after renal transplantation. Methods Thirty-five patients who had undergone renal transplantation were selected. Eighteen patients with clinical and pathological confirmed acute rejection were selected as the test group, and twelve patients without clinical acute rejection symptoms were selected as the control group. Flow cytometry analysis was used to determine the proportion of peripheral blood lymphocytes. The mRNA and protein expression of HLA II molecules on peripheral blood lymphocytes were detected using real-time fluorescence quantification and immunoblotting, respectively. Results The proportion of T lymphocytes, B lymphocytes, and CD4CD8 double positive T cells in the Control Group were 67.48% ± 5.35%, 10.82% ± 1.26%, and 0.88% ± 0.06%, respectively, and in the Test Group were 87.52% ± 6.28%, 3.36% ± 0.26%, and 0.34% ± 0.03%, with a significant difference respectively. The mRNA and protein expressions of HLA II molecules of peripheral blood B lymphocytes in the control group were significantly higher that these in the test group. Conclusion The proportion of peripheral blood T lymphocytes, B lymphocytes, CD4CD8 double positive T cells, and the expression of HLA II molecules of peripheral blood lymphocytes can all indicate the occurrence of acute renal transplantation rejection, which were exceedingly useful to clinicians in judging the acute rejection of renal transplantation in the early stages.
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Affiliation(s)
- Jianzhuang Guo
- Department of Clinical Laboratory, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, Shandong, People’s Republic of China
| | - Chengwei Qin
- Department of Anesthesiology, Shandong Second Provincial General Hospital, Jinan, Shandong, People’s Republic of China
| | - Xiangdong Li
- Department of Clinical Laboratory, The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, Shandong, People’s Republic of China
| | - Xiaoxuan Zhuang
- International Medical College of Chongqing Medical University, Chongqing, People’s Republic of China
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Zhang L, Hoyos IA, Zubler C, Rieben R, Constantinescu M, Olariu R. Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review. Front Immunol 2023; 14:1179195. [PMID: 37275912 PMCID: PMC10235447 DOI: 10.3389/fimmu.2023.1179195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Background Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic. Methods We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail. Results Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months. Conclusion Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.
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Affiliation(s)
- Lei Zhang
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Reconstructive Surgery, Plastic and Reconstructive Surgery Center, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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7
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Kumnig M, Jowsey-Gregoire SG, Gordon EJ, Werner-Felmayer G. Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantation: A scoping review and viewpoint of recent developments and clinical experiences in the field of vascularized composite allotransplantation. Front Psychol 2022; 13:1045144. [PMID: 36591015 PMCID: PMC9800026 DOI: 10.3389/fpsyg.2022.1045144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Vascularized Composite Allotransplantation (VCA) has evolved in recent years, encompassing hand, face, uterus, penile, and lower extremity transplantation. Accordingly, without centralized oversight by United States Organ Procurement and Transplantation Network (OPTN) or European Programs, centers have developed their own practices and procedures that likely vary, and accordingly, present different levels of rigor to the evaluation process, internationally. The importance of psychosocial factors in the selection process and treatment course has been widely recognized, and therefore, several approaches have been developed to standardize and guide care of VCA candidates and recipients. We propose to develop an international multidisciplinary platform for the exchange of expertise that includes clinical, patient, and research perspectives. Patient perspectives would derive from peer education and the assessment of patient-reported outcomes. To establish a foundation for such a platform, future research should review and combine current VCA protocols, to develop the ethical framework for a standardized psychosocial evaluation and follow-up of VCA candidates and recipients. This review presents a comprehensive overview of recent results in the field of VCA, developments in structural aspects of VCA, and provides viewpoints driven from clinical experience.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria,*Correspondence: Martin Kumnig,
| | - Sheila G. Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, Mayo Graduate School of Medicine, Rochester, MN, United States
| | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gabriele Werner-Felmayer
- Institute of Biological Chemistry and Bioethics Network Ethucation, Medical University of Innsbruck, Innsbruck, Austria
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Kumnig M, Järvholm S. Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant. Curr Opin Organ Transplant 2022; 27:501-507. [PMID: 36227757 DOI: 10.1097/mot.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Currently, several research approaches warrant further attention, given the influence of psychosocial and bioethical issues on the success of upper extremity (UETx), face (FTx), and uterine transplantation (UTx). This review will highlight recent results of psychosocial and bioethical research in the field of vascularized composite allotransplantation (VCA), discuss most recent findings, provide information to guide future research approaches, and address the importance of a multicenter research approach to develop international standards. RECENT FINDINGS Previously published reports have tried to identify psychosocial factors that are essential to predict psychosocial outcomes and guide posttransplant treatment after VCA procedures. These issues in VCA are receiving more attention but we are still at the beginning of a systematic investigation of these domains. This review article summarizes the emerging psychosocial issues in UeTx, FTx, and UTx by including recent literature and current clinical practice. SUMMARY Even though different VCA procedures address different domains leading to specific psychosocial issues, common aspects impacting all forms of VCA would benefit of further coordination. These domains include clinical resources, public attitude and perception, bioethical considerations, adherence and rehabilitation, motives for VCA, information needs and multidisciplinary communication, body image, domains of quality of life, coping strategies, and follow-up care.
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Affiliation(s)
- Martin Kumnig
- Medical University of Innsbruck, Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Innsbruck, Austria
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
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Finnie D, Griffin JM, Kennedy CC, Schaepe K, Boehmer K, Hargraves I, Amer H, Jowsey-Gregoire S. Education for patients with limb loss or absence: Aging, overuse concerns, and patient treatment knowledge gaps. Front Psychol 2022; 13:953113. [PMID: 36237690 PMCID: PMC9552948 DOI: 10.3389/fpsyg.2022.953113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
The goals of vascular composite allotransplantation (VCA) for hand are to maximize functional status and psychosocial wellbeing and to improve quality of life. Candidates are carefully vetted by transplant programs through an extensive evaluation process to exclude those patients with contraindications and to select those that are most likely to attain functional or quality of life benefit from transplant. Patient choice for any treatment, however, requires that candidates be able to understand the risks, benefits, and alternatives before choosing to proceed. This study aimed to understand patients’ knowledge and perceptions about treatment options for hand loss, including hand transplant. This study will be used to inform a standardized education approach and develop conversation aids for use by clinicians and patients throughout the treatment decision process. Ten individuals who had experienced hand amputation or had congenital limb loss were interviewed to better understand previous and current decisions about treatment, experiences in adjusting to their treatment, and perceptions about hand VCA. From this qualitative interview data, four findings emerged: (1) knowledge and education around VCA as a treatment option; (2) adaptation of individuals with limb loss; (3) fear of risk associated with transplantation; (4) issues of aging and overuse injuries to existing limbs. Results suggests that there is opportunity for expanding education about all treatment options for patients with new loss, long-term loss, and congenital limb loss. Establishing a baseline of knowledge about all options–prosthetics, rehabilitative strategies, and VCA—can help patients evaluate their values and goals of treatment. Issues associated with aging, including overuse and injury, and adaptability over the life course should be included in considerations about treatment choices. Data indicate the need for routinely assessing patient preferences about treatment choice so patients can plan for their future as they adapt and age and as technology for treatments change. To assure that thorough information is provided for current and future decision-making, education about treatment choices and selection procedures for VCA should be standardized.
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Affiliation(s)
- Dawn Finnie
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Dawn Finnie,
| | - Joan M. Griffin
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | | | - Karen Schaepe
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Ian Hargraves
- Knowledge Encounter Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Hatem Amer
- Transplant Center, Mayo Clinic, Rochester, MN, United States
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th 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.
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Clinical and preclinical tolerance protocols for vascularized composite allograft transplantation. Arch Plast Surg 2021; 48:703-713. [PMID: 34818720 PMCID: PMC8627932 DOI: 10.5999/aps.2021.00927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/06/2021] [Indexed: 12/01/2022] Open
Abstract
The field of vascularized composite allografts (VCAs) has undergone significant advancement in recent decades, and VCAs are increasingly common and accepted in the clinical setting, bringing hope of functional recovery to patients with debilitating injuries. A major obstacle facing the widespread application of VCAs is the side effect profile associated with the current immunosuppressive regimen, which can cause a wide array of complications such as infection, malignancy, and even death. Significant concerns remain regarding whether the treatment outweighs the risk. The potential solution to this dilemma would be achieving VCA tolerance, which would allow recipients to receive allografts without significant immunosuppression and its sequelae. Promising tolerance protocols are being studied in kidney transplantation; four major trials have attempted to withdraw immunosuppressive treatment with various successes. The common theme in all four trials is the use of radiation treatment and donor cell transplantation. The knowledge gained from these trials can provide valuable insight into the development of a VCA tolerance protocol. Despite similarities, VCAs present additional barriers compared to kidney allografts regarding tolerance induction. VCA donors are likely to be deceased, which limits the time for significant pre-conditioning. VCA donors are also more likely to be human leukocyte antigen–mismatched, which means that tolerance must be induced across major immunological barriers. This review also explores adjunct therapies studied in large animal models that could be the missing element in establishing a safe and stable tolerance induction method.
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