Hand Transplant simulation (Donor Part 1)
Hand and upper extremity allotransplantation is becoming a more widely accepted treatment modality for unilateral and bilateral upper limb loss. Nearly 110 hand/arm transplants have been performed on around 75 patients worldwide (1). Functional outcomes have been promising with all patients regaining protective sensation and the majority gaining meaningful use of their transplanted hands (2). A systematic review of hand transplant surgery functional outcomes by Landin et al. demonstrated a 27.6 point DASH score improvement on average compared to preoperatively, with only a 300 day average follow up (3).
Longer-term outcomes from the International Registry on Hand and Composite Tissue Transplantation have been presented which demonstrate continued functional improvement over life of hand allografts with average DASH scores of less than 10 after 12 years (4). The 5 year allograft survival rates for isolated hand transplants approach 91%, which is very favorable compared to deceased donor solid organ transplants, with the best 5-year survival rate being that of hearts at 75% (1, 5).
Hand transplants are also unique because they are not life saving transplants but instead life improving. A systematic literature review by Jensen and colleagues demonstrated that most hand transplant patients have experienced an increase in quality of life and satisfaction with overall cosmetic, sensory, functional, and social outcomes (6). As with solid organ transplantation, these promising outcomes have been tempered by the sequelae of lifelong immunosuppression including opportunistic infections, metabolic complications, and malignancies.
Furthermore, nearly all VCA patients experience acute rejection episodes (2), which are treatable but increase morbidity. Chronic transplant rejection is just now starting to be recognized and characterized in hand and face transplantation (7, 8). Poor patient compliance with immunosuppression protocols has led to short and long-term transplant losses, which emphasizes the importance of careful patient selection in hand transplantation.
As a new treatment modality for upper extremity amputation, the technical aspects of hand transplantation continue to evolve. Although similar to replantation in some ways, transplantation has many unique challenges (9- 10). The Touch Surgery modules demonstrate one approach to distal forearm transplantation as developed by the SIU team and should not be taken as the only approach to this new procedure. This technique will certainly continue to evolve and improve with further surgical rehearsal and clinical experience as VCA transplantation becomes more mainstream worldwide.
- Volar donor preparation of skin flaps, cutaneous vessels and nerves, superficial flexors, neurovascular anatomy, deep flexors, and bones.
- Dorsal donor preparation of skin flaps, cutaneous vessels and nerves, extensor muscles by compartment, and bones.
- Volar recipient stump preparation of skin flaps, cutaneous vessels and nerves, superficial flexors, neurovascular anatomy, deep flexors, and bones.
- Dorsal recipient stump preparation of skin flaps, cutaneous vessels and nerves, extensor muscles by compartment, and bones.
- Osteosynthesis of donor and recipient.
- Dorsal extensor tendon/muscle repairs from deep to superficial at appropriate tension.
- Dorsal cutaneous vein and nerve coaptations.
- Deep volar tendon/muscle repairs at appropriate tension.
- Median and Ulnar neurorrhaphies.
- Radial and Ulnar artery/vein anastomoses and revascularization.
- Superficial flexor tendon/muscle repairs.
- Cutaneous vein and nerve repairs.
- Skin flap closure.
A knowledge of all upper extremity anatomy and hand surgical principles is key for hand transplantation. Topographical relationships are particularly important for recipient stump dissection since no distal structures are available for reference.
- Unilateral or bilateral upper limb loss (longer than 6 months ago) desiring hand or arm transplantation.
- Below-shoulder amputation (preferably below the elbow, but above elbow amputees considered as well).
- Male or female amputees of any race, color or ethnicity.
- Ages: 18-69 years.
- Willing and able to comprehend and sign informed consent form.
- No major co-existing medical condition which, in the opinion of the study team, would place patient at high risk for the surgical procedure, immunosuppression protocol, or functional results.
- No major co-existing psychosocial problems (i.e., alcoholism, drug abuse, lack of social support) or issue identified during psychosocial testing.
- Strong family / social support system.
- No cancer for past 5 years.
- No HIV or Hepatitis C virus at transplant.
- Negative crossmatch with donor.
- If female of child-bearing potential, negative serum pregnancy test.
- If female of child-bearing potential, consent to use reliable contraception for at least one year following transplantation.
- Willing and able to sign consents for tissue research studies.
- Willing to comply with the immunosuppression and hand therapy protocols.
Donor and Recipient Exclusion Criteria
Positive for any of the following conditions:
- Untreated sepsis
- HIV (active or seropositive)
- Active tuberculosis
- Active Hepatitis B infection
- Hepatitis C
- Viral encephalitis
- Malignancy (within past 5 years)
- Current/recent (within 3 months of donation/screening consent) IV drug abuse
- Paralysis of ischemic or traumatic origin
- Inherited peripheral neuropathy
- Infectious, post infectious, or inflammatory (axonal or demyelinating) neuropathy
- Toxic neuropathy (i.e. heavy metal poisoning, drug toxicity, industrial agent exposure)
- Mixed connective tissue disease
- Severe deforming rheumatoid or osteoarthritis in the limb
Donor Only Exclusion Criteria
- Non-professional tattoo within last 6 months
- Personally identifiable tattoo (i.e. donor name) on potential transplant tissue
Recipient Only Exclusion Criteria
- Conditions that, in the opinion of the study team, would place them at unacceptably high risk for the surgical procedure, immunosuppression protocol, or functional results.
- Sensitized recipients with high levels (>70%) of panel-reactive HLA antibodies.
- Conditions that may impact the success of the surgical procedure or increase the risk of postoperative complications including inherited coagulopathies like Hemophilia, Von Willebrand disease, Protein C and S deficiency, Thrombocythemias, Thalassemias, Sickle Cell disease, etc.
- Mixed connective tissue diseases and collagen diseases that may result in poor wound healing after surgery.
- Liver transplant anesthesia team.
- Pre-op anesthesia evaluation.
- Supraclavicular brachial plexus indwelling catheter placement pre-op, one dose short acting, then post op long.
- Jugular large bore central line access, femoral arterial line.
- Prepare for massive blood loss and coagulopathy (stay ahead 10 units PRBCs/ 10 units FFP, rapid transfuser), consider cell saver.
- Consider use of thromboeslastograms (TEG).
- Follow ABG/Lactate, H&H, and Coags.
- Immunosuppression medication administration (thymo, Steroids).
- 2-4 days ICU care.
- 10-30 days in hospital.
- Close graft monitoring.
- Extensive hand therapy/ Splinting.
- Life long immunosuppression and monitoring.
- Intraoperative complications, bleeding, coagulopathy, graft loss and death.
- Post operative graft loss.
- Acute and hyperacute transplant rejection.
- Postoperative and opportunistic infections.
- Chronic rejection.
- Metabolic disorders.
- Medication side effects.
- Poor graft function and appearance.
- Shores JT, Brandacher G, Lee WP. Hand and Upper Extremity Transplantation: An Update of Outcomes in the Worldwide Experience. Plast Reconstr Surg. 2015 Feb;135(2):351e-60e.
- Petruzzo P, Lanzetta M, Dubernard JM, Landin L, Cavadas P, Margreiter R, Schneeberger S, Breidenbach W, Kaufman C, Jablecki J, Schuind F, Dumontier C. The International Registry on Hand and Composite Tissue Transplantation. Transplantation. 2010 Dec 27;90(12):1590-4.
- Landin L, Bonastre J, Casado-Sanchez C, Diez J, Ninkovic M, Lanzetta M, del Bene M, Schneeberger S, Hautz T, Lovic A, Leyva F, García-de-Lorenzo A, Casado-Perez C. Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review. Transpl Int. 2012 Apr;25(4):424-32.
- Petruzzo P, Update on the International Registry of Hand and Composite Tissue Transplantation. Presentation at the biennial meeting of the International Hand and Composite Tissue Allotransplantation Society, Philadelphia. PA 2015.
- Scientific Registry of Transplant Recipients (SRTR) 2012 Annual Data Report. Available at: http://srtr.transplant.hrsa.gov/annual_reports/2012/Default.aspx. Accessed August 28th, 2015.
- Jensen SE, Butt Z, Bill A, Baker T, Abecassis MM, Heinemann AW, Cella D, Dumanian GA. Quality of Life Considerations in Upper Limb Transplantation: Review and Future Directions. J Hand Surg Am. 2012 Oct;37(10):2126-35.
- Kaufman CL, Ouseph R, Marvin MR, Manon-Matos Y, Blair B, Kutz JE. Monitoring and Long-Term Outcomes in Vascularized Composite Allotransplantation. Curr Opin Organ Transplant. 2013 Dec;18(6):652-8.
- Petruzzo P, Kanitakis J, Testelin S, Pialat JB, Buron F, Badet L, Thaunat O, Devauchelle B, Morelon E. Clinicopathological Findings of Chronic Rejection in a Face Grafted Patient. Transplantation. 2015 May 16. [Epub ahead of print].
- Hartzell TL, Benhaim P, Imbriglia JE, Shores JT, Goitz RJ, Balk M, Mitchell S, Rubinstein R, Gorantla VS, Schneeberger S, Brandacher G, Lee WP, Azari KK. Surgical and Technical Aspects of Hand Transplantation: Is it Just Another Replant? Hand Clin. 2011 Nov;27(4):521-30.
- Higgins JP, Shores JT, Katz RD, Lee WP, Wolock BS. Forearm Transplantation Osteosynthesis Using Modified Ulnar Shortening Osteotomy Technique. J Hand Surg Am. 2014 Jan;39(1):134-42.
Michael W. Neumeister, MD, FRCS(C), FACS is the Professor and Chair of the Department of Surgery at Elvin G. Zook Endowed Chair, Institute for Plastic Surgery and Director of SIU Hand Transplant Program at Southern Illinois University School of Medicine.
Shaun D. Mendenhall, MD is a Plastic Surgery Resident, Hand Transplant Team Member and Researcher at the Institute for Plastic Surgery at Southern Illinois University School of Medicine.
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