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Hand transplantation
Editorial Hand Transplantation
Surgeons are accustomed to giving advice and making medical recommendations. Individually as practitioners and collectively as a group of professionals, we generally enjoy the trust of those who come to us for care and thus have an obligation to present the best information regarding the nature and potential outcome of various treatment alternatives. While we recognize that it is ultimately the patient’s responsibility to choose, we often feel compelled to influence patient decisions, particularly when there is potential risk to life or limb. Our advice necessarily proceeds from our frame of reference as the treating physician, which is often governed by the Hippocratic aphorism premum non nocere (“first do no harm”). As important as this basic tenant is to the practice of medicine, we must recognize that it constitutes a very conservative approach to medical problems and allows little room for innovation and risk taking, even those that might be acceptable to a patient. In this issue’s Clinical Perspective, Dr Edgell and colleagues’ presentation on “Decision Making and Hand Transplantation” makes the point that patients may proceed from a completely different frame of reference and a different prioritization of values when making surgical decisions. Patients are often influenced more by factors related to body image and potential functional gain than by medical risks. The resultant outcome of an individual patient’s decision-making algorithm may be totally at odds with that of the surgeon’s, albeit just as rational and valid. In 1998 and 1999, hand surgeons from 3 different centers in Lyon, France; Louisville, Kentucky; and Guangzhou, China independently reported the transplantation of cadaver hands to the forearm amputation stumps of 4 patients.1–3 These reports were widely published and heralded in the media, but aroused the concern of hand surgeons. Negative editorials and castigating commentaries were predicated on the anticipated limited functional gains and the ethical question of subjecting the recipients to a lifetime of immunosuppressive therapy for a non–life-threatening condition. From the perspective of many hand surgeons, hand transplantation has come to be viewed as a wishful flight of fanciful thinking that has little chance for success. And yet. . .. for the patient who has lost a hand, transplantation provides the potential for restoration of body image and functional improvement and therefore may rise to the level of an acceptable risk. Despite the expressed concerns of many in the hand surgery community, it is arguable that the procedures performed at the 3 hand centers were appropriate. It appears that all involved were aware of the potential benefits and risks, even though the ratio between the two was unclear. Although bilateral hand transplantation procedures have been reported in 2 additional patients, objective postoperative data at 6 to 20 months have been reported from only the original 4 in the medical Copyright © 2001 by the American Society for Surgery of the Hand doi:10.1053/jhsu.2001.24331
The Journal of Hand Surgery 193
194 Paul R. Manske / Editorial
literature.1–3 According to these limited reports, the results have varied among the 4 patients; however, the following objective clinical observations can be made from a compilation of the information. 1. A cadaver hand can be technically transposed to a human forearm amputation stump. The osseous and soft tissue structures will heal and remain viable for up to 20 months with only transcient episodes of immunologic reaction. 2. The immunosuppressive agents required to prevent rejection have been adequately tolerated to date, causing no major medical problems or life-threatening episodes. 3. Function is marginal as determined by standard measurement parameters: ● Sensibility is poor. Although there has been progressive advancement of the Tinel’s sign, patients only report perception of temperature, pain, and deep pressure, with diminished/loss of protective sensation. ● There is early electromyographic evidence of intrinsic muscle reintervention, but only minimal clinical evidence of intrinsic muscle function. Grip strength at 1 year ranges between 2.7 and 5.0 kg and lateral pinch is 1.4 kg; it must be recognized that much of this “strength” may come from the extrinsic forearm musculature. ● Finger motion is limited. The total active motion of the 3 digital joints was reported in 1 patient to range from 66° to 83°. 4. It is difficult to determine whether the transplanted hand has actually resulted in improvement in activities of daily living because most of the reported “improved activities” are 1-handed tasks, for which the patients likely would have used the normal opposite extremity. According to the standards proposed by Carroll4 for upper extremity function, 1 patient was rated good, 2 fair, and 1 poor.5
From the patients’ perspectives, three appear pleased with the results and have apparently incorporated the transplanted hand into their self-image. Although the fourth patient was initially enthusiastic, he is reported to have become noncompliant with postoperative rehabilitation, and the hand was recently amputated at his request. It is difficult to predict this procedure’s future as a viable treatment alternative. Surgeons are aware that many well-established medical procedures and concepts were initially ridiculed and the subject of skepticism. One of the most notable examples in hand surgery occurred at the University of Louisville, where Edgell and colleagues currently work. In 1967, hand surgeons from that institution presented a paper at the 22nd annual meeting of the American Society for Surgery of the Hand on the primary repair of flexor tendons in zone II, a concept that ran contrary to the accepted recommendation for surgical care at that time. The presentation was met with such derision and resistance that publication of the technique was delayed until 19736 and specific results were not reported until 1977.7 Some 30 years later, the primary repair of lacerated zone II flexor tendons is now the standard of care. Conversely, surgeons are aware that the road of surgical progress is littered with an even greater number of failed concepts and flawed ideas. History will eventually applaud the successes and deride the failures, but in the beginning the two are often indistinguishable. Although these preliminary results may improve with time, it would be unfortunate if hand surgery failed to obtain more data and learn from these initial endeavors before continuing on. It would be equally unfortunate if the principle of premum non nocerum would prevent the advancement of an idea whose time may well yet come. The statement in the Hippocratic Oath that advises physicians to do no harm also requires them to “prescribe regimen for the good of my patients.” This prescribing must necessarily consider the perspective of both the surgeon and the patient. No one is certain of the fate of hand transplantation. At this time we all hear the sound of one hand clapping. Some hear the faint stirrings of applause, while others hear only a deafening silence. Notwithstanding, now is the time for surgeons and
The Journal of Hand Surgery / Vol. 26A No. 2 March 2001 195
patients to return to the clinical drawing boards to review whether the benefit to risk ratio of this procedure is sufficient for it to be repeated and for scientists to return to the laboratory to determine how these limited functional results can be improved at a reduced risk. This is our responsibility as advisors and caretakers of those who come to us for care. P.R.M.
References 1. Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft: report on the first 6 months. Lancet 1999;353:1315–1320. 2. Jones JW, Gruber SA, Barker JH, Breidenbach WC. Successful hand transplantation. One-year follow-up. N Engl J Med 2000;343:468 – 473. 3. Francois C, Breidenbach WC, Maldonado C, et al. Hand transplantation: comparisons and observations of the first four clinical cases. Microsurgery 2000;20:360 –371. 4. Carroll D. A quantitative test of upper extremity function. J Chronic Dis 1965;18:479 – 491. 5. Russell RC, O’Brien B, Morrison WA. The late functional results of upper limb revascularization and replantation. J Hand Surg 1984;9A:623– 633. 6. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am 1973;4:865– 876. 7. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977;2:441– 451.
Surgeons are accustomed to giving advice and making medical recommendations. Individually as practitioners and collectively as a group of professionals, we generally enjoy the trust of those who come to us for care and thus have an obligation to present the best information regarding the nature and potential outcome of various treatment alternatives. While we recognize that it is ultimately the patient’s responsibility to choose, we often feel compelled to influence patient decisions, particularly when there is potential risk to life or limb. Our advice necessarily proceeds from our frame of reference as the treating physician, which is often governed by the Hippocratic aphorism premum non nocere (“first do no harm”). As important as this basic tenant is to the practice of medicine, we must recognize that it constitutes a very conservative approach to medical problems and allows little room for innovation and risk taking, even those that might be acceptable to a patient. In this issue’s Clinical Perspective, Dr Edgell and colleagues’ presentation on “Decision Making and Hand Transplantation” makes the point that patients may proceed from a completely different frame of reference and a different prioritization of values when making surgical decisions. Patients are often influenced more by factors related to body image and potential functional gain than by medical risks. The resultant outcome of an individual patient’s decision-making algorithm may be totally at odds with that of the surgeon’s, albeit just as rational and valid. In 1998 and 1999, hand surgeons from 3 different centers in Lyon, France; Louisville, Kentucky; and Guangzhou, China independently reported the transplantation of cadaver hands to the forearm amputation stumps of 4 patients.1–3 These reports were widely published and heralded in the media, but aroused the concern of hand surgeons. Negative editorials and castigating commentaries were predicated on the anticipated limited functional gains and the ethical question of subjecting the recipients to a lifetime of immunosuppressive therapy for a non–life-threatening condition. From the perspective of many hand surgeons, hand transplantation has come to be viewed as a wishful flight of fanciful thinking that has little chance for success. And yet. . .. for the patient who has lost a hand, transplantation provides the potential for restoration of body image and functional improvement and therefore may rise to the level of an acceptable risk. Despite the expressed concerns of many in the hand surgery community, it is arguable that the procedures performed at the 3 hand centers were appropriate. It appears that all involved were aware of the potential benefits and risks, even though the ratio between the two was unclear. Although bilateral hand transplantation procedures have been reported in 2 additional patients, objective postoperative data at 6 to 20 months have been reported from only the original 4 in the medical Copyright © 2001 by the American Society for Surgery of the Hand doi:10.1053/jhsu.2001.24331
The Journal of Hand Surgery 193
194 Paul R. Manske / Editorial
literature.1–3 According to these limited reports, the results have varied among the 4 patients; however, the following objective clinical observations can be made from a compilation of the information. 1. A cadaver hand can be technically transposed to a human forearm amputation stump. The osseous and soft tissue structures will heal and remain viable for up to 20 months with only transcient episodes of immunologic reaction. 2. The immunosuppressive agents required to prevent rejection have been adequately tolerated to date, causing no major medical problems or life-threatening episodes. 3. Function is marginal as determined by standard measurement parameters: ● Sensibility is poor. Although there has been progressive advancement of the Tinel’s sign, patients only report perception of temperature, pain, and deep pressure, with diminished/loss of protective sensation. ● There is early electromyographic evidence of intrinsic muscle reintervention, but only minimal clinical evidence of intrinsic muscle function. Grip strength at 1 year ranges between 2.7 and 5.0 kg and lateral pinch is 1.4 kg; it must be recognized that much of this “strength” may come from the extrinsic forearm musculature. ● Finger motion is limited. The total active motion of the 3 digital joints was reported in 1 patient to range from 66° to 83°. 4. It is difficult to determine whether the transplanted hand has actually resulted in improvement in activities of daily living because most of the reported “improved activities” are 1-handed tasks, for which the patients likely would have used the normal opposite extremity. According to the standards proposed by Carroll4 for upper extremity function, 1 patient was rated good, 2 fair, and 1 poor.5
From the patients’ perspectives, three appear pleased with the results and have apparently incorporated the transplanted hand into their self-image. Although the fourth patient was initially enthusiastic, he is reported to have become noncompliant with postoperative rehabilitation, and the hand was recently amputated at his request. It is difficult to predict this procedure’s future as a viable treatment alternative. Surgeons are aware that many well-established medical procedures and concepts were initially ridiculed and the subject of skepticism. One of the most notable examples in hand surgery occurred at the University of Louisville, where Edgell and colleagues currently work. In 1967, hand surgeons from that institution presented a paper at the 22nd annual meeting of the American Society for Surgery of the Hand on the primary repair of flexor tendons in zone II, a concept that ran contrary to the accepted recommendation for surgical care at that time. The presentation was met with such derision and resistance that publication of the technique was delayed until 19736 and specific results were not reported until 1977.7 Some 30 years later, the primary repair of lacerated zone II flexor tendons is now the standard of care. Conversely, surgeons are aware that the road of surgical progress is littered with an even greater number of failed concepts and flawed ideas. History will eventually applaud the successes and deride the failures, but in the beginning the two are often indistinguishable. Although these preliminary results may improve with time, it would be unfortunate if hand surgery failed to obtain more data and learn from these initial endeavors before continuing on. It would be equally unfortunate if the principle of premum non nocerum would prevent the advancement of an idea whose time may well yet come. The statement in the Hippocratic Oath that advises physicians to do no harm also requires them to “prescribe regimen for the good of my patients.” This prescribing must necessarily consider the perspective of both the surgeon and the patient. No one is certain of the fate of hand transplantation. At this time we all hear the sound of one hand clapping. Some hear the faint stirrings of applause, while others hear only a deafening silence. Notwithstanding, now is the time for surgeons and
The Journal of Hand Surgery / Vol. 26A No. 2 March 2001 195
patients to return to the clinical drawing boards to review whether the benefit to risk ratio of this procedure is sufficient for it to be repeated and for scientists to return to the laboratory to determine how these limited functional results can be improved at a reduced risk. This is our responsibility as advisors and caretakers of those who come to us for care. P.R.M.
References 1. Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft: report on the first 6 months. Lancet 1999;353:1315–1320. 2. Jones JW, Gruber SA, Barker JH, Breidenbach WC. Successful hand transplantation. One-year follow-up. N Engl J Med 2000;343:468 – 473. 3. Francois C, Breidenbach WC, Maldonado C, et al. Hand transplantation: comparisons and observations of the first four clinical cases. Microsurgery 2000;20:360 –371. 4. Carroll D. A quantitative test of upper extremity function. J Chronic Dis 1965;18:479 – 491. 5. Russell RC, O’Brien B, Morrison WA. The late functional results of upper limb revascularization and replantation. J Hand Surg 1984;9A:623– 633. 6. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am 1973;4:865– 876. 7. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977;2:441– 451.