First two bilateral hand transplantations in India (Part 2): Technical details (original) (raw)
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First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome
Indian Journal of Plastic Surgery, 2017
Introduction: This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India. Materials and Methods: The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year. Results: Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand. Conclusion: Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.
First two bilateral hand transplantations in India (Part 1): From vision to reality
Indian Journal of Plastic Surgery, 2017
BACKGROUND M ore than 110 hand transplants have been done worldwide with the longest surviving hand transplant being 18 years now. Hand transplants are superior to prosthetic hands, especially in the case of bilateral hand amputees. [1] Prosthetic arms can provide some degree of assistance to carry out basic activities, but none of these can substitute a human hand. The main drawbacks of prosthetic hands are the lack of sensory feedback and its weight, especially when used for amputation at the proximal forearm level. For the Indian patients, one of the major problems faced was of
Bilateral Hand Transplantation: Six Years After the First Case
American Journal of Transplantation, 2006
In this study we present our experience concerning bilateral hand transplantation. Two cases were performed: the first in January 2000 and the second in April 2003. Both recipients received the same immunosuppressive treatment, which was similar to those used in solid organ transplantation, including tacrolimus, prednisone and mycophenolate mofetil while antithymocyte globulins were added for induction. Both recipients presented two episodes of acute rejection (maculopapular lesions) in the first 3 months after transplantation; however, these were easily reversed after a few days increasing oral steroid doses and using topical immunosuppressants. The first recipient presented hyperglycemia and serum sickness while the second recipient suffered a thrombosis of the right ulnar artery and an osteomyelitis of left ulna. All the complications were successfully treated. Functional Magnetic Resonance Imaging (fMRI) showed that cortical hand representation progressively shifted from the lateral to the medial region in the motor cortex. After 6 and 2 years respectively, they showed a relevant sensorimotor recovery particularly of sensibility and activity of intrinsic muscles. They were able to perform the majority of daily activities and to lead a normal social life. The first recipient has been working since 2003. They are both satisfied with their grafted hands.
Indian Subcontinent’s First Proximal Forearm Level Double Upper Extremity Transplantation
Indian Journal of Plastic Surgery
Introduction Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols. Materials and Methods A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime. Discussion Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant “reestablishes” the “donor extremity length,” maintains the normal fu...
Hand Transplantation: The State-of-the-Art
Journal of Hand Surgery (European Volume), 2007
The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient’s pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.
Indian Journal of Plastic Surgery
Introduction: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the ‘self’ from the ‘non-self’. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as ‘non-self’. Materials and Methods: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Results: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropri...
Human hand transplantation: what have we learned?
Transplantation Proceedings, 2004
Hand transplantation may become an important procedure for upper limb functional restoration. To date, 18 patients have been undergone 24 hand operations in the world. Initial results are extremely promising; the functional results are apparently superior to those obtained with prostheses. We report on the combined French and Italian experience of six patients (eight hands), which is based on a jointly devised protocol and represents the largest available clinical series. Six male patients aged 43, 33, 35, 32, 33, and 22 years received either a single right hand-dominant transplantation (four cases) or a simultaneous double hand transplantation (two cases). The time since the amputation ranged from 3 to 22 years. The level of transplantation was at the wrist in five cases (six hands) and at the distal forearm in two cases (two hands). Cold ischemia averaged 11.5 hours. Three patients simultaneously received additional full-thickness skin taken from the donor and transplanted onto their left hip area. This skin served as a source for biopsies and as an additional area to monitor rejection (distant sentinel skin graft). The immunosuppressive protocol included polyclonal antibodies (three patients) or monoclonal anti-CD 25 antibody (three patients), tacrolimus, mycophenolate mofetil, and prednisolone. No surgical complications occurred. Skin rejection occurred at least once in all patients at a mean of 40 days postoperatively. Three patients recovered protective and some discriminative sensation in their palm and fingers. Two patients are recovering sensation, but are still in the early phases of the regenerative process, due to the short time since the transplantation. One patient was not compliant with the immunosuppressive therapy, and underwent uncontrolled rejection and reamputation. A N EFFECTIVE COLLABORATION between a group of international surgeons and physicians led to the first single hand transplantation performed in Lyon on September 23, 1998. The first double hand transplantation was performed in the same location on January 13, 2000, where French and Italian teams simultaneously transplanted the left and the right hands, respectively, to a 33-year-old bilateral amputee at the wrist. Following the Italian Department of Health authorization, the Italian Hand Transplantation Group performed the first hand transplantation in Italy on October 17, 2000, followed by a second operation on October 1, 2001, and a third on November 5, 2002. The French group performed another double hand transplantation on April 30, 2003. These procedures have been carried out using the same operative and postoperative protocols, especially in the area of immunosuppressive therapy. 1-4 With a follow-up ranging from 2 to 41 months, we have collected a significant amount of data for analysis and discussion, mainly in the areas of selection criteria, harvesting and transplantation surgical techniques, immunosuppressive regimens, monitoring of rejection, rehabilitation programs, and functional results and outcomes. In this article we present our combined experience on six cases (four single and two double transplantations-eight hands), which represents the largest series.