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Hand Transplantation Open Access to Scientific and Medical Research DOI Journal name: Transplant Research and Risk Management Article Designation: Review Year: 2017 Volume: 9 Transplant Research and Risk Management Dovepress Running head verso: Alolabi et al Running head recto: Hand transplantation open access to scientific and medical research DOI: http://dx.doi.org/10.2147/TRRM.S94298 Open Access Full Text Article REVIEW Hand transplantation: current challenges and future prospects Noor Alolabi1 Abstract: Over the last two decades, 113 vascularized composite allotransplantation (VCA) Haley Augustine1 of the hand have been performed in 76 patients globally. The procedure that was once regarded Achilles Thoma1–3 as experimental has certainly emerged as a clinical reality with multiple centers worldwide now performing it. The psychological and physical impact of losing an upper extremity is 1Division of Plastic Surgery, Department of Surgery, 2Surgical profound. Amputees face significant challenges contributing to disability and dependence even Outcomes Research Centre, with activities of daily living. Hand transplantation offers functions with restoring sensation, 3 Department of Clinical Epidemiology voluntary motor control, and proprioception, as well as a sense of feeling “whole” again. Along and Biostatistics, McMaster University, Hamilton, ON, Canada with these benefits, however, transplantation carries a significant risk profile attributed to the complications of life-long immunosuppression and possible rejection. Moreover, the procedure For personal use only. carries a significant financial burden to the health care system. As hand VCA is becoming more widely accepted and performed worldwide, there are still many challenges that will face its rapid growth. This review highlights some of the challenges facing hand VCA including patient selection, effect on quality of life, financial burden, functional outcomes, and complications of immunosuppression. Keywords: hand transplantation, vascularized composite allotransplantation Introduction The first attempted hand transplantation was performed in Ecuador in 1964. The trans- plant survived 2 weeks but was lost to acute rejection.1 Over the next three decades, surgical advancements in replantation microsurgery as well as medical advancements in transplant immunology and immunosuppressive therapy allowed for the success of such a procedure.2 In 1998, the second hand transplant was performed in Lyon, France. Transplant Research and Risk Management downloaded from https://www.dovepress.com/ by 54.70.40.11 on 25-Sep-2018 The patient ultimately lost the transplant after 2 years because of rejection secondary to medication noncompliance.3,4 Following this, the first successful hand transplant with long-term survivability was performed in Louisville, Kentucky, in 1999.5 The patient remains the longest surviving hand transplant recipient, 17 years since transplantation. Subsequent to this success, hand transplantation has evolved from what used to be regarded as experimental and potentially unethical to a procedure that is accepted and recognized, with 113 transplants performed on 76 patients worldwide.6–17 Though it offers sensation, function, cosmetic, and psychological benefits, there are significant Correspondence: Achilles Thoma risks associated with the lifelong immunosuppressive medication required with trans- 206 James Street South, Suite 101, Hamilton, Ontario L8P3A9, Canada plantation.4,5,7,12,18–34 This article aims to outline the challenges of hand transplantation Tel +1 905 523 0019 by discussing patient selection, effect on quality of life, financial burden, functional Fax +1 905 523 0229 Email [email protected] outcomes, and risks of immunosuppression. submit your manuscript | www.dovepress.com Transplant Research and Risk Management 2017:9 23–29 23 Dovepress © 2017 Alolabi et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://dx.doi.org/10.2147/TRRM.S94298 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Alolabi et al Dovepress Incidence, etiology, and alternative Table 1 Inclusion and exclusion criteria for hand transplant treatment recipients used by several USA hand transplant centers Upper extremity amputation in young patients is typically Inclusion criteria Exclusion criteria Age 18–69 years the result of trauma, infection, or is secondary to congenital Age <18 or >69 years No medical condition with Chronic infection anomalies. For older patients, amputation is more likely a negative immunologic, surgical, result of medications or peripheral vascular diseases. The or functional implications incidence of upper extremity loss is variable in the literature, No psychosocial issues Malignancy No cancer in past 10 years Immune condition though it is estimated to be 11.6 in 100,000 adults.35 No HIV Coagulopathies The psychological and physical impact of losing an upper Willingness to consent to Hematologic disease extremity is profound. Such a loss results in significant dis- cell collections/storage/bone ability, with severe impact on quality of life. The mainstay of marrow infusion Greater than 6 months since Connective tissue or vascular disease treatment for hand amputation has been prosthesis. Various extremity injury with attempt forms of prostheses are available and range from a nonfunc- at rehabilitation tional cosmetic prosthetic, to a hook, to a more advanced Lipipolysacharidosis myoelectric prosthetic. Though a prosthetic may provide Amyloidosis Metabolic/genetic bone disease an assisting hand, it is limited by the burden of weight, dis- Red flags during screening comfort, limited usefulness, and lack of functional feedback. Note: Reproduced from MacKay BJ, Nacke E, Posner M. Hand transplantation: Additionally, bilateral amputees face unique challenges with a review. Bull Hosp Jt Dis. 2014;72(1):76–88. With permission.39 basic grooming, self-care, and activities of daily living con- Table 2 Sample multidisciplinary team required for a hand tributing to significant disability and dependence.36 transplant center As a form of vascularized composite allotransplantation Physicians Health care aid (VCA), hand transplantation can functionally offer a far Replantation surgery Ethics For personal use only. superior option than prostheses. It provides superior dexter- Plastic surgery Psychology ity with restoring sensibility, intrinsic muscle function, and Orthopedic surgery Rehabilitation services proprioception. Moreover, it can potentially provide a match Transplant surgery Occupational therapy in color, size, and overall appearance. However, these benefits Psychiatry Physiotherapy Infectious diseases Social work could be outweighed by the complications secondary to the Immunology life-long immunosuppression required.6–7 Internal medicine Physiatry Anesthesia Patient selection Hematology Eligibility and indication for hand transplantation remain Neurology to be a challenge and topic of debate. Generally speaking, indications for transplant are based on both the expected Predictors of non-adherence to immunosuppressive medi- preoperative success of transplant and the impact on func- cation regimens include inadequate social support, higher Transplant Research and Risk Management downloaded from https://www.dovepress.com/ by 54.70.40.11 on 25-Sep-2018 tion for the patient. Indications may include amputation of education, and less conscientiousness.40 Patient selection the dominant hand, bilateral amputations, distal amputations and education are crucial as intensive daily hand therapy (less nerve regeneration required), and abrupt amputations and significant morbidity are associated with immunosup- with clean end points of distal stump.37,38 Table 1 outlines the pression.27,41 Once selection is determined, it is paramount inclusion and exclusion criteria used by several USA hand to explore patients’ expectations as well as educate them on transplant centers.39 the nature of the intense recovery. An assessment of the whole person is required to deter- mine eligibility. This involves a multidisciplinary team to Effectiveness of hand VCA properly evaluate the possible medical, psychological, and Performing high-quality studies such as a randomized con- social impacts of one’s amputation as well as to determine trolled trial to investigate the difference in outcomes between their potential for success and improved outcomes with hand VCA and, for example, prosthesis application is not transplant. Centers that contemplate performing hand VCA possible because of feasibility issues, ethical issues, costs, must have the capacity for a multidisciplinary team such as and patient recruitment. This poses a significant challenge the one listed in Table 2. when attempting to widely implement a new intervention 24 submit your manuscript | www.dovepress.com Transplant Research and Risk Management 2017:9 Dovepress Powered by TCPDF (www.tcpdf.org) 1 / 1 Dovepress Hand transplantation since little outcome data are available. However, when clinical This report included 72 patients
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