By the end of , 8 annual international Composite Tissue Allotransplantation CTA symposiums had been held to discuss the latest research, clinical findings, updates on outcomes of the past recipients, and future considerations. The first American conference was held in Philadelphia in July , and the American Society for Reconstructive Transplant Surgery was founded in the same year.
Despite various nonscientific criticisms from both the medical and nonmedical communities, each year, more surgeons attempt various CTA transplants, such as the face, larynx, and abdomen, and most report an excellent degree of success. Amputation of the hand and upper extremity can be caused by systemic diseases, such as cardiovascular disease or diabetes mellitus , bone or soft tissue malignancies, congenital birth defects, and trauma. Upper extremity limb loss has a significant psychosocial impact on the individual, in terms of both aesthetic and functional aspects. The disability related to the amputation includes missed work and loss of ability to resume regular work duties.
Contrary to claims made by opponents of hand transplantation, prostheses cannot fully duplicate the intricate actions of a native hand as well as a transplanted hand can. Even advanced myoelectric prostheses lack the advantage of providing sensation.
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The patient survival rate for unilateral or bilateral hand transplantation in isolation was Patients with amputations of one or both hands above the wrist and below the elbow are potential candidates for single or bilateral hand transplantation. Candidacy of above-elbow amputees has been debated; however, in July of , the first bilateral above-elbow transplantation was succssfully performed in Munich, Germany. Recipients must be in good health and aged years. Hand transplantation should not be attempted in children.
The decision to undergo such an extensive and complex procedure in an attempt to improve one's quality of life while maintaining a complete understanding and acceptance of the negative impact that immunosuppressive therapy may have on overall health can only be made by a capable and competent adult. The possible complications of the procedure and the expected functional outcome of the transplanted hand need to be clearly discussed with the amputee.
The decision to proceed is made solely by the recipient with the unbiased guidance of a chosen patient advocate. The surgeon is responsible for providing the appropriate information with regard to all available treatment options as well as their risks and benefits. Younger patients and those with an amputation below the elbow have more reliable outcomes and functional recovery than older patients with multiple comorbidities.
Because of the superiority of a transplanted limb over prosthesis with regard to appearance, functionality, and, especially, sensation, patients who report satisfaction and functional ability with a prosthetic hand are still potential candidates for hand transplantation. The image below illustrates the transverse cross-section of the mid forearm and the structures involved in the attachment of the donor hand to the recipient.
During the surgery, the ulnar and radial bones of the recipient and donor are attached with rigid plate-and-screw fixation. The bony structure and the size of the hand of the donor should be assessed preoperatively and should be similar to that of the recipient. The tendons in the forearm of both recipient and the donor need to be attached to their corresponding tendons or muscles and marked with labels intraoperatively, as shown in the image below.
Hand transplantation: current challenges and future prospects
In several previous cases, atrophy of the recipient tendon required the entire wad of flexor or extensor tendons of the donor to be attached to the residual tendon in the recipient. Despite concerns of loss of postoperative fine tendon function, this type of tendon attachment had to be used in the Louisville hand transplantation, and the postoperative outcome was better than expected. Such atrophy may make the recipient's anatomy confusing and more difficult to assess intraoperatively.
Finally, the radial and ulnar artery and vein and multiple peripheral veins on the dorsal and ventral side need to be identified in the mid forearm of both the recipient and the donor. The radial, ulnar, and median nerves also need to be identified. The hand donor exclusion criteria should be surveyed meticulously by the regional organ procurement organization OPO involved. These criteria include the following:. Human immunodeficiency virus HIV.
Viral hepatitis B or viral hepatitis C. Also, the donor should not require excessive vasopressors to maintain blood pressure prior to procurement. Currently, transplantation is contraindicated in children younger than 18 years and persons older than 65 years. A possible exception to this is transplantation of a limb to a child from an identical twin who is not going to survive.
One such case has been reported with success. Since immunosuppression is not required in such rare cases, this factor is removed from the ethical considerations.
Sept th Hand and upper extremity transplantation: an update of outcomes in the worldwide experience. Plast Reconstr Surg. Ethical considerations in the early composite tissue allograft experience: a review of the Louisville Ethics Program. Transplant Proc. Accessed: January 3, Chad R.
Gordon, Joseph M. Serletti, Kirby S. Black and Charles W. Charles W.
Hand Transplantation - an overview | ScienceDirect Topics
Hewitt, W. Andrew Lee and Chad R. Transplantation of Composite Tissue Allografts. Springer US; Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team. N Engl J Med. A level of amputation distal to the wrist as an inclusion criterion is more problematic. This becomes particularly complex if there is a remnant of thenar eminence function in the recipient. Obviously, these anatomic inclusion criteria are not absolute at the present time. Recipient stump with the level of amputation at the middle third of the forearm. Another anatomic defect that has been considered an indication for hand transplantation is blindness.
We would not, however, transplant such a patient now. We have evaluated such patients who wished transplantation, and since we cannot yet guarantee the extent or rapidity of sensory return in the hand, blind patients will be poor candidates. Furthermore, protective sensation might be insufficient sensory function for a blind patient. In other words, the patient might be blind both in his or her eyes and in his or her hands. Some have argued that the anatomic defect hand loss occurring in a solid organ transplant recipient is an indication for allotransplantation.
We would approach these patients with caution. The misunderstanding here is the failure to appreciate the extensive systemic damage that was done before hand transplantation by the solid organ failure. Hand transplantation, unlike organ transplantation, should be limited to healthy patients. A patient who is in renal, cardiac, pulmonary, or hepatic failure is excluded whether previously transplanted with solid organs or not. Simplistically, one can classify individuals as neurotic, borderline, or psychotic.
Ideally, we seek neurotic patients for hand transplants and exclude borderline and psychotic patients. Psychiatric evaluation of solid organ transplant patients has developed a methodology of evaluating the appropriate neurotic patient. Here is where the skill of the psychosocial team is paramount. The apparently ideal candidate who lacks family support is not an ideal candidate.
These patients will be dependent on a positive family structure, certainly within the first 3 months if not for the life of the transplant. A family support system that does not encourage strict adherence to the rigorous postoperative regimen will fail. This rigorous regimen includes physical therapy, timely compliance with multiple daily medications, repeated medical assessments, and avoiding certain activities and substances that can increase the risk of immunosuppressive-related complications.
The degree of expectations concerning the transplant outcome and the recognition of the experimental nature of the procedure are also estimated. Finally, the level of personality strength, including coping skills and regression, is assessed. An additional objective perspective regarding the pros and cons of hand transplantation is provided independent of the transplant team to the recipient through a patient advocate, who is a respected peer from the recipient's home community. It is beyond the scope of this chapter to elucidate how this delicate decision is made.
Psychological criteria are used to evaluate the competency of recipients to comply with the rigorous pretransplant and post-transplant rehabilitation program or drug regimens for the rest of their lives. We require that our patients be 6 months to 1 year from the time of amputation and to have made a good-faith effort at using prosthesis. Sufficient time needs to pass for the patient to conceivably accept his or her loss. Furthermore, a patient with hand transplant complications might be faced with a decision about stopping medications to save his or her life.
This risk evaluation requires that the patient understand the value of the prosthetic state. Our patients received surgery and the immediate postoperative care up to 3 months without charge. Accepting a patient and paying for all postoperative medications and management of complications raises the issue of moral hazard, with the specter of monetary enticement for hand transplantation.
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