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Tyner CE, Slotkin J, Kisala PA, Levin LS, Tintle SM, Tulsky DS. Assessment of quality of life after upper extremity transplantation: Framework for patient-reported outcome scale domains. Front Psychol 2023; 13:989593. [PMID: 36760917 PMCID: PMC9902934 DOI: 10.3389/fpsyg.2022.989593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/31/2022] [Indexed: 01/26/2023] Open
Abstract
Upper extremity transplantation offers the promise of restored function and regained quality of life (QOL) for individuals who have sustained hand or arm amputation. However, a major challenge for this procedure becoming an accessible treatment option for patients is the lack of standard measures to document benefits to QOL. Patient-reported outcomes (PRO) measures are well-suited for this kind of intervention, where the perspective of the patient is central to defining treatment success. To date, qualitative work with experts, clinicians, and patients has been used to identify the most important domains of QOL for PRO item development. Specifically, our group's qualitative work has identified several domains of QOL that are unique to individuals who have received upper extremity transplants, which are distinct from topics covered by existing PRO measures. These include emotional and social aspects of upper extremity transplant, such as Expectations and Perceived Outcomes, Integration and Assimilation of Transplant, Fitting in, and Post-Surgical Challenges and Complications. The broad topic of Satisfaction with Transplant was subdivided into three subtopics: Function, Sensation, and Aesthetics. Satisfaction with Sensation was also identified as a unique domain not evaluated by existing PRO measures. This report operationalizes these eight QOL domains by presenting scoping definitions. This manuscript describes the work that has been completed for domain characterization as an early step toward developing standardized PRO measures to evaluate these important outcomes specific to upper extremity transplantation.
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Affiliation(s)
- Callie E. Tyner
- Center for Health Assessment Research and Translation, University of Delaware, Newark, DE, United States,*Correspondence: Callie E. Tyner,
| | - Jerry Slotkin
- Center for Health Assessment Research and Translation, University of Delaware, Newark, DE, United States
| | - Pamela A. Kisala
- Center for Health Assessment Research and Translation, University of Delaware, Newark, DE, United States
| | - L. Scott Levin
- Department of Orthopedic Surgery, Penn Medicine, Philadelphia, PA, United States,Department of Surgery, Division of Plastic Surgery, Penn Medicine, Philadelphia, PA, United States
| | - Scott M. Tintle
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David S. Tulsky
- Center for Health Assessment Research and Translation, University of Delaware, Newark, DE, United States,Department of Physical Therapy, University of Delaware, Newark, DE, United States,Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, United States
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Efanov J, Tchiloemba B, Izadpanah A, Harris P, Danino M. A review of utilities and costs of treating upper extremity amputations with vascularized composite allotransplantation versus myoelectric prostheses in Canada. JPRAS Open 2022; 32:150-160. [PMID: 35402680 PMCID: PMC8989691 DOI: 10.1016/j.jpra.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- J.I. Efanov
- Corresponding author at: Plastic and Reconstructive Surgeon, Centre Hospitalier de l'Université de Montréal, 1051 Rue Sanguinet, Montréal, QC H2 × 3E4, Canada.
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Mendenhall SD, Brown S, Ben-Amotz O, Neumeister MW, Levin LS. Building a Hand and Upper Extremity Transplantation Program: Lessons Learned From the First 20 Years of Vascularized Composite Allotransplantation. Hand (N Y) 2020; 15:224-233. [PMID: 30060684 PMCID: PMC7076606 DOI: 10.1177/1558944718790579] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Upper extremity transplantation is a quality-of-life enhancing treatment for select patients with upper extremity loss. This article reviews the preoperative, intraoperative, and postoperative challenges in the upper extremity transplantation process and the lessons learned from the first 2 decades of hand transplantation. Methods: Key components of the author's hand transplantation protocol including patient selection, donor screening, surgical rehearsal, donor procurement, transplantation, immunosuppression, and patient outcome reporting/follow-up are reported to assist other teams who wish to establish a hand transplantation program. Results: There have been many advancements in the first 20 years of hand transplantation including better patient selection criteria, the recent addition of pediatric patients, improved surgical techniques such as the use of virtual surgical planning, and improved immunosuppression protocols. Improvement has also taken place in the tracking and reporting of hand transplant outcomes, but more work is clearly needed to fully define the benefits of transplantation, especially for pediatric patients. Conclusions: Over the past 20 years, significant progress has been made in upper extremity transplantation although a number of challenges remain including how to best document and share outcome measures, optimize immunosuppression, and diagnose/treat rejection. The authors encourage upper extremity transplant programs to report their experience and protocols to advance hand transplantation as standard of care for properly selected individuals.
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Affiliation(s)
- Shaun D. Mendenhall
- University of Utah School of Medicine, Salt Lake City, USA,Shaun D. Mendenhall, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT 84132, USA.
| | | | - Oded Ben-Amotz
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | | | - L. Scott Levin
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
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Park SH, Eun SC, Kwon ST. Hand Transplantation: Current Status and Immunologic Obstacles. EXP CLIN TRANSPLANT 2019; 17:97-104. [PMID: 30719955 DOI: 10.6002/ect.2018.0163] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Seong Hyuk Park
- From the Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea
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Honeyman C, Fries CA. Vascularised Composite Allotransplantation – Basic Science and Clinical Applications. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Changing attitudes toward hand allotransplantation among North American hand surgeons. Ann Plast Surg 2014; 72 Suppl 1:S56-60. [PMID: 24740026 DOI: 10.1097/sap.0000000000000147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Elliott RM, Tintle SM, Levin LS. Upper extremity transplantation: current concepts and challenges in an emerging field. Curr Rev Musculoskelet Med 2014; 7:83-8. [PMID: 24241894 PMCID: PMC4094126 DOI: 10.1007/s12178-013-9191-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- River M. Elliott
- />The Curtis National Hand Center, 3333 North Calvert Street, Baltimore, MD 21209 USA
| | - Scott M. Tintle
- />Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, America Building, 19 2nd Floor, Bethesda, MD 20889-5600 USA
| | - L. Scott Levin
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104 USA
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Evolution and trends in reconstructive facial surgery: an update. J Maxillofac Oral Surg 2013; 11:466-72. [PMID: 24293942 DOI: 10.1007/s12663-012-0363-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/01/2012] [Indexed: 10/28/2022] Open
Abstract
Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.
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Cavadas PC, Thione A, Carballeira A, Blanes M. Bilateral transfemoral lower extremity transplantation: result at 1 year. Am J Transplant 2013; 13:1343-9. [PMID: 23433015 DOI: 10.1111/ajt.12178] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/27/2012] [Accepted: 12/28/2012] [Indexed: 01/25/2023]
Abstract
Upper limb transplantation has become a treatment option for upper limb amputees with good midterm results. Lower extremity transplantation has never been considered for fear of poor results. The authors present a bilateral transfemoral transplantation of lower extremities performed to a 22-year patient at 12 months of follow-up. The donor was a full HLA-mismatched female multiorgan donor. CMV status was D-/R-. A primary CMV infection coincident with an acute rejection occurred at 3 months and responded to treatment. At 1 year, the Tinel's sign is at malleolar level, there is active knee extension and active plantar flexion of the foot. The patient is walking between parallel bars. Further substantial improvements are expected with longer rehabilitation and follow-up.
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Affiliation(s)
- P C Cavadas
- Clinica Cavadas, Reconstructive Surgery Unit, Universitary Hospital La Fe, Valencia, Spain
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Pomahac B, Becker YT, Cendales L, Ildstad ST, Li X, Schneeberger S, Siemionow M, Thomson AW, Zheng XX, Tullius SG. Vascularized composite allotransplantation research: the emerging field. Am J Transplant 2012; 12:1062-3. [PMID: 22225551 DOI: 10.1111/j.1600-6143.2011.03900.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Pomahac B, Diaz-Siso J, Bueno E. Evolution of indications for facial transplantation. J Plast Reconstr Aesthet Surg 2011; 64:1410-6. [DOI: 10.1016/j.bjps.2011.06.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 06/16/2011] [Accepted: 06/21/2011] [Indexed: 10/17/2022]
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Pomahac B, Nowinski D, Diaz-Siso JR, Bueno EM, Talbot SG, Sinha I, Westvik TS, Vyas R, Singhal D. Face Transplantation. Curr Probl Surg 2011; 48:293-357. [DOI: 10.1067/j.cpsurg.2011.01.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cavadas PC, Ibáñez J, Thione A, Alfaro L. Bilateral trans-humeral arm transplantation: result at 2 years. Am J Transplant 2011; 11:1085-90. [PMID: 21521475 DOI: 10.1111/j.1600-6143.2011.03503.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Unilateral and bilateral hand transplantations have been performed worldwide with good mid-term functional results. An above-elbow bilateral transplantation was performed in a 29-year-old male patient from a fully HLA-mismatched donor. Alemtuzumab induction and steroid-free maintenance immunosuppression with tacrolimus and mycophenolate was used. Due to acute rejection, steroids were introduced at 6 months. Three acute rejection episodes occurred, one treated with alemtuzumab. New-onset diabetes after transplant, dyslipemia and worsening of previous high blood pressure required treatment. At 26 months post-transplantation, the patient has excellent elbow active movement, active flexion and extension of the thumb and fingers, useful sensation and a gainful job. Based on the functional results of the case reported, bilateral trans-humeral transplantation could be a viable treatment for selected bilateral above-elbow amputees.
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Affiliation(s)
- P C Cavadas
- Reconstructive surgery, Clínica Cavadas, Valencia, Spain.
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Face, Upper Extremity, and Concomitant Transplantation: Potential Concerns and Challenges Ahead. Plast Reconstr Surg 2010; 126:308-315. [DOI: 10.1097/prs.0b013e3181dcb6f4] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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