In September 2011, a 30-member team, including 12 surgeons, three
anesthesiologists and 15 nurses, successfully performed the first double-hand transplant in the Delaware Valley at the Hospital of the
University of Pennsylvania. In early November 2011, team members held a press
conference detailing the successful 11 and a half hour surgery. The team
included experts in solid organ transplantation, orthopedic surgery, plastic
surgery, reconstructive microsurgery and anesthesia. One of the members of that
team, L. Scott Levin, MD, FACS, director of the Penn Hand Transplant Program
and chairman of the department of orthopaedic surgery spoke with O&P
Business News to discuss the recent progress of his patient, who wished
to remain anonymous.
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| L. Scott Levin |
“She has done very well,” Levin told O&P Business
News. “From a functional standpoint, she can wipe away a tear and
scratch her nose. We have also adapted some utensils to her splints so she can
eat by herself. She does not have to be fed anymore. She can gesture with her
hands as well. These are the functional things, right from the get go, that she
can do.”
Levin stressed that the patient must wait for her nerves to grow into
her muscles before it is possible to know the maximum benefits of the
transplant. This may take 18 months to 2 years. But in the shortterm, Levin
acknowledged that the patient, who is in her 20s, has a better sense of body
image than before the transplant. Prior to the transplant, the recipient felt
uncomfortable wearing upper extremity prostheses, although she was adept at
using her lower extremity prostheses.
It may take up to 2 years for the patient’s nerves to regenerate into her muscles.
Images: Hospital of the University of Pennsylvania.
“She certainly is more complete in terms of her upper extremity
aesthetics and normal appearance,” Levin said. “She looks at her body
and sees arms, hands and forearms. I think these are things, in the shortterm,
that have benefitted her greatly. She is enthusiastic and works her therapy
everyday. She is quite determined.”
The recipient’s therapy lasts several hours a day, including
shoulder and elbow motion. Therapy also helps keep her wrist and digit joints
supple and flexible. The recipient was able to give her grandmother a hug when
she visited her for Thanksgiving, according to Levin. She has shown early signs
of discomfort in the proximal third of her forearm. This is a good sign that
the nerves are trying to regenerate.
“We X-rayed her and the bones appear to be healing,” Levin
said. “She is now regaining movement in her fingers and has shown signs of
muscle recovery. She can move her forearms to maintain balance. We are still
very early in recovery. I don’t want to paint a picture that is too
optimistic. But those are some of the things she was not able to do at the time
of the press conference.”
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| In just a few short months, the recipient has regained movement in her fingers. |
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The Penn Transplant Institute has evaluated several patients for future
double-had transplantation. No decisions regarding who will be the next
recipient have been made. Levin believes a decision will be made in the next
few months.
“I think for multiple limb amputees, this provides great
hope,” Levin said. “For this recipient, she is already able to
perform functions that she was not able to do before the transplant. We
certainly hope this will give her promise for a better future than the one she
had.” — by Anthony Calabro
The
rehabilitation process for hand transplant patients becomes
just like a full-time job. They are expected to take medications on time
throughout the day, be seen frequently for monitoring of blood levels of
medications and spend 4 to 6 hours in therapy 5 days a week with a few hours
also on the weekend if possible. As the months go by, the level of therapy they
require depends on how much hand and forearm were transplanted.
For transplants at more proximal levels, their forearm muscles may not
be functional at first and their own nerves, which were combined with the
transplanted limbs’ nerves, may need to grow into the muscles. During this
process, therapy is focused on strengthening the working muscles in their arm
and shoulder, as well as motion to keep the joints supple and keep scar tissue
from growing into the tendons. If this isn’t done, when the muscles do
start to work, they will be unable to pull the tendons and make the joints and
digits move. The farther away the point of connection of the nerves, the longer
it takes the microscopic nerve fibers to grow down the connected nerve into the
muscle and allow it to move. If this process does not occur by 12-18 months,
the muscles may lose their ability to ever accept nerve signals at all. So,
this is a critical step in their recovery.
Another step that must occur for hands to be useful is the regeneration
of sensory nerves. By about a year’s time, most patients with transplants
at the wrist level will have “protective” sensation, meaning they can
feel pain, cold, and hot. This enables them to not injure themselves and
protect the transplanted hand. As time goes by, year after year, the sensory
nerve function in their hands tends to get better and better so that they get
more normal sensory discrimination similar to a normal hand.
Therapy throughout this time changes as their abilities improve and
needs change. Part of therapy is motion and strengthening, and part of it is
helping the brain to re-integrate the hand so that the sensations it feels make
sense to the brain, and so that the muscles activated by the brain can perform
useful function.
Therapists frequently help devise creative ways that allow the patients
to adapt to their environment and get more and more use out of the hands even
before they seem to have normal function. Recipients will always require some
therapy with exercises they can do on their own at home, but as time goes by,
the amount will decrease. Most patients should plan on being their hand
therapist’s best customer for the first 1 to 2 years, depending on the
level of transplantation; if their transplant was above the elbow, maybe even
longer.
— Jaimie Shores, MD
Assistant professor of
plastic and reconstructive surgery, Johns Hopkins Medicine
Disclosure: Shores has no relevant financial disclosures.
