History and ethics of hand transplants

[Prosthetic Fitting Concepts after Major Amputation in the Upper Limb - an Overview of Current Possibilities]

BACKGROUND

The upper extremity and particularly the hands are crucial for patients in interacting with their environment, therefore amputations or severe damage with loss of hand function significantly impact their quality of life. In cases where biological reconstruction is not feasible or does not lead to sufficient success, bionic reconstruction plays a key role in patient care. Classical myoelectric prostheses are controlled using two signals derived from surface electrodes in the area of the stump muscles. Prosthesis control, especially in high amputations, is then limited and cumbersome. The surgical technique of Targeted Muscle Reinnervation (TMR) offers an innovative solution: The major arm nerves that have lost their target organs due to amputation are rerouted to muscles in the stump area. This enables the establishment of cognitive control signals that allow significantly improved prosthesis control.

PATIENTS/MATERIALS AND METHODS

A selective literature review on TMR and bionic reconstruction was conducted, incorporating relevant articles and discussing them considering the clinical experience of our research group. Additionally, a clinical case is presented.

RESULTS

Bionic reconstruction combined with Targeted Muscle Reinnervation enables intuitive prosthetic control with simultaneous movement of various prosthetic degrees of freedom and the treatment of neuroma and phantom limb pain. Long-term success requires a high level of patient compliance and intensive signal training during the prosthetic rehabilitation phase. Despite technological advances, challenges persist, especially in enhancing signal transmission and integrating natural sensory feedback into bionic prostheses.

CONCLUSION

TMR surgery represents a significant advancement in the bionic care of amputees. Employing selective nerve transfers for signal multiplication and amplification, opens up possibilities for improving myoelectric prosthesis function and thus enhancing patient care. Advances in the area of external prosthetic components, improvements in the skeletal connection due to osseointegration and more fluid signal transmission using wireless, fully implanted electrode systems will lead to significant progress in bionic reconstruction, both in terms of precision of movement and embodiment.

Immunohistochemical Analysis of Lymphocyte Populations in Acute Skin Rejection: The University Health Network Addition to the Banff Classification

Acute rejection in vascularized composite allotransplantation has been identified using the Banff 2007 working classification. We propose an addition to this classification based on histological and immunological assessment within the skin and subcutaneous tissue.

Methods

Biopsies from vascularized composite transplant patients were obtained at scheduled visits and whenever skin changes occurred. Histology and immunohistochemistry were performed on all samples, looking at infiltrating cells.

Results

Observations were made specifically related to each component of the skin, including the epidermis, dermis, vessels, and subcutaneous tissue. Our findings led to the establishment of the University Health Network addition of skin rejection.

Conclusions

The high rate of rejection where the skin is involved requires novel techniques for early detection. The University Health Network skin rejection addition can serve as an adjunct to the Banff classification.

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.

Ethical Issues in Consultation-Liaison Psychiatry

This article contextualizes several key ethical issues in consultation-liaison (C-L) psychiatry within historical and principlist frameworks. After summarizing the history of the field, it focuses on 3 main areas of ethical import in C-L psychiatry: decisional capacity assessment, psychosocial evaluations for transplant, and treating mental illness in pregnant patients.

Functional Restoration of a Midforearm Level Amputation using the Second Toe Transfer

Unilateral midforearm level amputation is a severely debilitating situation. The present solution for this problem is either restoration of function using a prosthetic hand, or a vascularized composite allotransplant (VCA) in some very selected cases. In cases of distal forearm level amputations, even vascularized second toe transfer could be done on the radial side of the hand to achieve good functional restoration. We present a case of midforearm level amputation in which the second toe transfer has been done above the level of insertion of pronator teres muscle to achieve meaningful function. This report highlights the fact that a single toe transfer could be helpful in achieving meaningful prehension, even at this proximal.

Hand Transplantation-Risks and Benefits

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

Effectiveness of Interventional Strategies in Modulating Knowledge and Attitude of Health Care Professionals for Promoting Organ Donation: A Study in Tertiary Care Public Hospital of North India

Objective:

To evaluate the impact of interventional “educational module” on knowledge and attitude regarding organ donation amongst resident doctors and nurses in the Institute of National Importance.

Study Design:

Interventional and prospective.

Methods:

We devised an interactive educational module covering various aspects of organ donation through a series of audiovisual lectures and information booklets. Resident doctors and nurses posted in those areas of the 1948-bedded Postgraduate Institute of Medical Education and Research (PGIMER), where head injury patients were treated and were subject to intervention using this module. The pre and postinterventional scores of their knowledge and attitude regarding organ donation were compared to find out impact of the intervention.

Results:

A total of 242 nurses and 87 resident doctors participated in this research. Higher knowledge score was observed preintervention amongst doctors as compared to nurses. Significant improvement was seen in total knowledge scores of both groups postintervention. Doctors had better scores for the “concept of organ donation,” while nurses were more familiar with “procedures and protocols.” Both had low knowledge about “clinical criteria for brain death” and “legal issues” preintervention which improved significantly postintervention. The positive impact of intervention was also observed on attitude in both categories. A significant impact of intervention was observed on overall propensity of doctors and nurses to promote organ donation, for pledging their own organs and for counseling of the patient/attendants on this cause.

Conclusion:

Scientifically designed educational modules have a promising role in improving awareness and attitude of health care professionals regarding organ donation and their propensity to be prospective donors, effective counselors, and advocates of organ donation.

Upper extremity and craniofacial vascularized composite allotransplantation: ethics and immunosuppression

Vascularized composite allotransplantation (VCA) is the name most often used to refer to the transplantation of anatomical units composed of multiple tissue types (skin, bone, muscle, tendon, nerves, vessels, etc.) when such transplants do not have the primary purpose of extending life, as is the case in the more familiar field of solid organ transplantation (SOT). A serious interest in VCA developed in the late twentieth century following advances in immunosuppression which had led to significant improvements in short and medium-term survival among SOT recipients. Several ethical concerns have been raised about VCA, with many being connected in one way or another to the limitations, burdens, and risks associated with immunosuppression. This article will focus on upper extremity and craniofacial VCA, beginning with a brief review of the history of VCA including reported outcomes, followed by a discussion of the range of ethical concerns, before exploring in greater detail how immunological issues inform and shape several of the ethical concerns.

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

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

The Ethics of Hand Transplantation: A Systematic Review

PURPOSE

We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time.

METHODS

We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change.

RESULTS

We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002.

CONCLUSIONS

Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies.

CLINICAL RELEVANCE

Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.

From Face/Off to the face race: the case of Isabelle Dinoire and the future of the face transplant

Isabelle Dinoire, the world's first face transplant recipient has died, 11 years after the procedure that brought her unwanted fame and media attention. While medical debates centre mainly on ethical and medical concerns like immunosuppressant use, the psychological hazards of face transplants are still being overlooked. Using medical and media reports and examining the gendering of clinical and patient narratives, this article argues we need to look again at face transplants and their motivation for individuals as well as society.

Symbrachydactyly

Background: Symbrachydactyly is a unilateral congenital hand malformation characterized by failure of formation of fingers and the presence of rudimentary digit nubbins. The management is variable and are investigated in this review. Methods: A detailed review of the literature was compiled into succinct clinically relevant categories. Results: Etiology, classification, non-surgical management, surgical intervention, and patient oriented outcomes are discussed. Conclusions: All interventions should prioritize realistic, evidence-supported appearance and functional gains. Studies of the baseline function and quality of life of children with symbrachydactyly would allow surgeons to better understand functional changes associated with various interventions and would help surgeons and parents to make the best treatment decisions.

The utility of hand transplantation in hand amputee patients

PURPOSE

To measure the desirable health outcome, termed utility, and the expected quality-adjusted life years (QALYs) gained with hand composite tissue allotransplantation (CTA) using hand amputee patients and the general public.

METHODS

Using the standard gamble (SG) and time trade-off (TTO) techniques, utilities were obtained from 30 general public participants and 12 amputee patients. The health utility and net QALYs gained or lost with transplantation were computed. A sensitivity analysis was conducted to account for the effects of lifelong immunosuppression on the life expectancy of transplant recipients. Higher scores represent greater utility.

RESULTS

Hand amputation mean health utility as measured by the SG and TTO methods, respectively, was 0.72 and 0.80 for the general public and 0.69 and 0.70 for hand amputees. In comparison, hand CTA mean health utility was 0.74 and 0.82 for the general public and 0.83 and 0.86 for amputees. Hand CTA imparted an expected gain of 0.9 QALYs (SG and TTO) in the general public and 7.0 (TTO) and 7.8 (SG) QALYs in hand amputees. A loss of at least 1.7 QALYs was demonstrated when decreasing the life expectancy in the sensitivity analysis in the hand amputee group.

CONCLUSIONS

Hand amputee patients did not show a preference toward hand CTA with its inherent risks. With this procedure being increasingly adopted worldwide, the benefits must be carefully weighed against the risks of lifelong immunosuppressive therapy. This study does not show clear benefit to advocate hand CTA.

Facial transplantation: the first 9 years

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Above-elbow (supracondylar) arm transplantation: clinical considerations and surgical technique

Vascularized composite allotransplantation, also known as "Reconstructive Transplantation" is becoming more commonplace worldwide. Hand and upper extremity transplantation make up the majority of clinical vascularized composite allotransplantation cases performed so far. As success with reconstructive transplantation becomes more common, more challenging examples of limb loss are being addressed, including above-elbow, or "supracondylar" upper extremity transplants. Although very few of these cases have been performed worldwide, the authors' experience includes the only 2 cases performed in the United States at the time of this report. This article will discuss indications, challenges, surgical technique, expected outcomes, and alternative technologies for treatment of limb loss above the elbow.