Review of Hand Transplantation Cases Indicate Three Main Obstacles

PARK CITY, UTAH — Robin C. Crandall, MD, Shriners Hospital for Children presented his review of hand transplantations, their successes and complications at the 2011 Association of Children’s Prosthetics-Orthotics Clinics (ACPOC) Annual Meeting.

“At first, I thought this was a triumph of technology over reason,” Crandall explained to attendees, here. “But 10 years after the first hand transplantation, some of these patients are actually doing amazingly well.”

Still, failure is a major issue for this type of surgery. It costs an estimated $3 million for the first 3 months post-operation. So who is the ideal patient? The ideal patient for hand transplantation is a traumatic or acquired amputee at the mid or distal forearm, preferably bilateral with normal skin and anatomy if possible, he said.

According to Crandall there are three main obstacles to hand transplantation: acute rejection, chronic rejection and chronic immunosuppression. Acute rejection has occurred in most cases of transplantations. Chronic rejection generally means the patient will lose the implant due to a lack of blood flow to the hand. Despite these complications, the technicalities of the surgery have not been an issue. All of the hands have survived through the surgical procedure, according to Crandall.

Chronic immunosuppressive drugs are needed for all of the patients and the side effects of these drugs are significant.

“More than half of the patients will get some type of infection,” Crandall explained. “These infections — bacterial, viral, fungal or even mixed infections — can be devastating and difficult to eradicate. Many of the patients develop diabetes or at least chemical diabetes from the steroid use.”

Many of the centers who perform hand transplantations are no longer using steroids due to the advancements of immunosuppression drugs. But with advancements, comes cost.

“You are looking at about a $30,000 cost per year for anti-rejection drugs and that is provided there are no infections,” Crandall explained.

Scientists are working on microchimerism where doctors can actually condition the patient’s immune system prior to the actual transplant.

“This is being done, particularly at the University of Pittsburgh, where they have gotten away from all immunosuppression other than just one drug,” Crandall explained. “They treat the patient with bone marrow prior to the transplant and condition the patient’s immune system.”

According to questionnaires, hand transplantation patients feel as though they have increased function. This is particularly true for bilateral patients. They also feel as though they have a better body image and can engage in social interaction. — by Anthony Calabro

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