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

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.