Reaching New Heights: A Comprehensive Study of Hand Transplantations in Korea after Institutionalization of Hand Transplantation Law.

PURPOSE: With the revision of the Organ and Transplantation Act in 2018, the hand has become legal as an area of transplantable organs in Korea. In January 2021, the first hand allotransplantation since legalization was successfully performed, and we have performed a total of three successful hand transplantation since then. By comparing and incorporating our experiences, this study aimed to provide a comprehensive reconstructive solution for hand amputation in Korea. MATERIALS AND METHODS: Recipients were selected through a structured preoperative evaluation, and hand transplantations were performed at the distal forearm level. Postoperatively, patients were treated with three-drug immunosuppressive regimen, and functional outcomes were monitored. RESULTS: The hand transplantations were performed without intraoperative complications. All patients had partial skin necrosis and underwent additional surgical procedures in 2 months after transplantation. After additional operations, no further severe complications were observed. Also, patients developed acute rejection within 3 months of surgery, but all resolved within 2 weeks after steroid pulse therapy. Motor and sensory function improved dramatically, and patients were very satisfied with the appearance and function of their transplanted hands. CONCLUSION: Hand transplantation is a viable reconstructive option, and patients have shown positive functional and psychological outcomes. Although this study has limitations, such as the small number of patients and short follow-up period, we should focus on continued recovery of hand function, and be careful not to develop side effects from immunosuppressive drugs. Through the present study, we will continue to strive for a bright future regarding hand transplantation in Korea.

Hand transplantation: can we balance the risks and benefits?

Asking 'can we balance the risks and benefits?' implies that a quantification of both risk and benefit in hand transplantation (here the terms hand transplant and hand transplantation refer to allotransplantation of the human hand or hand and part or all of the upper limb or limbs) is possible. Despite all we have learned in recent years about hand transplantation, much remains unknown. Even if reliable methods for quantification of risk and benefit were available, fundamental issues relating to effective communication across the gulf of lived experience between the (presumably) handed surgeon and the handless patient remain. Inherent complexities mean some consider hand transplantation an unsolved problem, but we believe the medical and technical considerations fall within the ambit of a competent multidisciplinary team, and that psychosocial and ethical challenges are open to management through robust frameworks for assessment and decision making, underpinned by an extended period of assessment and dialogue, with candid acknowledgement where uncertainty remains. This respects the patient's autonomy while addressing the need for a prolonged period of informing consent.Level of evidence: V.

Designing and utilizing 3D-printed skin incision guides during the first Dutch bilateral hand-arm transplantation.

OBJECTIVE: To preoperatively plan skin incision in the case of the first Dutch bilateral hand-arm transplantation. BACKGROUND: A bilateral hand-arm transplantation has been performed for the first time in the Netherlands in 2019. In the context of preparation for this surgical procedure, the optimal patient-specific skin flap was determined. Skin flaps should be properly matched between donor and recipient to ensure sufficient tissue for the approximation of skin over the tendon anastomosis, adequate distal tip perfusion, and esthetics. METHODS: Preoperatively, stereophotogrammetry was obtained from the upper extremities of the patient and a volunteer with similar body physique. Skin flap dimensions were determined for each extremity, which resulted in patient-specific incision patterns. Combining this digital information yielded practical skin incision guides for both the donor and acceptor arms. Finally, the computer-aided designs were 3D printed. RESULTS: The 3D prints were convenient to utilize in both shaping the donor flaps as in preparing the acceptor extremities, taking only a few seconds during precious ischemia time. There was sufficient skin flap perfusion, and the wound-healing followed an uncomplicated course. No corrections were made to the initial skin incisions. CONCLUSIONS: Three-dimensional printed templates were successfully utilized in the first Dutch bilateral hand-arm transplantation. We believe its usage increased time efficiency, improved the match of skin flaps in donor and recipient arms, and allowed us to control the amount of skin surplus without skin flap tip necrosis. In these procedures where time is of the essence, we believe preoperative planning is imperative for its success.

Four-Year Follow-Up of the World's First Pediatric Bilateral Hand-Forearm Transplants: Do They Grow as Expected?

BACKGROUND: In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. METHODS: Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. RESULTS: From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. CONCLUSIONS: Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The Leeds hand transplant programme: Review of the laboratory management of the first six cases.

The UK hand transplantation programme is hosted by the Department of Plastic and Reconstructive Surgery at Leeds Teaching Hospitals under the leadership of Professor Simon Kay. Since programme launch in 2013, ten procedures in six individuals have been performed involving unilateral or bilateral transplants. The multi-disciplinary team that delivers the programme includes the transplant immunology service. The laboratory experience in programme support is reported here.

Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation.

PURPOSE OF REVIEW: The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk. RECENT FINDINGS: Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors. SUMMARY: Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.

Clinical Application of Mathematical Long Bone Ratios to Calculate Appropriate Donor Limb Lengths in Bilateral Upper Limb Transplantation.

Background: Limited methods exist to aid in deciding the appropriate donor limb lengths in bilateral upper limb amputees qualifying for vascularized composite allotransplantation. We hypothesized mathematical equations could be created using long bone length ratios, and applied to radiographs, to approximate the patient's limb length prior to amputation. Methods: A data set of 30 skeletons' unilateral upper limb long bones measured using osteometric board and calipers was used. Anatomic segment ratios were calculated based on humerus length after multivariate linear regression analysis. For clinical application testing, 5 cadavers' upper limbs were radiographed. Radiographic bone lengths were then measured along the long axis of each long bone. These measured radiographic lengths were then compared with the predicted bone lengths, generated from the skeleton data set ratios, for each cadaver. Results: The chi-square goodness-of-fit test showed excellent fit (P < .01) between the predicted and radiographically measured lengths for the 5 cadavers, and interobserver measurements showed no statistical difference. Depending on the cadaver, percent error in total limb length predicted to measure ranged from 0.9% to 2.7%. The variables to multiply an individual humerus length to calculate a given anatomic segment thus proved to be effective. Conclusions: If a bilateral upper limb amputee has 1 intact humerus, ratios to the humerus length can be reliably applied to calculate the preamputation limb length based on the patient's radiographic humerus length. These formulas are indicated for finding the appropriate limb lengths, and smaller anatomic segments, for donor-recipient matching in upper limb transplantation.

The Untold Story of the First Hand Transplant: Dedicated to the Memory of one of the Great Minds of the Ecuadorian Medical Community and the World.

BACKGROUND: In 1964, faced with the challenge of traumatic amputation, a team of surgeons at Clinica Guayaquil was convinced that the transplantation of a hand could significantly improve function and quality of life for the recipient. With a current but basic understanding of immunosuppression, the surgeons identified a recipient and waited for the correct donor. A human hand transplant had never been performed to date. METHODS: The surgeons' criteria for the recipient included a young healthy individual who had sustained a traumatic amputation at the distal forearm level with full motion of the proximal joints. Communication with receiving hospitals and military facilities identified what they perceived to be a feasible donor for an allograft transplantation. Consent was obtained from the family in conjunction with the local military medical authorities and the clergy. Iced saline solution and Heparin irrigation were to be used to prepare the donor extremity. The immunosuppression regimen, limited at the time, consisted only of intravenous cortisone, Imuran, and a single dose of radiation. RESULTS: A member of the Ecuadorian marine sustained a limited blast injury that amputated his dominant hand but spared the forearm. He was transferred to the emergency department of Clinica Guayaquil. A donor who had recently died in a nearby hospital was identified not long after. A successful technical surgical transplantation was achieved. Consultants from major hospitals around the world (including Peter Bent Brigham Hospital) convened at the patient's bedside to observe the results. Despite all efforts, the patient suffered an irreversible rejection at 21 days post-transplant. CONCLUSION: This was the first allograft transplantation of a hand. The surgeons embarked on an intervention never tried before, firmly believing that better function and quality of life would result. The bravery of this surgical team was commendable. This early surgical endeavor opened the way for future successes in transplant surgery today.

Vascularized Composite Allotransplantation: Alternatives and Catch-22s.

Technical success has been achieved in several forms of vascularized composite allotransplantation, including hand, face, penis, and lower extremity. However, the risks of lifelong immunosuppression have limited these procedures to a select group of patients for whom nontransplant alternatives have resulted in unsatisfactory outcomes. Recent reports of facial allograft failure, and subsequent reconstruction using autologous tissues, have reinforced the idea that a surgical contingency plan must be in place in case this devastating complication occurs. Interestingly, backup plans in the setting of vascularized composite allotransplantation consist of the nontransplant alternatives that were deemed suboptimal in the first place. Moreover, these options may have been exhausted before transplantation, and may therefore be limited in the case of allograft loss or reamputation. In this article, the authors describe the surgical and nonsurgical alternatives to hand, face, penis, and lower extremity transplantation. In addition, the authors explore the ethical implications of approaching vascularized composite allotransplantation as a "last resort" or as a "high-risk, improved-outcome" procedure, focusing on whether nontransplant options eventually preclude vascularized composite allotransplantation, or whether vascularized composite allotransplantation limits future nontransplant reconstruction.

Preparation is the Only Shortcut You Need in Surgery: A Guide to Surgical Rehearsals for Hand and Upper Extremity Transplantation.

As upper extremity transplantation is becoming more accepted worldwide, the demand for a fresh tissue cadaveric training model for this procedure is increasing and necessary to assure surgical success. Surgical rehearsals can decrease operative time, improve technique, and reduce errors made on the actual day of surgery. The purpose of this article is to describe a method for surgical rehearsal of upper extremity transplantation using cadaveric specimens based on the clinical experience of an academic institution with an active transplantation program. The logistics of rehearsal setup, equipment, and modified version of procedural checklists are described.

Logistics in Coordinating the First Adult Transatlantic Bilateral Hand Transplant: Lessons Learned.

Hand transplantation requires precise preoperative planning and surgical execution. Coordinating a transplant team-including surgeons, anesthesiologists, nurses, and supporting staff-is a time-sensitive challenge when a donor-recipient match is confirmed. International human limb transplantation occurs when the recipient and donor are in separate countries. The authors describe the logistics behind the first transatlantic adult bilateral hand transplantation, which, to date, required the highest level of coordination and timing. The authors' experience serves as a proof of concept that international limb transplantation or salvage is possible when the complex logistics of such an endeavor are carefully anticipated.

Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study.

BACKGROUND: Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft. METHODS: Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted. RESULTS: Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes). CONCLUSION: Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.

Partial Hand Transplant: Lessons Learned From Cadaveric Dissection Studies.

As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.

From Auto- to Allotransplantation: Immunomodulatory Protocol for Hand and Arm Transplantation.

AIM: To achieve a favorable risk-benefit balance for hand transplantation, an immunomodulatory protocol was developed in the laboratory and translated to clinical application. METHODS: Following donor bone marrow infusion into transplant recipients, hand and arm allografts have been maintained on low-dose tacrolimus monotherapy. RESULTS: Good-to-excellent functional recovery has been achieved in patients compliant with medication and therapy, thus restoring autonomous and productive lives. CONCLUSION: The risk-benefit balance can be tilted in favor of the hand transplant recipients by using an immunomodulatory protocol with minimum immunosuppression.

The Battle Ground between Two Giants: Toe Transfer and Hand Allotransplantation.

A few severe hand injuries represent a gray zone for the reconstructive surgeon, for which autologous tissue transfer and allotransplantation can yield satisfactory results, but not without downsides or morbidity.This article is written to address the dilemma of application of both techniques in those selected cases.

[History of hand transplantation: advancement in the operative technics, medications and the survival of the transplanted hands. Review of literature]. / A kézátültetés története: fejlodés a mutéti technikában, a gyógyszeres kezelésben és az átültetett kezek túlélésében. Irodalmi áttekintés.

The author summarizes briefly the history of hand allograft transplantation, the basics of the operative technics, and the medicinal treatment of the immunosuppression. He establishes that this operation requires complicated team-work: many specialists must be united in the interest of the successful final outcome. The biggest problem is not the technical challenge of the complicated operation, but the ineffectiveness of immunosuppression, its complications; even though significant development has happened in this field and experimental results are also encouraging. The author discusses these questions in this publication in the mirror of literature data. He states, that a successful hand transplantation, with its sensory and motoric functions can increase quality of life, in contrast with the ortheses. Orv Hetil. 2017; 158(38): 1483-1487.

[Hand transplantation in Sweden ­ preparations under way]. / Handtransplantation snart verklighet i Sverige.

English summary: Hand transplantation in Sweden - preparations under way Some patients with a uni- or bilateral hand- or forearm amputation cannot use a hand prosthesis, although high-tech prostheses have been developed. A hand transplantation, particularly for those with bilateral amputations, may be an alternative solution. In a hand-transplanted patient, grip function, strength, sensibility and subsequent improved quality of life can be restored. Risks related to immunosuppression must be balanced by expected benefits, and thorough selection of patients has to be performed from both medical and psychological point of view. Therefore, a national network has been established in Sweden to achieve coordination with the needed competence.