Additionally, the individuals considered for transplantation present with varying mechanisms of initial injury, a range of prior surgical repairs, and different degrees GSI-IX of physical, emotional, and psychological recovery. Thus, imaging is individually tailored as a set protocol may fail to appropriately characterize each candidate’s medical and surgical past. The selection of imaging modalities was affected by several factors. First, since each of these patients were committing to life-long surveillance imaging, much consideration was lent to limiting radiation exposure as much as possible. Due to the impact of long-term immunotherapy on renal function, attempts were made to limit total contrast dose when possible, with a preference given for conventional angiography over CT angiography.

Another caveat with imaging selection was monetary, as all screening and subsequent imaging was provided for the patient. This partially accounted for the reliance on radiography and ultrasound over cross-sectional imaging with sinus radiographs and abdomen sonography (3�C7MHz) being used rather than CT during preoperative screening. Thus, imaging selection may vary between institutions depending on the investigational protocol in place. 4.1. Screening from a Musculoskeletal Point of View Presurgical imaging was specifically performed to characterize the structural integrity of the native bones and soft tissues by identifying the level of healthy tissue and describing existing structural damage to guide the surgical approach.

The goal of such imaging being to maximize the viability at the anastamotic site and the rehabilitation potential of the entire limb by ensuring adequate native soft tissues to support transplantation. Patients showing either arthropathy of the wrist or elbow were transplanted above the level of the diseased joint. Similarly, if the level of injury showed maceration of the distal residual tissues, with bone fragmentation or intra-articular fracture extension, transplantation would extend proximal to the level where muscle bulk and bone integrity were preserved. Thus, marked muscle atrophy of the proximal arm, significant rotator cuff or labral injury, and degenerative change of the shoulder were MRI findings that caused disqualification, as these features directly impacted the eventual functionality of the extremity that could not be bypassed surgically.

The limitation of preoperative GSK-3 assessment of the musculoskeletal system occurred in instances where the imaging findings did not correspond with the clinical performance of the patient. This was particularly evident in the instance of one individual with an unremarkable upper extremity MRI who failed consideration due to poor range-of-motion from extensive contractures not visible by imaging.