Screened patients with severe shoulder arthropathy were not accepted, contributing to the disqualification of one person. Individuals with distal arthropathy were considered for transplantation above the level of the involved joint. Figure 1 (a) Radiograph of selected candidate selleck kinase inhibitor shows osseous integrity of the amputation site and no significant arthropathy of the proximal joint. (b) Radiograph showing diffuse osteopenia and proximal arthropathy of a patient who failed screening. Despite multiple prior surgeries and the various causes of extremity loss, all of the individuals accepted for transplant maintained sufficient healthy bone to permit transplantation at the level of the mid forearm or mid-humerus. One of the five had degenerative disease of the wrist, prompting the decision to extend the level of the transplant to include that joint.
None of the chosen individuals showed any evidence of underlying systemic disease per abdominal ultrasound or maxillofacial radiography. MRI was utilized on four people only to further characterize suspected pathology. One individual underwent MRI for bilateral upper extremity cellulites to exclude osteomyelitis and was accepted for transplantation following antibiotic treatment (Figure 2(a)). Another person failed screening when found to have marked muscle atrophy of the residual limb, indicating underlying irreversible denervation injury (Figure 2(b)). A third individual with a history of femoral head avascular necrosis underwent bilateral arthroplasty prior to transplant consideration.
The fourth MRI demonstrated preserved muscle bulk despite limited upper extremity functionality secondary to contractures. Figure 2 (a) Axial IR MRI without contrast of the extremity shows circumferential edema and skin thickening consistent with cellulites. This patient underwent antibiotic therapy prior to transplantation. (b) Corresponding radiograph showing extensive soft tissue … 3.2. Vascular Presurgical Planning These patients also underwent presurgical conventional angiography or CT angiography. All of the 5 individuals chosen for transplantation showed relative preservation of normal vascular anatomy approximating the residual limb with retained patency of at least one major vessel (ulnar and/or radial) to serve as the anastomotic vascular pedicle.
Angiographic findings that precluded patients from consideration were instances where there was diminished arterial supply or venous drainage to the remaining limb resulting either secondary to the initial injury AV-951 or to the subsequent surgeries (Figure 3(a)). One individual with significantly abnormal arterial examinations underwent separate venography. Absence of dominant venous return from the remaining limb was considered an absolute contraindication for transplant candidacy and resulted in disqualification of this individual (Figure 3(b)).