Quality of life considerations in upper limb transplantation: review and future directions

A Nationwide Analysis on Major Upper Extremity Amputations and Replantations

BACKGROUND

The loss of an upper extremity is a severely disabling condition made medically challenging by the limited window for replantation. This study aims to investigate the burden of traumatic major upper extremity amputations in the United States and uncover possibilities for improvements in treatment.

METHODS

The Healthcare Cost and Utilization Project's National Inpatient Sample was screened for International Classification of Diseases-9/10 diagnosis/procedure codes for traumatic and nontraumatic major upper extremity amputations and replantations within the years 2008 to 2017. The resulting pool of cases was analyzed for multiple variables, including level of injury, patient demographics, hospital type and location, length of stay, costs, comorbidities, and complications.

RESULTS

A total of 15 155 major upper extremity amputations were recorded, of which 15.20% (n = 2305) were traumatic amputations-almost half of them related to the upper arm (49.6%; P = .0002). The great majority of replantations, however, was conducted at the lower arm level (87.4%; P < .0001), with an overall replantation rate of 22.3%. Nontraumatic amputations were overall associated with significantly higher burden of comorbidities relative to traumatic amputations except for long-term alcohol use (P < .0001). Both, amputations and replantations, were predominantly treated in large urban teaching hospitals, and were significantly more likely to occur in white men. The Southern region of the United States was handling the highest proportion of amputations in the United States, but had the lowest likelihood of replantation.

CONCLUSION

This study provides an overview of the national trends in major traumatic upper extremity amputations and replantations, revealing potential health care shortcomings.

A Single-Center Retrospective Evaluation of Decision-Making and Factors Motivating Hand Transplant Candidates

INTRODUCTION

Advancements in vascularized composite allotransplantation have made hand transplants possible for persons living with upper limb loss. Hand transplantation is not a life-saving procedure, but rather a quality-of-life enhancing procedure; hence the risk of morbidity and mortality must be weighed against improvements in function and appearance. This study explored the decision-making process of patients evaluated for hand transplantation.

METHODS/APPROACH

A qualitative case series study using retrospective chart data of evaluations was conducted between January 1, 2011 and February 28, 2020. Notes were extracted and read by three reviewers. Each case was summarized noting similarities and differences.

FINDINGS

Nine patients underwent evaluation. Eight were no longer under evaluation and did not receive transplant; one was still undergoing evaluation. Patient motivations for evaluation were dissatisfaction with prostheses or self-image, chronic pain, performing activities of daily living, occupation, burden placed on caregivers, and concerns about overuse of non-affected limbs. Patients chose not to pursue transplantation due to rehabilitation time, immunosuppression, alternative treatments, and social and financial challenges. The clinical team discontinued evaluations due to unmet evaluation requirements, medical contraindications, or treatment alternatives. Different modes of shared decision-making were present depending on the party most heavily featured in the charts as driving decisions.

DISCUSSION

This was an examination of shared decision-making with hand transplant candidates who did not proceed to transplant. Reasons for choosing alternative strategies for management were multifactorial. Lessons learned regarding patient motivations and shared decision-making can inform future interventions to better support patients.

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

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.

Ex vivo normothermic preservation of amputated limbs with a hemoglobin-based oxygen carrier perfusate

BACKGROUND

Ex vivo normothermic limb perfusion (EVNLP) preserves amputated limbs under near-physiologic conditions. Perfusates containing red blood cells (RBCs) have shown to improve outcomes during ex vivo normothermic organ perfusion, when compared with acellular perfusates. To avoid limitations associated with the use of blood-based products, we evaluated the feasibility of EVNLP using a polymerized hemoglobin-based oxygen carrier-201 (HBOC-201).

METHODS

Twenty-four porcine forelimbs were procured from Yorkshire pigs. Six forelimbs underwent EVNLP with an HBOC-201-based perfusate, six with an RBC-based perfusate, and 12 served as static cold storage (SCS) controls. Ex vivo normothermic limb perfusion was terminated in the presence of systolic arterial pressure of 115 mm Hg or greater, fullness of compartments, or drop of tissue oxygen saturation by 20%. Limb contractility, weight change, compartment pressure, tissue oxygen saturation, oxygen uptake rates (OURs) were assessed. Perfusate fluid-dynamics, gases, electrolytes, metabolites, methemoglobin, creatine kinase, and myoglobin concentration were measured. Uniformity of skin perfusion was assessed with indocyanine green angiography and infrared thermography.

RESULTS

Warm ischemia time before EVNLP was 35.50 ± 8.62 minutes (HBOC-201), 30.17 ± 8.03 minutes (RBC) and 37.82 ± 10.45 (SCS) (p = 0.09). Ex vivo normothermic limb perfusion duration was 22.5 ± 1.7 hours (HBOC-201) and 28.2 ± 7.3 hours (RBC) (p = 0.04). Vascular flow (325 ± 25 mL·min-1 vs. 444.7 ± 50.6 mL·min-1; p = 0.39), OUR (2.0 ± 1.45 mL O2·min-1·g-1 vs. 1.3 ± 0.92 mL O2·min-1·g-1 of tissue; p = 0.80), lactate (14.66 ± 4.26 mmol·L-1 vs. 13.11 ± 6.68 mmol·L-1; p = 0.32), perfusate pH (7.53 ± 0.25 HBOC-201; 7.50 ± 0.23 RBC; p = 0.82), flexor (28.3 ± 22.0 vs. 27.5 ± 10.6; p = 0.99), and extensor (31.5 ± 22.9 vs. 28.8 ± 14.5; p = 0.82) compartment pressures, and weight changes (23.1 ± 3.0% vs. 13.2 ± 22.7; p = 0.07) were not significantly different between HBOC-201 and RBC groups, respectively. In HBOC-201 perfused limbs, methemoglobin levels increased, reaching 47.8 ± 12.1% at endpoint. Methemoglobin saturation did not affect OUR (ρ = -0.15, r2 = 0.022; p = 0.45). A significantly greater number of necrotic myocytes was found in the SCS group at endpoint (SCS, 127 ± 17 cells; HBOC-201, 72 ± 30 cells; RBC-based, 56 ± 40 cells; vs. p = 0.003).

CONCLUSION

HBOC-201- and RBC-based perfusates similarly support isolated limb physiology, metabolism, and function.

Hand Transplantation-Risks and Benefits

Composite tissue allotransplantation (CTA) is the culmination of progress in transplantation, allowing the reconstruction of the hand in amputees. Worldwide, more than 100 procedures have been performed. The aim of this work was to understand the hand allotransplantation approach, making known current aspects, risks, and benefits. A PubMed research was realized between October 2018 and March 2019, including terms like "Hand transplantation" AND "Composite tissue allotransplantation," "Hand transplantation" AND "Functional outcomes," "Hand transplantation" AND "Immunosuppression," "Hand prosthetics," "Hand Transplantation" AND "Ethics." There were included papers between 1995 and 2018, with English language, amputee human adults, systematic reviews, and clinical studies. Seventy-two papers were fully evaluated. There are technical aspects that influence the procedure like team coordination or surgical technique. It requires a long-life treatment, which has risks such as toxicity or infections. However, it allows the recovery of fine movements, and independence, to perform detailed tasks. The indications must be carefully considered, because some patients benefit from the use of prosthesis. CTA has become an option for amputees so it is important to do more research, to determine the benefits of this procedure. It is not considered a life-saving procedure, so there is an ethical debate because of the risks.

Does pediatric hand transplantation undermine a child's right to an open future?

To date, pediatric hand transplantations have only been performed twice. The ethical issue most often discussed in the literature on this surgery concerns the risks of immunosuppression. While these risks are significant, they can be at least partially mitigated by selecting for patients who are already immunocompromised. Nevertheless, as we will argue, pediatric hand transplantation raises ethical issues that go beyond the risks of immunosuppression. In this paper, we focus on three additional ethical issues: the fact that pediatric hand transplantation aims to improve, rather than save life; the fact that it is an experimental surgery; and the fact that it will be performed on non-autonomous patients whose 'right to an open future' may potentially be undermined by the surgery. Taken together, we think that these considerations suggest that transplantation should be postponed until a child is mature enough to make their own decision about it.

Uterus transplantation: joys and frustrations of becoming a ‘complete’ woman—a qualitative study regarding self-image in the 5-year period after transplantation

STUDY QUESTION

How is a women’s self-image affected by uterus transplantation (UTx)?

SUMMARY ANSWER

Women experienced receiving a uterus in both positive and negative ways, but in general, their self-image was positively affected; regardless of whether they have given birth to a child or not, recipients describe themselves as being ‘back to normal’ after the hysterectomy to remove the transplanted uterus.

WHAT IS KNOWN ALREADY

UTx has repeatedly proved to be a successful treatment for absolute uterine factor infertility. However, there has been no previous qualitative long-term research into the self-image of women undergoing UTx.

STUDY DESIGN, SIZE, DURATION

This complete, prospective cohort study included the nine recipients of the first UTxs performed in Sweden mostly in 2013. Interviews took place in the 5 years following surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Eight out of the nine recipients had congenital absence of the uterus, a characteristic of Mayer–Rokitansky–Küster–Hauser syndrome, and one recipient lacked a uterus after a radical hysterectomy due to cervical cancer. The mean age of participants was 31.5 years at inclusion and at this time they all lived in stable marital relationships. Post-transplantation, interviews were performed annually for 5 years, comprising a total of 43 interviews. The interview followed a semi-structured guide. All interviews (median duration of around 25 minutes) were recorded, transcribed verbatim and then analysed by thematic approach.

MAIN RESULTS AND THE ROLE OF CHANCE

The joys and frustrations of becoming a ‘complete’ woman are seen as a master theme, which influences the three underlying subthemes, a changed self-perception, a changed body and a changed sexuality. Each of these subthemes have three underlying categories.

LIMITATIONS, REASONS FOR CAUTION

The small sample size is a limitation.

WIDER IMPLICATIONS OF THE FINDINGS

The results provide information that will be helpful in pre-operative screening procedures and in the psychological support offered both to women who experienced successful and unsuccessful outcomes following UTx.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Jane and Dan Olsson Foundation for Science; the Knut and Alice Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; the Swedish Research Council; a Ferring Pharmaceuticals scholarship in memory of Robert Edwards; and the Iris Jonzén-Sandblom and Greta Jonzén Foundation. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

NCT01844362.

All hands on deck: Hand replantation versus transplantation

Objectives:

Our hands play a remarkable role in our activities of daily living and the make-up of our identities. In the United States, an estimated 41,000 individuals live with upper limb loss. Our expanding experience in limb transplantation—including operative techniques, rehabilitation, and expected outcomes—has often been based on our past experience with replantation. Here, we undertake a systematic review of replantation with transplantation in an attempt to better understand the determinants of outcome for each and to provide a summary of the data to this point.

Methods:

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted PubMed searches from 1964 to 2013 for articles in English. In total, 53 primary and secondary source articles were found to involve surgical repair (either replantation or transplantation) for complete amputations at the wrist and forearm levels. All were read and analyzed.

Results:

Hand replantations and transplantations were compared with respect to pre-operative considerations, surgical techniques, post-operative considerations and outcomes, including motor, sensation, cosmesis, patient satisfaction/quality of life, adverse events/side effects, financial costs, and overall function. While comparison of data is limited by heterogeneity, these data support our belief that good outcomes depend on patient expectations and commitment.

Conclusion:

When possible, hand replantation remains the primary option after acute amputation. However, when replantation fails or is not possible, hand transplantation appears to provide at least equal outcomes. Patient commitment, realistic expectations, and physician competence must coincide to achieve the best possible outcomes for both hand replantation and transplantation.

Attitudes of Hand Surgeons and Hand Reconstruction Patients Toward Hand Allotransplantation in Taiwan

BACKGROUND

Recent advances in immunosuppressive protocols have increasingly made hand allotransplantation a realistic reconstructive option with more than 100 cases performed worldwide. While attitudes toward allotransplantation have been assessed for North American surgeons and patients alike, similar assessments have previously remained unconducted in Asia in general and Taiwan in specific. This study examines the perceptions of both Taiwanese hand surgeons and hand reconstruction patients.

METHODS

An email-based survey was sent to all active members of the Taiwanese Society for Surgery of the Hand. Surgeon training backgrounds and practice profiles were gathered as well as current beliefs on indications, risks, ethicality, priority of psychosocial issues, and obstacles to implementation. Patients receiving rehabilitation at Chang Gung Memorial Hospital Linkou after severe upper extremity injuries were invited to complete a patient survey. Demographics, injury characteristics, understanding of allotransplantation and immunosuppression, willingness to donate, and willingness to receive transplantation were assessed.

RESULTS

Forty-four hand surgeons responded (24.3% response rate). The majority (61.4%) considered hand allotransplantation to be a high-risk operation, although 40% supported the development of hand allotransplantation under current techniques and immunosuppression. Bilateral hands loss was the most commonly accepted indication for transplant (90.9%), whereas dominant hand loss was less frequently accepted (43.2%). Treatment compliance and functional outcomes were the most frequent psychosocial issues of concern regarding patient counseling. Patient respondents were mostly in the fifth decade of life (29.5%) with at least a high school education (75.0%). Most were aware of the feasibility of hand transplantation (68.2%). Patients were more likely than surgeons to consider nondominant hand, multiple-digit, and thumb-only amputations as indications for transplantation. Functional outcomes and financial considerations were the most frequent patient concerns.

CONCLUSIONS

This study indicates there is support for hand allotransplantation as a solution for limb loss in both hand surgeons and hand patients in Taiwan. This study adds to the lack of knowledge regarding surgeon and patient attitudes toward allotransplantation in Asia, although further work is required to assess the willingness of broader Taiwanese medical to refer candidates and for the general population to donate.

The functional assessment and rehabilitation programme of the UK hand and upper limb transplant service

Introduction

Hand and upper limb transplants are becoming internationally recognised as an effective treatment to improve function and quality of life in carefully selected patients. A comprehensive functional assessment and rehabilitation programme are an essential component of the multi-disciplinary assessment and treatment approach. Although there is an increasing body of published data on the surgical techniques and outcomes following hand transplant, little exists in the literature to guide the hand therapist.

Method

The pre-transplant functional assessments and rehabilitation programme provided for patients undergoing hand transplantation in the UK are described and critically analysed. The UK programme is based on that provided in Lyon, France, but adapted to suit the resources and structure of the UK National Health Service.

Results

Twelve patients have received a functional assessment as part of the multi-disciplinary hand transplant assessment process, with the loss of autonomy a key reason for patients seeking hand transplant. Six of these patients have received hand transplants, with patients more than one year post-transplant having achieved good and fair outcomes according to the Hand Transplantation Score System.

Conclusions

Although hand and upper limb transplant surgery is innovative, the therapy provided is based on the fundamental principles of good communication, accurate assessment and delivery of a bespoke rehabilitation programme; values which are common to all areas of hand therapy practice. A future study reporting the long-term outcomes of patients following hand transplant in the UK is needed to allow the effectiveness of the programme to be evaluated.

Narrative methods for assessing "quality of life" in hand transplantation: five case studies with bioethical commentary

Despite having paved the way for face, womb and penis transplants, hand transplantation today remains a small hybrid of reconstructive microsurgery and transplant immunology. An exceptionally limited patient population internationally (N < 200) complicates medical researchers' efforts to parse outcomes "objectively." Presumed functional and psychosocial benefits of gaining a transplant hand must be weighed in both patient decisions and bioethical discussions against the difficulty of adhering to post-transplant medications, the physical demands of hand transplant recovery on the patient, and the serious long-term health risks of immunosuppressant drugs. This paper relates five narratives of hand transplantation drawn from an oral history project to show how narrative methods can and should inform ethical evaluations and the clinical process of hand transplantation. The interviews with patients and their partners analyzed here lead us to suggest that qualitative accounts of patient experiences should be used to complement clinical case studies reported in medical journals and to help develop instruments to assess outcomes more systematically.

Myoelectric Signal Classification of Targeted Muscles Using Dictionary Learning

Surface electromyography (sEMG) signals comprise electrophysiological information related to muscle activity. As this signal is easy to record, it is utilized to control several myoelectric prostheses devices. Several studies have been conducted to process sEMG signals more efficiently. However, research on optimal algorithms and electrode placements for the processing of sEMG signals is still inconclusive. In addition, very few studies have focused on minimizing the number of electrodes. In this study, we investigated the most effective method for myoelectric signal classification with a small number of electrodes. A total of 23 subjects participated in the study, and the sEMG data of 14 different hand movements of the subjects were acquired from targeted muscles and untargeted muscles. Furthermore, the study compared the classification accuracy of the sEMG data using discriminative feature-oriented dictionary learning (DFDL) and other conventional classifiers. DFDL demonstrated the highest classification accuracy among the classifiers, and its higher quality performance became more apparent as the number of channels decreased. The targeted method was superior to the untargeted method, particularly when classifying sEMG signals with DFDL. Therefore, it was concluded that the combination of the targeted method and the DFDL algorithm could classify myoelectric signals more effectively with a minimal number of channels.

Case-study of a user-driven prosthetic arm design: bionic hand versus customized body-powered technology in a highly demanding work environment

BACKGROUND

Prosthetic arm research predominantly focuses on "bionic" but not body-powered arms. However, any research orientation along user needs requires sufficiently precise workplace specifications and sufficiently hard testing. Forensic medicine is a demanding environment, also physically, also for non-disabled people, on several dimensions (e.g., distances, weights, size, temperature, time).

METHODS

As unilateral below elbow amputee user, the first author is in a unique position to provide direct comparison of a "bionic" myoelectric iLimb Revolution (Touch Bionics) and a customized body-powered arm which contains a number of new developments initiated or developed by the user: (1) quick lock steel wrist unit; (2) cable mount modification; (3) cast shape modeled shoulder anchor; (4) suspension with a soft double layer liner (Ohio Willowwood) and tube gauze (Molnlycke) combination. The iLimb is mounted on an epoxy socket; a lanyard fixed liner (Ohio Willowwood) contains magnetic electrodes (Liberating Technologies). An on the job usage of five years was supplemented with dedicated and focused intensive two-week use tests at work for both systems.

RESULTS

The side-by-side comparison showed that the customized body-powered arm provides reliable, comfortable, effective, powerful as well as subtle service with minimal maintenance; most notably, grip reliability, grip force regulation, grip performance, center of balance, component wear down, sweat/temperature independence and skin state are good whereas the iLimb system exhibited a number of relevant serious constraints.

CONCLUSIONS

Research and development of functional prostheses may want to focus on body-powered technology as it already performs on manually demanding and heavy jobs whereas eliminating myoelectric technology's constraints seems out of reach. Relevant testing could be developed to help expediting this. This is relevant as Swiss disability insurance specifically supports prostheses that enable actual work integration. Myoelectric and cosmetic arm improvement may benefit from a less forgiving focus on perfecting anthropomorphic appearance.

The First Hand Allotransplantation in Taiwan: A Report at 9 Months

PURPOSE

Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan.

MATERIALS AND METHODS

On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support.

RESULTS

The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient.

CONCLUSIONS

Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

Surgical, ethical, and psychosocial considerations in human head transplantation

Transplanting a head and brain is perhaps the final frontier of organ transplantation. The goal of body-to-head transplantation (BHT) is to sustain the life of individuals who suffer from terminal disease, but whose head and brain are healthy. Ideally BHT could provide a lifesaving treatment for several conditions where none currently exists. BHT is no ordinary experiment, to transfer a head to another body involves extraordinarily complex medical challenges as well as ethical and existential dilemmas that were previously confined to the imagination of writers of fiction. The possibility of replacing an incurably ill body with a healthy one tests not only our surgical limits, but also the social and psychological boundaries of physical life and alters what we recognize life to be. The purpose of this target article, the complementary manuscript focused on immunological issues in BHT, and the accompanying Commentaries by scholars and practitioners in medicine, immunology, and bioethics is to review major surgical and psychosocial-ethical and immunological considerations surrounding body-to-head transplantation. We hope that together these ideas will provide readers with a comprehensive overview of the possibilities and challenges associated with BHT and initiate professional discussion and debate through which this new frontier in medicine is considered and approached.

Hips, Knees, and Hernia Mesh: When Does Gender Matter in Surgery?

This paper draws attention to gendered dimensions of surgical device failure, focusing on two case studies—hernia repair mesh for pelvic organ prolapse, and metal-on-metal hip implants. We explore possible reasons for higher rates of harms to women, including systematic biases in health research and device regulation. Given that these factors are readily identifiable, we look to feminist scholarship to understand what might maintain them, including the role of cultural factors within surgery, such as gendered communication patterns and sexism. We then canvas potential measures to mitigate the increased risk of harms faced by women who use implanted devices.

Psychosocial Evaluation for First Hand Allotransplantation in Taiwan

Hand transplantation has raised ethical and psychological concerns. Few studies have focused on reasons for not selecting candidates on waiting lists. To describe the psychosocial evaluation of referred prospective hand transplant candidates, we investigated candidate suitability by using 22-month follow-up data regarding the first hand transplant recipient in Taiwan. Pretransplant psychosocial assessments comprised an interview with 2 psychiatrists, a social worker, and a psychologist, followed by intelligence quotient scoring with the Wechsler Adult Intelligence Scale and Taiwanese Depression Questionnaire. After team member consensus, of the 20 patients referred to our team to confirm their hand transplantation suitability during April 26, 2013, to March 19, 2015, 7 potential recipients were placed on the waiting list after completing all prehand transplant evaluations. On September 3, 2014, the left distal forearm and hand of a brain-dead man was transplanted to a 45-year-old man who had undergone traumatic amputation of the distal third of his right forearm 30 years previously. During a 22-month follow-up, he complied with scheduled visits, including routine posttransplant laboratory tests, skin biopsies, and intensive physical therapy. Moreover, he overcame repeated graft rejections, bacterial and viral infections, immunosuppressant side effects, considerable economic stress, and the difficulties associated with the adhesion of hand tendons. Finally, he regained some satisfactory function of the transplanted hand. Considering posttransplantation difficulties, suitable candidates for hand transplantation should have persistent motivation, appropriate expectations, patience, immediate availability, fair intelligence, fair social functioning, and adequate economic and familial support.

Outcomes after bilateral hand allotransplantation: a risk/benefit ratio analysis

BACKGROUND

The clinic era of composite tissue allotransplantation was inaugurated by hand allotransplantation in 1998, giving rise to many controversies and scepticism because of the lifelong immunosuppression, the unclear risk-benefit ratio, and the uncertain long-term functional results of the procedure. The aim of this study was to evaluate the outcomes and the risk/benefit balance in bilateral hand allotransplantation.

METHODS

The study included 5 cases of bilateral hand allotransplantation performed in a single center, with a follow-up ranging from 3 to 13 years. The recipients (4 men, 1 woman) were young. The level of amputation was distal in all cases except for 2 patients amputated at the midforearm level. All the recipients initially received the same immunosuppressive treatment that included tacrolimus, mycophenolate mofetil, prednisone, and, for induction, antithymocyte globulins.

RESULTS

Patient and graft survival was 100%. All recipients showed adequate sensorimotor recovery (protective and tactile sensitivity and partial recovery of intrinsic muscles), they were able to perform the majority of activities of daily living, and had a normal social life. Most complications occurred in the first posttransplant year and were successfully managed. All recipients experienced at least 1 episode of acute rejection, which was easily reversed by increasing oral steroid dose or by intravenous steroids, except for patient 3, who presented 6 episodes of acute rejection, the latest 2 treated with Campath-1H.

CONCLUSIONS

Although bilateral hand transplantation may be a satisfactory treatment option for amputees, a careful selection of candidates and a rigorous evaluation of recipients after transplantation are imperative.

Changing attitudes toward hand allotransplantation among North American hand surgeons

OBJECTIVES

Although more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons' opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons.

METHODS

An email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure's associated ethical and financial implications.

RESULTS

A total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation.

CONCLUSIONS

Our study's results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today's immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.

A new hand enhances life for quadruple amputee: A single case study

This single case study discusses the various challenges and rehabilitation of Australia’s first hand transplant from the hand therapy perspective. The recipient was a 65-year-old quadrimembral amputee male following overwhelming pneumococcal sepsis. Key issues included cognitive relearning following the four-year loss of cortical feedback, extrinsic muscle retraining, poor coordination and functional limitations as a result of intrinsic dennervation, and an insensate hand. Distinct clinical differences from total hand replantation included consideration of immunosuppression drugs and potential rejection episodes. Although the patient was highly motivated, a client-centred approach was critical for ongoing commitment to the intensive long-term rehabilitation programme. The recipient’s progress in the first two and a half years has been impressive with achievement of many personal goals including eating, drinking, writing, driving and lawn bowls. His results, recorded on the International Hand Transplant Registry, showed superior measurements in areas of the DASH, grip strength, and TAM of forearm, wrist, and fingers.

Perceptions of the risks and benefits of upper limb transplantation among individuals with upper limb amputations

BACKGROUND

Upper limb transplantation is a life-enhancing rather than life-saving procedure. Little research has investigated how individuals with upper limb amputations perceive the benefits and risks of this complex procedure. To address this knowledge gap, the authors conducted qualitative research with individuals with upper limb amputations to understand their perspectives.

METHODS

Twenty-two individuals with upper limb amputations (age range, 24 to 73 years) participated in a focus group (n=5) or semistructured interview (n=17) about the benefits and risks of upper limb transplantation. Data were analyzed by means of constant comparative methods and a two-phase analysis process.

RESULTS

Participants identified enhanced functional performance and improved appearance as the greatest potential benefits. Over half of participants indicated that function was a more important consideration than appearance. Enhanced function performance was a relative concept strongly influenced by individual expectations, which varied widely. Increased sensation, psychological well-being, and social acceptability were also described as potential benefits. Identified risks included health risks and the demands of transplantation and recovery, decreased functional performance, and uncertainty over outcomes from upper limb transplantation as an experimental procedure. Participants also expressed concerns regarding the psychological impact of negative outcomes and adverse events.

CONCLUSIONS

Participants had a large variation in their perceived importance of the many risks and benefits of upper limb transplantation. These findings elucidate how potential upper limb transplantation candidates evaluate the benefits and risks of the procedure. The findings can also inform important issues to address and outcomes to assess in the pretransplant and posttransplant settings.

Upper extremity transplantation: current concepts and challenges in an emerging field

Loss of an isolated upper limb is an emotionally and physically devastating event that results in significant impairment. Patients who lose both upper extremities experience profound disability that affects nearly every aspect of their lives. While prosthetics and surgery can eventually provide the single limb amputee with a suitable assisting hand, limited utility, minimal haptic feedback, weight, and discomfort are persistent problems with these techniques that contribute to high rates of prosthetic rejection. Moreover, despite ongoing advances in prosthetic technology, bilateral amputees continue to experience high levels of dependency, disability, and distress. Hand and upper extremity transplantation holds several advantages over prosthetic rehabilitation. The missing limb is replaced with one of similar skin color and size. Sensibility, voluntary motor control, and proprioception are restored to a greater degree, and afford better dexterity and function than prosthetics. The main shortcomings of transplantation include the hazards of immunosuppression, the complications of rejection and its treatment, and high cost. Hand and upper limb transplantation represents the most commonly performed surgery in the growing field of Vascularized Composite Allotransplantation (VCA). As upper limb transplantation and VCA have become more widespread, several important challenges and controversies have emerged. These include: refining indications for transplantation, optimizing immunosuppression, establishing reliable criteria for monitoring, diagnosing, and treating rejection, and standardizing outcome measures. This article will summarize the historical background of hand transplantation and review the current literature and concepts surrounding it.

Can we regrow a human arm? A negative perspective from an upper-limb surgeon

If we would like to devote time and money to the task of regrowing a human arm, we should feel free to do it, in principle. However, if we recognize a purpose in biomedical research, we must scrutinize this task in the light of a possible clinical application. We will then discover that regrowing a human arm is not only likely to be not possible, but also not required in the clinic. Bionic arms and better reconstructive surgery already provide a different, simpler and easier solution to the loss of a human arm, and should be promoted. Probably, ‘‘can we regrow a human arm?’’ is not the right question. Instead, we should ask, ‘‘can we restore the function of a lost human arm?’’.

Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges

BACKGROUND

In vascularized composite allotransplantation, multiple types of tissue are transferred from donor to recipient as a single functional unit. This technique has been performed for upper extremity, face, and abdominal wall transplants, among many others.

OBJECTIVE

To review the existing cases of face and upper extremity vascularized composite allotransplantation performed to date and to describe the functional outcomes and challenges associated with this new procedure. We also review the immune suppression protocols required for these procedures.

METHODS

A literature review was performed using PubMed and online registries where available to identify patients who have undergone upper extremity and face transplant procedures. These were compiled and cross-referenced to abstracts, conference presentations, and press releases in the media to create a list of procedures performed to date.

RESULTS

More than seventy patients have undergone upper extremity transplantation with very good functional outcomes routinely achieved. Twenty-five face transplants were identified that have been completed to date and details regarding patient outcome are included. One cases of human face allotransplantation with pre- and post-operative images is included as an example of what can be achieved with this technique.

CONCLUSIONS

Vascularized composite allotransplantation is an emerging field that provides an exciting new avenue for reconstructive procedures and achieves functional and cosmetic outcomes not previously possible with existing techniques. However, it is not without its challenges and considerable work is still required prior to widespread adoption of these new reconstructive techniques.