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Kumnig M, Kobler C, Zaccardelli A, Brandacher G, Talbot SG. Advancing vascularized composite allotransplantation: essential factors for upper extremity transplant program development. FRONTIERS IN TRANSPLANTATION 2024; 3:1406626. [PMID: 38993746 PMCID: PMC11235377 DOI: 10.3389/frtra.2024.1406626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/27/2024] [Indexed: 07/13/2024]
Abstract
Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Caroline Kobler
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Gerald Brandacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Simon G. Talbot
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
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Hummel NR, Zuo KJ, Talbot S, Zimmerman ZE, Katz JN, Kinsley SE, Kumnig M. Psychosocial predictors in upper-extremity vascularized composite allotransplantation: A qualitative study of multidimensional experiences including patients, healthcare professionals, and close relatives. Front Psychol 2023; 14:1092725. [PMID: 36844321 PMCID: PMC9948017 DOI: 10.3389/fpsyg.2023.1092725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Background The impact of patient-specific psychosocial factors on functional outcomes after upper-extremity (UE) vascularized composite allotransplantation (VCA) is poorly understood. The objective of this study was to identify relevant psychosocial predictors for success or failure of UE VCA in an Austrian cohort. Methods A qualitative study was undertaken consisting of semi-structured interviews with UE VCA staff, transplanted patients, and close relatives. Participants were asked about their perceptions of factors that either favored or hindered a successful transplant outcome, including functional status before surgery, preparation for transplant, decision-making, rehabilitation and functional outcome after surgery, and family and social support. Interviews were conducted online and recorded with the consent of interviewees. Results Four bilateral UE VCA patients, 7 healthcare professionals, and a sister of a patient participated in the study. Thematic analysis revealed the importance of an expert interdisciplinary team with adequate resources for patient selection. Psychosocial aspects of prospective candidates are crucial to evaluate as they contribute to success. Both patients and providers may be impacted by public perceptions of UE VCA. Functional outcomes are optimized with a life-long commitment to rehabilitation as well as close, ongoing provider involvement. Conclusion Psychosocial factors are important elements in the assessment and follow-up care for UE VCA. To best capture psychosocial elements of care, protocols must be individualized, patient-centered, and interdisciplinary. Investigating psychosocial predictors and collecting outcomes is, thus, critical to justifying UE VCA as a medical intervention and to providing accurate and salient information to prospective candidates.
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Affiliation(s)
- Nikolas R. Hummel
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin J. Zuo
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Simon Talbot
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Zoe E. Zimmerman
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Jeffrey N. Katz
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sarah E. Kinsley
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria,*Correspondence: Martin Kumnig, ✉
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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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Kumnig M, Hummel NR, Jowsey-Gregoire SG, Zuo KJ, Gordon EJ, Talbot SG. Editorial: Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantations. Front Psychol 2023; 14:1186113. [PMID: 37151323 PMCID: PMC10157283 DOI: 10.3389/fpsyg.2023.1186113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: Martin Kumnig
| | - Nikolas R. Hummel
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria
| | - Sheila G. Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Graduate School of Medicine, Mayo Clinic Rochester, Rochester, MN, United States
| | - Kevin J. Zuo
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Simon G. Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Kumnig M, Jowsey-Gregoire SG, Gordon EJ, Werner-Felmayer G. 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. Front Psychol 2022; 13:1045144. [PMID: 36591015 PMCID: PMC9800026 DOI: 10.3389/fpsyg.2022.1045144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Martin Kumnig
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology Transplantation Medicine (CAPTM), Medical University of Innsbruck, Innsbruck, Austria
| | - Sheila G. Jowsey-Gregoire
- Department of Psychiatry and Psychology, Mayo Clinic Rochester, Mayo Graduate School of Medicine, Rochester, MN, United States
| | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gabriele Werner-Felmayer
- Institute of Biological Chemistry and Bioethics Network Ethucation, Medical University of Innsbruck, Innsbruck, Austria
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Kumnig M, Järvholm S. Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant. Curr Opin Organ Transplant 2022; 27:501-507. [PMID: 36227757 DOI: 10.1097/mot.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Currently, several research approaches warrant further attention, given the influence of psychosocial and bioethical issues on the success of upper extremity (UETx), face (FTx), and uterine transplantation (UTx). This review will highlight recent results of psychosocial and bioethical research in the field of vascularized composite allotransplantation (VCA), discuss most recent findings, provide information to guide future research approaches, and address the importance of a multicenter research approach to develop international standards. RECENT FINDINGS Previously published reports have tried to identify psychosocial factors that are essential to predict psychosocial outcomes and guide posttransplant treatment after VCA procedures. These issues in VCA are receiving more attention but we are still at the beginning of a systematic investigation of these domains. This review article summarizes the emerging psychosocial issues in UeTx, FTx, and UTx by including recent literature and current clinical practice. SUMMARY Even though different VCA procedures address different domains leading to specific psychosocial issues, common aspects impacting all forms of VCA would benefit of further coordination. These domains include clinical resources, public attitude and perception, bioethical considerations, adherence and rehabilitation, motives for VCA, information needs and multidisciplinary communication, body image, domains of quality of life, coping strategies, and follow-up care.
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Affiliation(s)
- Martin Kumnig
- Medical University of Innsbruck, Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Innsbruck, Austria
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
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Sturma A, Stamm T, Hruby LA, Bischof B, Salminger S, Gstoettner C, Prahm C, Pittermann A, Wakolbinger R, Hofer C, Farina D, Aszmann OC. Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation. J Hand Ther 2022; 35:58-66. [PMID: 33250398 DOI: 10.1016/j.jht.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a Delphi study based on a scoping literature review. INTRODUCTION Targeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists. PURPOSE OF THE STUDY We aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training. METHODS European clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round. RESULTS Experts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one. DISCUSSION Within this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists' practice. CONCLUSION Graded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction. LEVEL OF EVIDENCE Low.
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Affiliation(s)
- Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Bioengineering, Imperial College London, London, United Kingdom; Health Assisting Engineering, University of Applied Sciences FH Campus Wien, Vienna, Austria
| | - Tanja Stamm
- Institute for Outcomes Research Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria.
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | - Cosima Prahm
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department for Plastic and Reconstructive Surgery, BG Trauma Clinic, Eberhard-Karls University, Tuebingen, Germany
| | - Anna Pittermann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
| | - Robert Wakolbinger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria
| | | | - Dario Farina
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Austria; Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria
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What we still don't know about vascularized composite allotransplantation (VCA) outcomes and quality of life measurements. Transplant Rev (Orlando) 2022; 36:100708. [DOI: 10.1016/j.trre.2022.100708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/12/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022]
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Kinsley SE, Williams EE, Lenhard NK, Shah SB, Edwards RR, Katz JN, Talbot SG. A Provider Perspective of Psychosocial Predictors of Upper-Extremity Vascularized Composite Allotransplantation Success. J Hand Surg Am 2022; 47:387.e1-387.e19. [PMID: 34266683 DOI: 10.1016/j.jhsa.2021.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/14/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We performed a qualitative study to understand the psychosocial factors associated with success in upper-extremity vascularized composite allotransplantation from the perspective of transplant providers. METHODS We recruited 13 providers actively involved in upper-extremity vascularized composite allotransplantation. Participants included physicians, nurses, social workers, occupational therapists, and research administrators. We conducted semistructured face-to-face focus group interviews using a guide that explored providers' perceptions of qualities contributing to transplant outcome. Topics included social support networks and their influence on recovery, barriers to treatment compliance and successful posttransplant rehabilitation, and the process of setting patients' expectations. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS The analysis identified numerous factors that contribute to transplant success: (1) recipients' prior experiences modify their ability to cope and adapt after transplantation, (2) behaviors and characteristics such as positivity influence candidacy and may be predictive of successful outcomes, and (3) social support is essential for improved function and compliance. The provider care team cited difficulty in predicting recipient compliance and in setting realistic expectations. CONCLUSIONS Motivated recipients with developed coping and resiliency, a positive attitude, and stable, physically-able caregivers are perceived by providers to have greater success after transplantation. CLINICAL RELEVANCE Findings from this work may help providers determine optimal candidates for upper-extremity vascularized composite allotransplantation.
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Affiliation(s)
- Sarah E Kinsley
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Emma E Williams
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Nora K Lenhard
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sejal B Shah
- Department of Psychiatry; Brigham and Women's Hospital, Boston, MA
| | - Robert R Edwards
- Department of Anesthesiology, Pain Management Center, Brigham and Women's Hospital, Boston, MA
| | - Jeffrey N Katz
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Simon G Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA.
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Advanced Amputation Techniques in Orthopedic Surgery: Hand Transplantation. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kinsley SE, Lenhard NK, Lape EC, Shah SB, Edwards RR, Katz JN, Talbot SG. Perceived Success in Upper-Extremity Vascularized Composite Allotransplantation: A Qualitative Study. J Hand Surg Am 2021; 46:711.e1-711.e35. [PMID: 33722470 DOI: 10.1016/j.jhsa.2021.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We performed a qualitative study to understand psychosocial factors associated with perceived success of upper-extremity vascularized composite allotransplantation (VCA). We interviewed transplant recipients and their primary caregivers. METHODS We recruited 4 upper-extremity VCA recipients and primary caregivers for 3 of them. We conducted semistructured face-to-face interviews using a guide that explored participants' transplantation experiences. Topics included comparison of pretransplant and posttransplant expectations, reflections on factors contributing to the success of the transplant experience, and posttransplant rehabilitation and functioning. We performed a thematic analysis that produced a list of themes, subthemes, and proposed hypotheses explaining how the themes related to the study's guiding questions. RESULTS Participants described several factors as contributing to the success of the transplant experience, including developing realistic expectations about posttransplant function and lifelong immunosuppression, support from one's community and particularly the primary caregiver, and framing the experience in a positive light. Social, aesthetic, and other values unique to the hands, as opposed to prosthetics, motivated recipients to undergo VCA despite its inherent risk and uncertainties. CONCLUSIONS Despite inherent challenges, undergoing VCA was viewed as worthwhile to regain benefits unique to hands. Participants met the challenges of the transplant process through setting realistic expectations, strong social support, and a positive perspective. CLINICAL RELEVANCE Findings from this work may help clinicians and prospective patients to prepare for and set appropriate expectations of VCA.
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Affiliation(s)
- Sarah E Kinsley
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Nora K Lenhard
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Emma C Lape
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sejal B Shah
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
| | - Robert R Edwards
- Department of Anesthesiology, Pain Management Center, Brigham and Women's Hospital, Boston, MA
| | - Jeffrey N Katz
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Simon G Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA.
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Lessons Learned from the Amputation of a Bilateral Hand Grafted Patient due to Psychiatric Disorders. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2905. [PMID: 33173656 PMCID: PMC7647659 DOI: 10.1097/gox.0000000000002905] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients’ assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting.
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Abstract
Abstract
Purpose of Review
This article aims to review published outcomes associated with full-thickness vascularized abdominal wall transplantation, with particular emphasis on advances in the field in the last 3 years.
Recent Findings
Forty-six full-thickness vascularized abdominal wall transplants have been performed in 44 patients worldwide. Approximately 35% of abdominal wall transplant recipients will experience at least one episode of acute rejection in the first year after transplant, compared with rejection rates of 87.8% and 72.7% for hand and face transplant respectively. Recent evidence suggests that combining a skin containing abdominal wall transplant with an intestinal transplant does not appear to increase sensitization or de novo donor-specific antibody formation.
Summary
Published data suggests that abdominal wall transplantation is an effective safe solution to achieve primary closure of the abdomen after intestinal or multivisceral transplant. However, better data is needed to confirm observations made and to determine long-term outcomes, requiring standardized data collection and reporting and collaboration between the small number of active transplant centres around the world.
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Psychosocial Predictors of Upper Extremity Transplantation Outcomes: A Review of the International Registry 1998-2016. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3133. [PMID: 33133972 PMCID: PMC7544328 DOI: 10.1097/gox.0000000000003133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/31/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Upper extremity transplantation (UET) is becoming increasingly common. This article attempts to collate data from cases contributing to the International Registry on Hand and Composite Tissue Transplantation (IRHCTT), define psychosocial themes perceived as predictors of success using statistical methods, and provide an objective measure for optimization and selection of candidates. Methods: The IRHCTT provided anonymous data on UET recipients. A supplementary psychosocial survey was developed focusing on themes of depression, posttraumatic stress disorder (PTSD), anxiety, interpersonal functioning and dependence, compliance, chronic pain, social support, quality of life, and patient expectations. We determined the risk of transplant loss and psychological factors associated with higher risk of transplant loss. Results: Sixty-two UET recipients reported to the IRHCTT. Forty-three psychosocial surveys (68%) were received, with 38 (88%) having intact transplants and 5 (12%) being amputated. Among recipients with a diagnosis of anxiety (N = 29, 67%), 5 (17%) reported transplant loss (P = 0.03). Among those with depression (N = 14, 33%), 2 recipients (14%) has transplant loss (P = 0.17); while 4 recipients (22%) with PTSD (N = 18, 42%) had transplant loss (P = 0.01). Of participants active in occupational therapy (N = 28, 65%), 2 (7%) reported transplant loss (P = 0.09). Of recipients with realistic functional expectations (N = 34, 79%), 2 (6%) had transplant loss versus 3 (34%) who were felt to not have realistic expectations (N = 9, 21%, P = 0.05). Recipients with strong family support (N = 33, 77%) had a lower risk of transplant loss compared with poor or fair family support (N = 10, 23%), but did not reach statistical significance (6% versus 30%, P = 0.14). Conclusion: Anxiety, depression, PTSD, participation in occupational therapy, expectations for posttransplant function, and family support are associated with postsurgical transplant status.
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Van Pilsum Rasmussen SE, Ferzola A, Cooney CM, Shores JT, Lee WA, Goldman E, Kaufman CL, Brandacher G, Segev DL, Henderson ML. Psychosocial factors and medication adherence among recipients of vascularized composite allografts. SAGE Open Med 2020; 8:2050312120940423. [PMID: 32695395 PMCID: PMC7350038 DOI: 10.1177/2050312120940423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/15/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives Psychosocial factors are important predictors of medication adherence, and subsequently graft survival, in solid organ transplantation. Early experiences suggest this may also be the case in vascularized composite allotransplantation. Methods Using validated tools, we surveyed upper extremity transplant recipients at two centers to assess depression (Patient Health Questionnaire-9), personality (Ten-Item Personality Inventory), anxiety (Generalized Anxiety Disorder 7-Item Scale), post-traumatic stress disorder (Primary Care Post-Traumatic Stress Disorder Screen for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), and social support (Multidimensional Scale of Perceived Social Support). Medication adherence among vascularized composite allotransplantation recipients at two centers was assessed by a member of the clinical research team using the recipients' medical records. Results Medication adherence was reported for 12 vascularized composite allotransplantation recipients, and 9 vascularized composite allotransplantation recipients completed psychosocial assessments. Most recipients were believed to be adherent to their immunosuppression, however, three recipients were believed to be non-adherent and a member of the clinical team had discussed non-adherence at least once with five recipients. Results from the psychosocial assessment (n = 9) indicated that eight participants had high levels of social support, and eight demonstrated high levels of conscientiousness which have been associated with better medication adherence in solid organ transplantation. However, three participants demonstrated mild anxiety, two demonstrated minimal symptoms of depression, and one demonstrated post-traumatic stress disorder which have been associated with worse medication adherence in solid organ transplantation. Conclusion These findings lay the groundwork for future assessments of the role psychosocial factors play in facilitating medication adherence and broader transplant outcomes.
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Affiliation(s)
| | - Alexander Ferzola
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaime T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wp Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Goldman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Christina L Kaufman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, USA
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Kimberly LL, McQuinn MW, Caplan AL, Levy-Carrick NC. The Ethics of Psychosocial Assessment in Vascularized Composite Allotransplantation: A Call for Transparency of Process to Support the Equitable Selection of Patients. THE JOURNAL OF CLINICAL ETHICS 2019. [DOI: 10.1086/jce2019304318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation. Curr Opin Organ Transplant 2019; 24:705-713. [PMID: 31689261 DOI: 10.1097/mot.0000000000000712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk. RECENT FINDINGS Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors. SUMMARY Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.
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Mendenhall SD, Sawyer JD, West BL, Neumeister MW, Shaked A, Levin LS. Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States? Pediatr Transplant 2019; 23:e13466. [PMID: 31081211 DOI: 10.1111/petr.13466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 12/27/2018] [Indexed: 01/14/2023]
Abstract
Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57 300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.
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Affiliation(s)
- Shaun D Mendenhall
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Justin D Sawyer
- The Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Bradford L West
- Department of Transplant Nephrology, Springfield Clinic, Springfield, Illinois
| | - Michael W Neumeister
- The Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Abraham Shaked
- Division of Transplant Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lawrence S Levin
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Talbot SG, Carty MJ, Jensen SE, Dumanian GA. Adjustment to amputation and interest in upper limb transplantation. SAGE Open Med 2019; 7:2050312119858248. [PMID: 31217973 PMCID: PMC6563387 DOI: 10.1177/2050312119858248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: Upper limb transplantation provides a new restorative option for individuals with amputations. As true for most operations, patient selection is critical to optimizing transplantation outcomes. To improve on the patient selection process, we used qualitative methods to better understand the issues regarding upper extremity loss as well as upper limb transplantation from the amputee point of view. Methods: Individuals with upper limb amputations (age range = 24–73 years) discussed their adjustment following amputation and their interest toward transplantation in either a focus group (n = 5) or semi-structured interview (n = 17). Transcripts were coded by theme and summarized. Results: Participants described a year-long process typified by adjustment to a new role as an amputee, both psychosocially and functionally. We found that the extent of adjustment was inversely related to an interest in transplantation. Conclusions: These findings could explain the difficulty in identifying “ideal” candidates for upper extremity transplantation and may have implications for patient selection and counseling. Level of Evidence: Prognostic Study, Level V
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Affiliation(s)
- Simon G Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew J Carty
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Sally E Jensen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gregory A Dumanian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Hedges CE, Rosoff PM. Transplants for non-lethal conditions: a case against hand transplantation in minors. JOURNAL OF MEDICAL ETHICS 2018; 44:661-665. [PMID: 29903852 DOI: 10.1136/medethics-2018-104819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/18/2018] [Accepted: 05/31/2018] [Indexed: 06/08/2023]
Abstract
Human allografts for life-threatening organ failure have been demonstrated to be lifesaving and are now considered to be standard of care for many conditions. Transplantation of non-vital anatomic body parts has also been accomplished. Hand transplantation after limb loss in adults has been shown to offer some promising benefits in both functional and psychological measures in preliminary studies. It has been suggested to expand eligibility criteria to include minors, with one such operation having already been performed. With this in mind, we examine the current state of hand transplantation research in the context of available alternatives. We examine the ethics of carrying out these operations in minors, including under the protections of clinical research. We argue that children should not be considered for this surgery due to the substantial risks of immunosuppressive medication, the likelihood that the graft will need to be replaced during the patient's lifetime and the lack of significant compensatory advantages over modern prosthetics.
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Affiliation(s)
- Charles E Hedges
- Duke Initiative for Science and Society, Duke University, Durham, North Carolina, USA
| | - Philip M Rosoff
- Duke Initiative for Science and Society, Duke University, Durham, North Carolina, USA
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Departments of Pediatrics and Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Hruby LA, Pittermann A, Sturma A, Aszmann OC. The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries. PLoS One 2018; 13:e0189592. [PMID: 29298304 PMCID: PMC5751989 DOI: 10.1371/journal.pone.0189592] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction. Methods Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction. Results Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary scale increased from 30.80 ± 5.31 to 37.37 ± 8.41 (p-value = 0.028), the mental component summary scale improved from 43.19 ± 8.32 to 54.76 ± 6.78 (p-value = 0.018). VAS scores indicative of deafferentation pain improved from 7.8 to 5.6 after prosthetic hand replacement (p-value = 0.018). Negative body evaluation improved from 60.71 ± 12.12 to 53.29 ± 11.03 (p-value = 0.075). Vital body dynamics increased from 38.57 ± 13.44 to 44.43 ± 16.15 (p-value = 0.109). Conclusions Bionic reconstruction provides hope for patients with complete brachial plexopathies who have lived without hand function for years or even decades. Critical patient selection is crucial and the psychosocial assessment procedure including a semi-structured interview helps identify unresolved psychological issues, which could preclude or delay bionic reconstruction. Bionic reconstruction improves overall quality of life, restores an intact self-image and reduces deafferentation pain.
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Affiliation(s)
- Laura Antonia Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- General Hospital of Vienna, Department of Clinical Psychology, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria
| | - Oskar Christian Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Jowsey-Gregoire S, Kumnig M. Standardizing psychosocial assessment for vascularized composite allotransplantation. Curr Opin Organ Transplant 2016; 21:530-5. [DOI: 10.1097/mot.0000000000000351] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Kumnig M, Jowsey-Gregoire SG. Key psychosocial challenges in vascularized composite allotransplantation. World J Transplant 2016; 6:91-102. [PMID: 27011907 PMCID: PMC4801807 DOI: 10.5500/wjt.v6.i1.91] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 12/16/2015] [Accepted: 01/08/2016] [Indexed: 02/05/2023] Open
Abstract
Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation (VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation (SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.
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Zhang ZY, Li FC, Shao M, Yang C, Shang J, Bi ZG. Allogeneic hand transplantation and rehabilitation of hand function: a 10-year follow-up study. Int Wound J 2015; 13:1303-1308. [PMID: 26481453 DOI: 10.1111/iwj.12520] [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: 06/29/2015] [Accepted: 09/20/2015] [Indexed: 11/28/2022] Open
Abstract
The purpose of this study is to present the long-term outcomes of allogenic hand transplantations performed at our centre. Between January 2001 and October 2002, five allogeneic limb transplantations were performed in three patients (two bilateral forearm and one left hand transplantation). Donors and recipients were matched for blood types (ABO/Rh) and had at least two human leukocyte antigen (HLA) matches. A comprehensive rehabilitation plan integrating preoperative, intraoperative and postoperative management was developed for each patient. After 10 years, all transplantations were performed successfully without complications. As of 2014, all grafts were viable. The transplanted hands showed palmate morphology, perceived superficial pain and tactile sensations, and the static two-point discrimination ranged from 2·5 to 4·0 mm. Chronic rejection at 4 years after surgery reduced hand function in case 2. Grip strength ranged from 3 kg (case 2) to 16-18 kg (case 1) to 41-43 kg for case 3. Lifting strength ranged from 3 kg (case 2) to 21-23 kg (case 1) to 47-51 kg for case 3. They lead a completely independent life. In summary, hand function following allogeneic limb transplantation allows the ability to perform tasks of daily living.
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Affiliation(s)
- Zhen-Yu Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Fu-Chun Li
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ming Shao
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Cao Yang
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jian Shang
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zheng-Gang Bi
- Department of Orthopaedics, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Psychosocial Outcomes after Bilateral Hand Transplantation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e533. [PMID: 26579339 PMCID: PMC4634170 DOI: 10.1097/gox.0000000000000520] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/28/2015] [Indexed: 11/26/2022]
Abstract
Since the first successful hand transplantation in 1998, there have been multiple reports about surgical technique, transplant survival, and immunosuppression. However, very limited published data exist on psychosocial outcomes following hand transplantation.
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Weissenbacher A, Hautz T, Pierer G, Ninkovic M, Zelger BG, Zelger B, Löscher W, Rieger M, Kumnig M, Rumpold G, Piza-Katzer H, Bauer T, Zimmermann R, Gabl M, Arora R, Ninkovic M, Margreiter R, Brandacher G, Schneeberger S, RTI-Group Innsbruck. Hand Transplantation in Its Fourteenth Year: The Innsbruck Experience. ACTA ACUST UNITED AC 2014. [DOI: 10.4161/23723505.2014.973798] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Perceptions of the risks and benefits of upper limb transplantation among individuals with upper limb amputations. Plast Reconstr Surg 2014; 134:979-987. [PMID: 25054242 DOI: 10.1097/prs.0000000000000584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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