Download PDF
J Hand Microsurg 2021; 13(04): 207-215
DOI: 10.1055/s-0040-1715427
Review Article

Hand Transplantation—Risks and Benefits

Maria João Lúcio 
1   Department of Plastic and Reconstructive Surgery, and Burn Unity, Centro Hospitalar Universitário de São João, Porto Medical School, University of Porto, Porto, Portugal
,
Ricardo Horta
1   Department of Plastic and Reconstructive Surgery, and Burn Unity, Centro Hospitalar Universitário de São João, Porto Medical School, University of Porto, Porto, Portugal
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

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.

Keywords

hand allotransplantation - composite tissue allotransplantation - immunosuppression - ethics - functional outcomes - rehabilitation


Publication History

Article published online:
19 November 2020

© 2020. Society of Indian Hand & Microsurgeons. All rights reserved.

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Errico M, Metcalfe NH, Platt A. History and ethics of hand transplants. JRSM Short Rep 2012; 3 (10) 207
    CrossrefPubMedGoogle Scholar
  • 2 Bowen WT, Slaven EM. Evidence-based management of acute hand injuries in the emergency department. Emerg Med Pract 2014; 16 (12) 1-215
    PubMedGoogle Scholar
  • 3 Grob M, Papadopulos NA, Zimmermann A, Biemer E, Kovacs L. The psychological impact of severe hand injury. J Hand Surg Eur Vol 2008; 33 (03) 358-362
    CrossrefPubMedGoogle Scholar
  • 4 Jette AM, Spicer CM, Flaubert JL. National Academies of sciences, Engineering, and Medicine. The Promise of Assistive Technology to Enhance Activity and Work Participation. 2017. Available at: https:/doi.org/10.17226/24740
  • 5 Jensen SE, Butt Z, Bill A. et al Quality of life considerations in upper limb transplantation: review and future directions. J Hand Surg Am 2012; 37 (10) 2126-2135
    CrossrefPubMedGoogle Scholar
  • 6 Elliott RM, Tintle SM, Levin LS. Upper extremity transplantation: current concepts and challenges in an emerging field. Curr Rev Musculoskelet Med 2014; 7 (01) 83-88
    CrossrefPubMedGoogle Scholar
  • 7 Brandacher G, Gorantla VS, Lee WP. Hand allotransplantation. Semin Plast Surg 2010; 24 (01) 11-17
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch Phys Med Rehabil 2006; 87 (3, Suppl 1) S34-S43
    CrossrefPubMedGoogle Scholar
  • 9 Schuind F, Abramowicz D, Schneeberger S. Hand transplantation: the state-of-the-art. J Hand Surg Eur Vol 2007; 32 (01) 2-17
    CrossrefPubMedGoogle Scholar
  • 10 Eun SC. Composite tissue allotransplantation immunology. Arch Plast Surg 2013; 40 (02) 141-153
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Shores JT, Brandacher G, Schneeberger S, Gorantla VS, Lee WP. Composite tissue allotransplantation: hand transplantation and beyond. J Am Acad Orthop Surg 2010; 18 (03) 127-131
    CrossrefPubMedGoogle Scholar
  • 12 Tobin GR, Breidenbach III WC, Ildstad ST, Marvin MM, Buell JF, Ravindra KV. The history of human composite tissue allotransplantation. Transplant Proc 2009; 41 (02) 466-471
    CrossrefPubMedGoogle Scholar
  • 13 Swearingen B, Ravindra K, Xu H, Wu S, Breidenbach WC, Ildstad ST. Science of composite tissue allotransplantation. Transplantation 2008; 86 (05) 627-635
    CrossrefPubMedGoogle Scholar
  • 14 Medawar PB. The behaviour and fate of skin autografts and skin homografts in rabbits: a report to the War Wounds Committee of the Medical Research Council. J Anat 1944; 78 (Pt 5): 176-199
    PubMedGoogle Scholar
  • 15 Hettiaratchy S, Randolph MA, Andrew Lee WP. Long-term consideration of hand transplantation. Transplantation 2003; 75 (09) 1605
    CrossrefPubMedGoogle Scholar
  • 16 Palmina P, Dubernard JM. The International Registry on Hand Composite Tissue Allotransplantation. Clin Transpl 2011; 247-253
    PubMedGoogle Scholar
  • 17 Dubernard JM, Owen E, Herzberg G. et al Human hand allograft: report on first 6 months. Lancet 1999; 353 (9161) 1315-1320
    CrossrefPubMedGoogle Scholar
  • 18 Breidenbach III WC, Tobin II GR, Gorantla VS, Gonzalez RN, Granger DK. A position statement in support of hand transplantation. J Hand Surg Am 2002; 27 (05) 760-770
    CrossrefPubMedGoogle Scholar
  • 19 Petruzzo P, Dubernard JM. The International Registry on Hand and Composite Tissue allotransplantation. Clin Transpl 2011; 247-253
    PubMedGoogle Scholar
  • 20 Pomahac B, Gobble RM, Schneeberger S. Facial and hand allotransplantation. Cold Spring Harb Perspect Med 2014; 4 (03) a015651
    CrossrefPubMedGoogle Scholar
  • 21 Ben-Amotz O, Kruger EA, McAndrew C. et al Logistics in coordinating the first adult transatlantic bilateral hand transplant: lessons learned. Plast Reconstr Surg 2018; 142 (03) 730-735
    CrossrefPubMedGoogle Scholar
  • 22 Cooney CM, Siotos C, Aston JW. et al The ethics of hand transplantation: a systematic review. J Hand Surg Am 2018; 43 (01) 84.e1-84.e15
    CrossrefPubMedGoogle Scholar
  • 23 Brandacher G, Lee WP, Schneeberger S. Minimizing immunosuppression in hand transplantation. Expert Rev Clin Immunol 2012; 8 (07) 673-683
    CrossrefPubMedGoogle Scholar
  • 24 Petruzzo P, Lanzetta M, Dubernard JM. et al The International Registry on Hand and Composite Tissue Transplantation. Transplantation 2008; 86 (04) 487-492
    CrossrefPubMedGoogle Scholar
  • 25 Azari KK, Imbriglia JE, Goitz RJ. et al Technical aspects of the recipient operation in hand transplantation. J Reconstr Microsurg 2012; 28 (01) 27-34
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Hartzell TL, Benhaim P, Imbriglia JE. et al Surgical and technical aspects of hand transplantation: is it just another replant?. Hand Clin 2011; 27 (04) 521-530
    CrossrefPubMedGoogle Scholar
  • 27 Jones JW, Gruber SA, Barker JH, Breidenbach WC. Louisville Hand Transplant Team. Successful hand transplantation. One-year follow-up. N Engl J Med 2000; 343 (07) 468-473
    CrossrefPubMedGoogle Scholar
  • 28 Cetrulo Jr CL, Kovach SJ. Procurement of hand and arm allografts. Tech Hand Up Extrem Surg 2013; 17 (04) 232-238
    CrossrefPubMedGoogle Scholar
  • 29 Cavadas PC, Landin L, Ibañez J. Bilateral hand transplantation: result at 20 months. J Hand Surg Eur Vol 2009; 34 (04) 434-443
    CrossrefPubMedGoogle Scholar
  • 30 Labana N, Messer T, Lautenschlager E, Nagda S, Nagle D. A biomechanical analysis of the modified Tsuge suture technique for repair of flexor tendon lacerations. J Hand Surg [Br] 2001; 26 (04) 297-300
    CrossrefPubMedGoogle Scholar
  • 31 Chang J, Jones N. Twelve simple maneuvers to optimize digital replantation and revascularization. Tech Hand Up Extrem Surg 2004; 8 (03) 161-166
    CrossrefPubMedGoogle Scholar
  • 32 Siegler M. Ethical issues in innovative surgery: should we attempt a cadaveric hand transplantation in a human subject?. Transplant Proc 1998; 30 (06) 2779-2782
    CrossrefPubMedGoogle Scholar
  • 33 Hautz T, Brandacher G, Engelhardt TO. et al How reconstructive transplantation is different from organ transplantation–and how it is not. Transplant Proc 2011; 43 (09) 3504-3511
    CrossrefPubMedGoogle Scholar
  • 34 Jones NF. Concerns about human hand transplantation in the 21st century. J Hand Surg Am 2002; 27 (05) 771-787
    CrossrefPubMedGoogle Scholar
  • 35 Andrew Lee WP. The debate over hand transplantation. J Hand Surg Am 2002; 27 (05) 757-759
    CrossrefPubMedGoogle Scholar
  • 36 Chang J, Mathes DW. Ethical, financial, and policy considerations in hand transplantation. Hand Clin 2011; 27 (04) 553-560
    CrossrefPubMedGoogle Scholar
  • 37 Cooney WP, Hentz VR. American Society for Surgery of the Hand. Hand transplantation–primum non nocere. J Hand Surg Am 2002; 27 (01) 165-168
    CrossrefPubMedGoogle Scholar
  • 38 Ravindra KV, Wu S, Bozulic L, Xu H, Breidenbach WC, Ildstad ST. Composite tissue transplantation: a rapidly advancing field. Transplant Proc 2008; 40 (05) 1237-1248
    CrossrefPubMedGoogle Scholar
  • 39 Bermúdez J, Latorre LF, Moreno C, DeBedout R. Hand transplantation: is it an ethical decision, a bioethical one, or both?. Transplant Proc 2011; 43 (09) 3512-3515
    CrossrefPubMedGoogle Scholar
  • 40 Salminger S, Sturma A, Roche AD. et al Functional and psychosocial outcomes of hand transplantation compared with prosthetic fitting in below-elbow amputees: a multicenter cohort study. PLoS One 2016; 11 (09) e0162507
    CrossrefPubMedGoogle Scholar
  • 41 Salminger S, Roche AD, Sturma A, Mayer JA, Aszmann OC. Hand transplantation versus hand prosthetics: pros and cons. Curr Surg Rep 2016; 4: 8
    CrossrefPubMedGoogle Scholar
  • 42 Ninkovic M, Weissenbacher A, Gabl M. et al Functional outcome after hand and forearm transplantation: what can be achieved?. Hand Clin 2011; 27 (04) 455-465
    CrossrefPubMedGoogle Scholar
  • 43 Bernardon L, Gazarian A, Petruzzo P. et al Bilateral hand transplantation: functional benefits assessment in five patients with a mean follow-up of 7.6 years (range 4-13 years). J Plast Reconstr Aesthet Surg 2015; 68 (09) 1171-1183
    CrossrefPubMedGoogle Scholar
  • 44 Hautz T, Engelhardt TO, Weissenbacher A. et al World experience after more than a decade of clinical hand transplantation: update on the Innsbruck program. Hand Clin 2011; 27 (04) 423-431
    CrossrefPubMedGoogle Scholar
  • 45 Shores JT, Brandacher G, Lee WP. Hand and upper extremity transplantation: an update of outcomes in the worldwide experience. Plast Reconstr Surg 2015; 135 (02) 351e-360e
    CrossrefPubMedGoogle Scholar
  • 46 Cavadas PC, Ibáñez J, Thione A, Alfaro L. Bilateral trans-humeral arm transplantation: result at 2 years. Am J Transplant 2011; 11 (05) 1085-1090
    CrossrefPubMedGoogle Scholar
  • 47 Salminger S, Sturma A, Herceg M, Riedl O, Bergmeister K, Aszmann OC. Prosthetic reconstruction in high amputations of the upper extremity [in German]. Orthopade 2015; 44 (06) 413-418
    CrossrefPubMedGoogle Scholar
  • 48 Aszmann OC, Roche AD, Salminger S. et al Bionic reconstruction to restore hand function after brachial plexus injury: a case series of three patients. Lancet 2015; 385 (9983) 2183-2189
    CrossrefPubMedGoogle Scholar
  • 49 Schneeberger S, Ninkovic M, Gabl M. et al First forearm transplantation: outcome at 3 years. Am J Transplant 2007; 7 (07) 1753-1762
    CrossrefPubMedGoogle Scholar
  • 50 Yan Y, Johnson PJ, Glaus SW, Hunter DA, Mackinnon SE, Tung TH. A novel model for evaluating nerve regeneration in the composite tissue transplant: the murine heterotopic limb transplant. Hand (N Y) 2011; 6 (03) 304-312
    CrossrefPubMedGoogle Scholar
  • 51 Bozulic LD, Breidenbach WC, Ildstad ST. Past, present, and future prospects for inducing donor-specific transplantation tolerance for composite tissue allotransplantation. Semin Plast Surg 2007; 21 (04) 213-225
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Karam S, Wali RK. Current state of immunosuppression: past, present, and future. Crit Rev Eukaryot Gene Expr 2015; 25 (02) 113-134
    CrossrefPubMedGoogle Scholar
  • 53 Chang J, Davis CL, Mathes DW. The impact of current immunosuppression strategies in renal transplantation on the field of reconstructive transplantation. J Reconstr Microsurg 2012; 28 (01) 7-19
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Schneeberger S, Khalifian S, Brandacher G. Immunosuppression and monitoring of rejection in hand transplantation. Tech Hand Up Extrem Surg 2013; 17 (04) 208-214
    CrossrefPubMedGoogle Scholar
  • 55 Schneeberger S, Landin L, Jableki J. et al ESOT CTA Working Group. Achievements and challenges in composite tissue allotransplantation. Transpl Int 2011; 24 (08) 760-769
    CrossrefPubMedGoogle Scholar
  • 56 Kanitakis J, Jullien D, Petruzzo P. et al Clinicopathologic features of graft rejection of the first human hand allograft. Transplantation 2003; 76 (04) 688-693
    CrossrefPubMedGoogle Scholar
  • 57 Tullius SG, Tilney NL. Both alloantigen-dependent and -independent factors influence chronic allograft rejection. Transplantation 1995; 59 (03) 313-318
    CrossrefPubMedGoogle Scholar
  • 58 Womer KL, Vella JP, Sayegh MH. Chronic allograft dysfunction: mechanisms and new approaches to therapy. Semin Nephrol 2000; 20 (02) 126-147
    PubMedGoogle Scholar
  • 59 Hautz T, Zelger B, Brandacher G. et al Histopathologic characterization of mild rejection (grade I) in skin biopsies of human hand allografts. Transpl Int 2012; 25 (01) 56-63
    CrossrefPubMedGoogle Scholar
  • 60 Kvernmo HD, Gorantla VS, Gonzalez RN, Breidenbach III WC. Hand transplantation. A future clinical option?. Acta Orthop 2005; 76 (01) 14-27
    CrossrefPubMedGoogle Scholar
  • 61 Chim H, Amer H, Mardini S, Moran SL. Vascularized composite allotransplant in the realm of regenerative plastic surgery. Mayo Clin Proc 2014; 89 (07) 1009-1020
    CrossrefPubMedGoogle Scholar
  • 62 Landin L, Bonastre J, Casado-Sanchez C. et al Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review. Transpl Int 2012; 25 (04) 424-432
    CrossrefPubMedGoogle Scholar
  • 63 Weissenbacher A, Hautz T, Pratschke J, Schneeberger S. Vascularized composite allografts and solid organ transplants: similarities and differences. Curr Opin Organ Transplant 2013; 18 (06) 640-644
    CrossrefPubMedGoogle Scholar
  • 64 Labroo P, Ho S, Sant H, Shea J, Gale BK, Agarwal J. Controlled delivery of FK506 to improve nerve regeneration. Shock 2016; 46 (3, Suppl 1) 154-159
    CrossrefPubMedGoogle Scholar
  • 65 Konofaos P, Terzis JK. FK506 and nerve regeneration: past, present, and future. J Reconstr Microsurg 2013; 29 (03) 141-148
    Article in Thieme ConnectPubMedGoogle Scholar
  • 66 Tung TH. Clinical strategies to enhance nerve regeneration. Neural Regen Res 2015; 10 (01) 22-24
    CrossrefPubMedGoogle Scholar
  • 67 Labroo P, Shea J, Sant H, Gale B, Agarwal J. Effect Of combining FK506 and neurotrophins on neurite branching and elongation. Muscle Nerve 2017; 55 (04) 570-581
    CrossrefPubMedGoogle Scholar
  • 68 Yan Y, Wood MD, Moore AM. et al Robust axonal regeneration in a mouse vascularized composite allotransplant model undergoing delayed tissue rejection. Hand (N Y) 2016; 11 (04) 456-463
    CrossrefPubMedGoogle Scholar
  • 69 Severance G, Walsh L. Rehabilitation after bilateral hand transplantation in the quadrimembral patient: review and recommendations. Tech Hand Up Extrem Surg 2013; 17 (04) 215-220
    CrossrefPubMedGoogle Scholar
  • 70 Bueno E, Benjamin MJ, Sisk G. et al Rehabilitation following hand transplantation. Hand (N Y) 2014; 9 (01) 9-15
    CrossrefPubMedGoogle Scholar
  • 71 Kumnig M, Jowsey SG, Rumpold G. et al The psychological assessment of candidates for reconstructive hand transplantation. Transpl Int 2012; 25 (05) 573-585
    CrossrefPubMedGoogle Scholar
  • 72 Pei G, Gu L, Yu L. A preliminary report of two cases of human hand allograft [in Chinese]. Zhonghua Yi Xue Za Zhi 2000; 80 (06) 417-421
    PubMedGoogle Scholar
  • 73 Amirlak B. Hand Transplantation Treatment & Management. Available at: https://emedicine.medscape.com/article/1370502- treatment. Accessed October 2 2020