The utility of hand transplantation in hand amputee patients

Crowdsourcing Opinions and Awareness of Upper Extremity Transplantation in the United States

Introduction As of 2008, the United States had 41,000 people living with upper extremity amputation. This number is projected to reach 300,000 by 2050. Human upper extremity transplantation (HUET) may become a more common treatment option with the potential to significantly improve the quality of life for certain amputees. Awareness and opinions regarding HUET among Americans, particularly in Veterans/Service Members (VSM) affiliates, are largely unknown. Materials and methods We administered a survey on Amazon Mechanical Turk (MTurk) workers. Eligible participants were US citizens aged ≥18 years; MTurk worker selection targeted workers who self-reported being a VSM. We used descriptive statistics to summarize study findings and Fisher's exact and Wilcoxon's rank-sum tests for between-group comparisons. Results The survey was completed by 764 individuals, 604 (79.1%) of whom reported being aware of HUET. Among those familiar versus unfamiliar, a significantly higher proportion were aged ≤35 years (n=385, 64.0% vs. n=86, 53.7%; p=0.017), employed (n=523, 86.6% vs. n=114, 71.3%; p<0.001), and aware of their religion's stance on organ/tissue donation (n=341, 54.5% vs. n=62, 38.8%; p<0.001). Amputees and/or respondents related to an amputee were more likely to be aware of HUET than individuals who were amputation naive (n=211, 90.6% vs. n=393, 74.0%, respectively; p<0.001), as were individuals with a personal or familial military affiliation (n=286, 85.4% with vs. n=318, 74.1% with no affiliation; p<0.001). The most reported HUET information sources were digital media (n=157, 31.2%) and internet (n=137, 27.2%). Conclusions Our survey of MTurk workers found greater awareness of HUET among individuals with a VSM or amputee connection. Our additional findings that the internet and academic sources, such as journals or reputable medical publications, were respondents' preferred sources of HUET information emphasize the importance of vascularized composite allotransplantation (VCA) centers' involvement in creating accurate and accessible content to help educate the public about this treatment.

Health-related quality of life in patients with conditions affecting the hand: meta-analysis

BACKGROUND

Health state utility values provide the quality component of quality-adjusted life years and are essential for health economic analyses, such as the National Institute for Health and Care Excellence Technology Appraisal. The aims of this systematic review were to: catalogue utility values for health states experienced by patients with hand conditions; provide pooled utility estimates for common hand conditions; and determine how utilities have been estimated.

METHODS

A PRISMA-compliant systematic review and meta-analysis was conducted (registered in PROSPERO, the international prospective register of systematic reviews (CRD42021226098)). Five databases were searched from inception until April 2023 (Embase, MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL)). All studies that reported primary utility values for hand health states in adult patients were eligible for inclusion. Pooled utility estimates were determined across conditions and intervention status using random-effects meta-analysis.

RESULTS

A total of 10 254 articles were identified; 57 studies met the full inclusion criteria and reported 363 distinct health state utility values. Health state utility values were estimated using a range of methods; the most common measure was the EQ-5D. Pooled utility estimates for carpal tunnel syndrome and hand osteoarthritis before surgical intervention were 0.69 (95% c.i. 0.66 to 0.73) and 0.63 (95% c.i. 0.60 to 0.67) respectively.

CONCLUSION

Pooled utility estimates for patients with untreated carpal tunnel syndrome and hand osteoarthritis are 11% and 18% lower than age-matched population norms respectively. Hand conditions have a significant detrimental impact on health-related quality of life and this study provides catalogued utility values for use in future economic analyses to support the delivery of value-based hand surgery.

Education for patients with limb loss or absence: Aging, overuse concerns, and patient treatment knowledge gaps

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.

Special Considerations for Secondary Surgery After Upper Extremity Transplantation

BACKGROUND

Upper extremity (UE) transplantation is a complex undertaking that may require emergent or elective secondary surgery (SS) days to years following transplant. Various patient and transplantation may help determine what SS is needed. In this study, we characterize the SS needed by our UE transplant patients.

METHODS

We retrospectively reviewed 6 patients who underwent hand and UE transplantation by one of the authors. Transplantation and SS details were obtained from medical records. Hand and arm function was quantified both subjectively (patient-reports) and objectively (Disabilities of the Arm, Shoulder, and Hand Score; Carroll test; Action Research Arm Tests; Box and Block test).

RESULTS

Six patients underwent transplantation for a total of 10 transplanted limbs. Five transplants were performed below and 5 above the elbow. Mean time post-transplantation at last follow-up was 5 years (range: 1-9 years). In all, 66.7% of the patients required SS: total 7 surgeries comprising 13 procedures. The most common procedures were to improve hand function-nerve decompressions and tendon transfer, both in above-elbow transplant. Both patients showed a mean improvement of 15 points on Carroll scores. One above-elbow transplant had a brachioplasty for excess skin and another had a hematoma evacuation immediately after transplantation. Procedures in the below-elbow transplants included multiple incision and drainages for a septic wrist and an open reduction and internal fixation for a forearm fracture.

CONCLUSION

Patients receiving UE transplantation often require one or more secondary procedures which may vary with level of transplantation. Secondary surgery should be an important aspect of pretransplant planning and cost-effectiveness determinations.

LEVEL OF EVIDENCE

Level IV.

Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb

Twenty years have surpassed since the first vascularised composite allotransplantation (VCA) of the upper limb. This is an opportunity to reflect on the position of VCA as the gold standard in limb reconstruction. The paucity of recipients, tentative clinical outcomes, and insufficient scientific progress question whether VCA will remain a viable treatment option for the growing numbers of amputees. Bionic technology is advancing at a rapid pace. The prospect of widely available, affordable, safely applied prostheses with long-standing functional benefit is appealing. Progress in the field stems from the contributions made by engineering, electronic, computing and material science research groups. This review will address the ongoing reservations surrounding VCA whilst acknowledging the future impact of bionic technology as a realistic alternative for limb reconstruction.

Hand Transplants, Daily Functioning, and the Human Capacity for Limb Regeneration

Unlike some of our invertebrate and vertebrate cousins with the capacity to regenerate limbs after traumatic loss, humans do not have the ability to regrow arms or legs lost to injury or disease. For the millions of people worldwide who have lost a limb after birth, the primary route to regaining function and minimizing future complications is via rehabilitation, prosthetic devices, assistive aids, health system robustness, and social safety net structures. The majority of limbs lost are lower limbs (legs), with diabetes and vascular disorders being significant causal contributors. Upper limbs (arms) are lost primarily because of trauma; digits and hands are the most common levels of loss. Even if much of the arm remains intact, upper limb amputation significantly impacts function, largely due to the loss of the hand. Human hands are marvels of evolution and permit a dexterity that enables a wide variety of function not readily replaced by devices. It is not surprising, therefore, for some individuals, dissatisfaction with available prosthetic options coupled with remarkable advances in hand surgery techniques is resulting in patients undertaking the rigors of a hand transplantation. While not “regeneration” in the sense of the enviable ability with which Axolotls can replace a lost limb, hand transplants do require significant regeneration of tissues and nerves. Regaining sophisticated hand functions also depends on “reconnecting” the donated hand with the areas of the human brain responsible for the sensory and motor processing required for complex actions. Human hand transplants are not without controversy and raise interesting challenges regarding the human regenerative capacity and the status of transplants for enabling function. More investigation is needed to address medical and ethical questions prior to expansion of hand transplants to a wider patient population.

Applying Health Utility Outcome Measures and Quality-Adjusted Life-Years to Compare Hand Allotransplantation and Myoelectric Prostheses for Upper Extremity Amputations

BACKGROUND

An amputation of the upper extremity not only is devastating for the patient's physical, emotional, and social well-being but also constitutes a financial stress for both the patient and the health care system. The objective of this study was to determine the utility and quality-adjusted life-years of hand allotransplantation versus myoelectric prostheses and to compare these measures in patients afflicted with unilateral versus bilateral amputations.

METHODS

A survey was administered on bilateral amputees, unilateral amputees, replantation patients, and healthy controls. Patient demographics, functional patient-reported outcomes, quality-of-life questionnaires, and utility outcome measures were calculated for four different scenarios: hand transplantation and myoelectric prostheses with or without complications.

RESULTS

Five bilateral amputees, 12 unilateral amputees, nine replantation patients, and 45 healthy controls completed the survey. The highest quality-adjusted life-years were obtained in the replantation patient group for the scenario of myoelectric prosthesis without complications (mean, 34.8 years). Altogether, there was no statistically significant difference between hand transplantation and myoelectric prostheses (p = 0.36). On subgroup analysis, unilateral amputees reported significantly higher quality-adjusted life-years for myoelectric prostheses rather than hand transplantation (6.4; p = 0.0015), whereas bilateral amputees did not demonstrate a significant difference (-2.4; p = 0.299).

CONCLUSIONS

Utility and quality-adjusted life-years do not differ significantly between hand transplantation and myoelectric prostheses, except in unilateral amputees with myoelectric prostheses, who had higher quality-of-life scores. Based on trends from this pilot study, myoelectric prostheses may be considered for unilateral amputees, whereas no superiority can be demonstrated between both treatments in bilateral amputees.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Evaluating Treatment Preferences and Perceptions of a Prosthetic Versus a Transplanted Hand: A Conjoint Analysis-Based Study

INTRODUCTION

This study used a conjoint analysis-based survey to assess which factors are most influential when considering treatment with a prosthesis or transplant after a unilateral hand amputation.

METHODS

Overall, 469 respondents were recruited using Amazon Mechanical Turk and asked to assume that they experienced a hand amputation. To determine preferences for a prosthetic, respondents chose among 11 pairs of alternatives with variations in the following attributes: appearance, function, maintenance, and learning time. Respondents were then presented with descriptions of the risks and outcomes of hand transplantation. The most compelling reasons for and against a transplant were determined and characteristics predictive of support for a transplant were identified.

RESULTS

The most important attributes for a prosthesis were "lifelike appearance" and "myolectric function." For hand transplantation, respondents were most concerned about immunosuppression side effects (n = 323, 69%) and the intense nature of surgery (n = 275, 59%), whereas the most positive benefit was the concept of the transplant being "natural" (n = 339, 72%). When faced with the choice of a hand transplant or a prosthetic, approximately 50% of respondents chose a transplantation. Younger age, previous medical experiences, a perceived "familiarity with medical issues," and the regular attendance of religious services were associated with strong support for a hand transplantation (P < 0.01).

CONCLUSIONS

When considering a hand prosthesis, respondents are motivated most by appearance and function. Meanwhile, with hand transplantation, the risks of immunosuppression and the intense nature of surgery and recovery are predominant concerns. These findings may help inform patient-physician discussions when considering treatment after unilateral hand amputation.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS.

Methods

A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure.

Results

In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated.

Conclusions

The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

Comparison of health state utility measures and disabilities of arm, shoulder and hand questionnaire scores in bilateral hand amputees

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .

Pediatric Hand Transplantation: A Decision Analysis

Background: The first successful bilateral pediatric hand transplant was performed in 2015. Previous hand transplant decision analysis models have focused on the adult population. This model principally aimed to determine whether adverse outcomes associated with immunosuppression outweigh the benefits of performing bilateral hand transplant surgery in a pediatric candidate. The model also conceptualized the valuation of losing years of life and sought to determine the impact of that valuation on the surgical decision. Methods: A decision model compared undergoing bilateral hand transplant surgery with using prosthetics for an 8-year-old patient. The outcome measure used was quality adjusted life years (QALYs), and sensitivity analysis was performed on the immunosuppressive risks associated with the surgical decision, as well as the perceived valuation of aversion to life years lost. Results: The decision to perform surgery was marginally optimal compared to the prosthetic decision (50.11 QALY vs. 47.95 QALY). A Monte Carlo simulation revealed that this difference may be too marginal to detect an optimal decision (50.14 ± 8.28 QALY vs. 47.95 ± 2.12 QALY). Sensitivity analysis identified decision thresholds related to immunosuppression risks (P = 29% vs. P = 33% modeled), and a trend of increasing risk as a patient is more averse to losing life years. Conclusions: The marginally optimal treatment strategy currently is bilateral hand transplant, compared to prosthetics for pediatric patients. Key determinants of the future optimal strategy will be whether immunosuppressive regimens become safer, with a reduced risk of losing life years due to immunosuppressive complications, and whether prosthetics become more acceptable and enable higher functioning.

Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study

BACKGROUND

Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA.

METHODS

The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants.

RESULTS

Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation.

CONCLUSIONS

Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

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.

A health utility assessment of trapeziectomy with ligament reconstruction and tendon interposition for thumb trapeziometacarpal osteoarthritis

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal joint osteoarthritis may have both postoperative benefits and complications. This study sought to determine the health state utility outcome measures of trapeziectomy with LRTI. Patients who underwent trapeziectomy with LRTI were invited to complete the brief Michigan Hand Questionnaire and utility questionnaires outcomes using a visual analogue scale , time trade-off and standard gamble. Quality-adjusted life years (QALYs) were derived from these utility measures. For this study 32 patients were recruited, with a mean age of 61. Most patients (27/32) perceived the procedure as successful. Utility measures and QALYs serve the purpose of comparing different surgical procedures in terms of their impact on the quality of life of patients as a function of the benefits and complications of each procedure. In this study, the utility of trapeziectomy with LRTI was less than has been described for open palmar fasciectomy but more than for total wrist arthrodesis. Level of evidence: IV.

Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review

BACKGROUND

Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery.

METHODS

A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article.

RESULTS

The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments.

CONCLUSIONS

Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.

Hand Transplantation: Current Status and Immunologic Obstacles

Hand transplantation is the most common form of modern composite tissue allotransplantation, with 89 cases reported worldwide since 1998. The procedure is a treatment option for complex injuries that leave patients with structural, functional, and aesthetic deficits that cannot be addressed by other means. Successful application of this technology requires a multidisciplinary approach, incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and so on. Its long-term results depend on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection. Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation. Despite the enormous antigen load associated with composite tissue allografts, hand transplant has become a clinical reality, with immunosuppression comparable to that of solid-organ transplants. Our understanding of hand transplantation is still evolving, and ongoing research is needed to improve functional outcomes and to decrease the morbidity associated with long-term immunosuppression. This review discusses the current protocols for upper extremity donation, transplant receipt, surgical techniques, postoperative rehabilitation and immunosuppression, nerve regeneration, functional outcomes, ethical issues, and financial considerations.

Quality of Life and Health Utility Scores Among Canadians Living With Traumatic Spinal Cord Injury - A National Cross-Sectional Study

STUDY DESIGN

National, multicenter, cross-sectional study.

OBJECTIVE

The goal of this study was to provide overall quality of life (QOL) and health utility (HU) values for patients with traumatic spinal cord injury (SCI) stratified by injury level and neurological status.

SUMMARY OF BACKGROUND DATA

Traumatic SCI is a leading cause of disability. Varying injury level and severity generate a spectrum of neurological dysfunction and reduction in long-term QOL.

METHODS

The Canadian SCI Community Survey was sent to Canadians living in the community after SCI. The impact of demographics, complications, and SCI classification on QOL was assessed using Analysis of variance, multiple linear regressions and ordinal logistic regression analyses.

RESULTS

There were 1109 respondents with traumatic SCI. american spinal injury association impairment scale (AIS) grade was reported to be cervical motor complete in 20%, cervical motor incomplete in 28%, thoracolumbar motor complete in 32%, thoracolumbar motor incomplete in 16%, and normal (any level) in 1%. Injury level or AIS grade had no impact on either HU or QOL. The physical component of health-related quality of life (HRQOL) was significantly affected by the neurological level, but not the social or mental components. With a mean health utility score of 0.64 ± 0.12, SCI patients living in the community reported having HRQOL similar to patients after total knee arthroplasty or lumbar spinal stenosis decompression.

CONCLUSION

QOL or HU measured by generic HRQOL outcome tools should not be used as outcomes to assess the effectiveness of interventions targeting neurological function in traumatic SCI. A disease-specific instrument that captures the nuances specific to spinal cord injury patients is required.

LEVEL OF EVIDENCE

1.

A quiet revolution in organ transplant ethics

A quiet revolution is occurring in the field of transplantation. Traditionally, transplants have involved solid organs such as the kidney, heart and liver which are transplanted to prevent recipients from dying. Now transplants are being done of the face, hand, uterus, penis and larynx that aim at improving a recipient's quality of life. The shift away from saving lives to seeking to make them better requires a shift in the ethical thinking that has long formed the foundation of organ transplantation. The addition of new forms of transplants requires doctors, patients, regulators and the public to rethink the risk and benefit ratio represented by trade-offs between saving life, extending life and risking the loss of life to achieve improvements in the quality of life.

Sagittal craniosynostosis: a utility outcomes study

OBJECTIVE Sagittal craniosynostosis results in a characteristic scaphocephalic head shape that is typically corrected surgically during a child's 1st year of life. The authors' objective was to determine the potential impact of being born with sagittal craniosynostosis by using validated health state utility assessment measures. METHODS An online utility assessment was designed to generate health utility scores for scaphocephaly, monocular blindness, and binocular blindness using standardized utility assessment tools, namely the visual analog scale (VAS) and the standard gamble (SG) and time trade-off (TTO) tests. Utility scores were compared between health states using the Wilcoxon and Kruskal-Wallis tests. Univariate regression was performed using age, sex, income, and education as independent predictors of utility scores. RESULTS Over a 2-month enrollment period, 122 participants completed the online survey. One hundred eighteen participants were eligible for analysis. Participants rated scaphocephaly due to sagittal craniosynostosis with significantly higher (p < 0.001) median utility scores (VAS 0.85, IQR 0.76-0.95; SG 0.92, IQR 0.84-0.98; TTO 0.91, IQR 0.84-0.95) than both monocular blindness (VAS 0.60, IQR 0.50-0.70; SG 0.84, IQR 0.68-0.94; TTO 0.84, IQR 0.67-0.91) and binocular blindness (VAS 0.25, IQR 0.20-0.40; SG 0.51, IQR 0.18-0.79; TTO 0.55, IQR 0.36-0.76). No differences were noted in utility scores based on participant age, sex, income, or education. CONCLUSIONS Using objective health state utility scores, authors of the current study demonstrated that the preoperatively perceived burden of scaphocephaly in a child's 1st year of life is less than that of monocular blindness. These relatively high utility scores for scaphocephaly suggest that the burden of disease as perceived by the general population is low and should inform surgeons' discussions when offering morbid corrective surgery, particularly when driven by aesthetic concerns.

Pushing the Boundaries of Salvage in Mutilating Upper Limb Injuries: Techniques in Difficult Situations

With the available microsurgical techniques, salvage of the limb can almost always provide a useful upper limb, even in the most complex combined injuries. Having a low threshold for revascularization of doubtfully viable extremities and making full use of the current armamentarium of soft tissue cover techniques, including flow through free flaps, will salvage many limbs. Secondary procedures, including free functioning muscle transfers and toe transfers, further increase the possible functional outcome. Even in the most complex combined injuries, intelligent reconstruction will obtain better outcomes than the best available prosthesis, making the efforts of salvage worthwhile.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Regeneration and repair of human digits and limbs: fact and fiction

A variety of digit and limb repair and reconstruction methods have been used in different clinical settings, but regeneration remains an item on every plastic surgeon's "wish list." Although surgical salvage techniques are continually being improved, unreplantable digits and limbs are still abundant. We comprehensively review the structural and functional salvage methods in clinical practice, from the peeling injuries of small distal fingertips to multisegmented amputated limbs, and the developmental and tissue engineering approaches for regenerating human digits and limbs in the laboratory. Although surgical techniques have forged ahead, there are still situations in which digits and limbs are unreplantable. Advances in the field are delineated, and the regeneration processes of salamander limbs, lizard tails, and mouse digits and each component of tissue engineering approaches for digit- and limb-building are discussed. Although the current technology is promising, there are many challenges in human digit and limb regeneration. We hope this review inspires research on the critical gap between clinical and basic science, and leads to more sophisticated digit and limb loss rescue and regeneration innovations.