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Section 2: Upper Limb
Tab le 2
Indications and Contraindications for Glenohumeral
Arthrodesis, Transhumeral Amputation, and Early Prosthetic Fitting
Indications Severe brachial plexus injury (accid shoulder, elbow, hand)
Contraindications Paralysis of the scapulothoracic muscles (trapezius, levator scap-
Combined Transhumeral
Amputation and
Glenohumeral Arthrodesis
The rationale for transhumeral amputation after a BPI is to allow prosthetic fitting, whereas glenohumeral arthrodesis
permits shoulder protraction through
the preserved thoracoscapular muscles
to operate a mechanical prosthesis.95 In
1961, Yeoman and Seddon96 noted that
patients who underwent transhumeral
amputation and shoulder arthrodesis
within 16 months of injury were more
likely to use their prosthesis compared
with patients who became proficient at
one-handedness within 2 years after the
BPI. Subsequently, Parry97 reported that
of 14 patients with complete BPIs who
underwent combined amputation and
arthrodesis procedures within 6 months
of injury, 10 patients returned to work
within 1 year. However, Ransford and
Hughes98 reviewed their series of early
versus late combined amputation and
arthrodesis procedures in 13 patients
with complete BPIs and noted that only
2 patients with BPI in the dominant limb
truly used their prosthesis functionally
irrespective of the time to amputation.
Transhumeral amputation, glenohumeral arthrodesis, and an externally
powered prosthesis may facilitate early
with a poor prognosis for additional recovery (preganglionic)
Failed primary brachial plexus reconstruction for a complete
brachial plexus injury
Patient dissatisfaction with lack of usefulness and/or discomfort
of the ail limb
Patient willing to attempt prosthetic use
Shoulder pain or discomfort secondary to inferior glenohumeral
subluxation
Recurrent infections or injuries to the insensate arm
ulae, latissimus dorsi, serratus anterior, or rhomboids)
Active infection in the proximal humerus or glenohumeral joint
Prior glenohumeral arthrodesis in the contralateral side
return of upper limb function in patients
with complete preganglionic BPIs. In
traumatic upper limb amputations, immediate use of a postoperative prosthesis
has been associated with marked improvements in rehabilitation.99 Malone
et al7 reported on a 23-year-old patient
with a complete preganglionic BPI who
underwent transhumeral amputation
and glenohumeral arthrodesis and received an early myoelectric elbow and
hand prosthesis at 6 years after injury.
This patient was able to return to work
and was satisfied with the functional results. Similarly, Thyberg and Johansen
observed 16 hours of daily myoelectric
transhumeral prosthesis use and function in a 20-year-old patient with a nonspecified BPI that was equivalent to that
of a patient with a myoelectric transradial prosthesis. More recently, Bedi et
101
al
anecdotally observed considerable
relief from pain caused by shoulder instability and inferior subluxation and
improved functional rehabilitation in
carefully selected patients who were
treated with combined amputation and
arthrodesis.
For the authors of this chapter, the
role of amputation and arthrodesis procedures is limited given the current advances in brachial plexus reconstruction.
Previously, amputation and arthrodesis
procedures were recommended in patients with dominant limb involvement
who had difficulty transferring hand
dominance to the nondominant limb,
in patients who could not participate in
athletic activities because of interference
from the limb, or in patients who were
repulsed by their flaccid limb.
recently, early physical therapy and attempted brachial plexus reconstruction
have been advocated, reserving combined amputation and arthrodesis as a
salvage procedure.
102
The authors’ current indications and contraindications
for the combined procedure are listed
in Table 2.
101,103-105
Initial Brachial Plexus
Reconstruction Versus
Transhumeral Amputation
and Glenohumeral
Arthrodesis
Brachial plexus exploration and reconstruction should be performed
before proceeding with combined transhumeral amputation and glenohumeral
arthrodesis for all BPIs that show no
evidence of reinnervation.
ically, the combined amputation and
arthrodesis procedures were performed
early after a complete BPI to facilitate
successful two-handed function with
100
the aid of a prosthesis.
was a proponent of this treatment option
until excellent recovery of elbow and
shoulder function was observed in 11
of 12 patients with a complete BPI who
were initially recommended to undergo
combined amputation and arthrodesis
procedures but refused. Current microsurgical techniques for brachial plexus
reconstruction can result in an animate
arm that is functional in most cases, irrespective of complete or partial and
preganglionic or postganglionic BPIs.86
If index reconstruction efforts fail, secondary reconstruction procedures can
still improve outcomes.
the setting of complete BPI, Allieu and
Cenac1 recommended that “no patient
93,97,98,107
10,11,2 5,69
95,98
106
Histor-
Parry94
Even in
More
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
402
Chapter 32: Brachial Plexus Injuries
should be subjected to upper extremity amputation…because they never
require it emergently and almost never
ask for it later. Thus, a totally paralyzed
arm is better than amputation.”
Authors’ Current
Treatment Algorithm
For most open BPIs, including penetrating trauma and high-velocity gunshot
wounds, immediate brachial plexus
exploration and primary nerve repair
or brachial plexus reconstruction is
performed. For closed traumatic BPIs,
the patient is initially evaluated in a
multidisciplinary fashion (neurology,
orthopaedic surgery, neurosurgery,
and physical medicine and rehabilitation) 3 to 6 weeks after injury to obtain a baseline physical examination.
An electrodiagnostic study and finecut CT myelography are performed
to determine the type (preganglionic
or postganglionic) and level of BPI in
conjunction with the physical examination. Upper limb splinting, occupational therapy, and antineuropathic pain
medications are initiated immediately
after the injury. Serial examinations are
performed until 6 months after injury. If
no evidence exists of substantial nerve
regeneration or motor recovery, brachial plexus reconstruction is performed;
otherwise, patient observation continues. If necessary, additional secondary
brachial plexus reconstruction is performed to enhance the function gained
by the index reconstruction attempt. If
primary and secondary reconstruction
both fail in the patient with functional
scapulothoracic muscles, a salvage procedure of transhumeral amputation,
glenohumeral arthrodesis, and early
prosthetic fitting is indicated and can
be performed if requested by the patient.
Summary
BPIs can result in a wide range of dysfunction to the upper limbs and have
variable potential for nerve regeneration.
A meticulous physical examination, in
concert with imaging and electrodiagnostic studies, is necessary to characterize the BPI and formulate a treatment
plan. A multidisciplinary approach to
patient care is necessary to maximize
clinical outcomes. With current advances in microsurgical techniques,
brachial plexus reconstruction should
be attempted. Amputation of the upper
limb after a BPI should be reserved as a
salvage procedure.
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Wahegaonkar A: Role of wrist
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92. Leert R: Brachial Plexus Injuries.
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Chapter 32: Brachial Plexus Injuries
96. Seddon HJ, Yeoman PM: Brachial plexus injuries: Treatment of
the ail arm. J Bone Joint Surg Br
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407
Chapter 33
Hand Transplantation
LCDR Scott M. Tintle, MD, MC, USN Jaimie T. Shores, MD, FACS L. Scott Levin, MD, FACS
Abstract
Because hand loss aects nearly every activity of daily living and results in substantial
disability, vascularized composite allotransplantation oers an alternative to prosthesis
use and can be considered a restorative option for carefully selected patients. Because the
outcome of a hand transplant is greatly dependent on the participation, cooperation, and
compliance of a patient with hand therapy, medications, and follow-up screening appointments, careful evaluation of transplantation candidates is mandatory. Evaluation factors
should include a patient’s behavior, social support, nancial security, and psychiatric and
psychological health. If hand transplantation is elected, the surgeon must be familiar with
donor procurement procedures, surgical techniques for transplantation at various levels,
postoperative care requirements, possible complications, and the lifelong need of immunotherapy for the patient.
Keywords: amputation; hand transplant; nerve transfer; restorative
surgery; vascularized composite allotransplantation
Introduction
Although vascularized composite allotransplantation (VCA) remains a
controversial topic in upper limb amputations, there is little disagreement
that hand transplantation is the most
important restorative surgery that can
currently be provided for upper limb
amputations. Hand loss is a devastating
event that affects nearly every activity
of daily living and leaves patients with
substantial disability.
patient of losing both sensibility and
prehension often results in despondency, and its adverse consequences cannot be overstated. Despite promising
technological advances in upper limb
Dr. Shores or an immediate family member has received research or institutional support from
AxoGen. Dr. Levin or an immediately family member has received research or in stitutional support
from AxoGen and serves as a board member, owner, ocer, or committee member of the American
College of Surgeons, the American Society for Reconstructive Microsurgery, the American Society
for Surgery of the Hand, the International Hand and Composite Tissue Allotransplantation Society,
the United Network for Organ Sharing, the Vascularized Composite Allogra Transplantation
Committee, and the World Society for Reconstructive Microsurgery. Neither Dr. Tintle nor any
immediate family member has received anything of value from or has stock or stock options held
in a commercial company or institution related directly or indirectly to the subject of this chapter.
1,2
The effect on a
prostheses, including targeted muscle reinnervation and osseointegrated
implants, the available literature still
demonstrates high prosthesis rejection rates for upper limb amputations.
These findings suggest that prostheses
cannot replicate the complex prehensile and sensory functions of the native
hand and arm in a reliably comfortable
and useful form.
3-11
Residual limb discomfort, prosthesis weight, and limited
usefulness remain the most commonly
cited reasons for the rejection of upper
limb prosthetics.
3,12,13
Hand transplant pioneers surmised
that prosthetic devices would never
completely satisfy an individual with
an upper limb amputation. Even if dexterity and prehensile function of the
human hand could be restored, these
would do little to restore highly coveted
body image or hand sensibility. Rather, they postulated that these functions
could be replaced only with “like” human tissue and full neural reintegration.14 The VCA field has grown from
this desire to fully restore the functional and emotional aspects of the human
hand (Figure 1).
History
The world’s first hand transplant, likely
inspired by the solid organ transplantation community’s rapid growth, was performed in South America in 1964.
Unfortunately, because of relatively
primitive immunosuppression techniques as well as a lack of basic science
preparation, acute rejection predictably
occurred, and the transplanted limb was
amputated less than 1 month later.
This failure, or the realization that the
hand surgery community had reached
too far too fast, resulted in a long interval before the next hand transplant
attempt in Lyon, France, in 1998.
Technically, this procedure succeeded;
however, the technical success was unsustainable because the patient did not
adapt psychologically to the new hand
and discontinued immunosuppressive
medications. The limb was eventually
amputated because of chronic rejection
and a lack of function.1 Dr. Warren
Breidenbach performed the first truly
successful hand transplant in the United States in 1999. The patient still has
the transplanted hand today—nearly
16 years later—with excellent function,
even returning to work afterward.
1,15,16
12, 17
12,18,19
12,13,20
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
409
Section 2: Upper Limb
Figure 1
on the patient ’s quadrimembral amputations. Ultimately, a multidisciplinary approach led this patient and the surg eon to determine that prosth etic function was too go od for the risk involved with
hand transplantation. (Copyright L. Scott Levin, MD, Philadelphia, PA.)
Advances in solid organ transplantation made possible the early success in
hand transplantation in the late 1990s.
New medications, such as tacrolimus
and mycophenolate mofetil, decreased
the likelihood of rejection. Animal
models of VCA have provided the basic
and translational science evidence that
successful allotransplantation without
rejection is possible with these medications.
grown dramatically. Worldwide, 107
hand transplants have been performed
to date, and at least seven centers in the
United States have performed a hand
transplant.
Clinical photograph of an ideal candidate for bilateral hand transplantation based
slowed the growth of VCA compared
with growth in solid organ transplantation. Because the patient considering
hand transplantation is not faced with a
life-or-death situation, hand transplantation is very different from most solid
organ transplantations.25 Developing
widely accepted indications for subjecting a physiologically healthy person to
the risks of lifelong immunosuppression
12,21-23
Since then, the VCA field has
remain the preeminent challenges for
the allotransplantation community.
In 2009, Hollenbeck et al14 indicated that well-defined indications do
not exist for hand or face transplants.
Unfortunately, this statement is rela-
26
tively accurate today, but the indica-
Indications and Ethical
Considerations
Primum non nocere—“first do no
harm”—must be the paramount principle as the VCA field progresses. Cooney
et al24 echoed this sentiment in their
2002 American Society for Surgery of
the Hand position statement, when they
recommended “great caution and a mea
sured approach to the patient requesting limb transplant.” This caution has
tions remain open to interpretation
by individual VCA centers.
27, 28
recognized the need for more refined
indications for hand transplantation,
the allotransplantation community
founded the American Society for Reconstructive Transplantation in 2008,
whose goal is to provide a platform for
-
advancing composite tissue allotransplantation as relevant to reconstructive
and transplant surgery. The society
Having
published guidelines for medical ne
cessity determination for transplanting
the hand and/or an upper limb. Despite
this comprehensive and admirable attempt at defining indications, further
refinement is necessary to ensure the
safe advancement of the field.
13
Screening for VCA
Hand allotransplantation represents a
lifelong commitment by a surgeon, the
patient, the patient’s family, and, ultimately, the healthcare system. Without
the commitment of each entity, the true
lifelong success of transplantation will
not be realized. For this reason, screening for VCA is expensive and laborious,
but vitally important. Every aspect of
the life of the transplant candidate must
be reviewed. Medical screening should
include primary care, cardiology, infectious disease, and transplant medicine.
In-depth evaluations of a patient’s behavior, social support, financial security, and psychiatric and psychological
health are necessary and may ultimately disqualify a patient for transplant if
possible risk factors that could lead to
failure are identified. The outcome of a
hand transplant is very much dependent on the participation, cooperation,
and compliance of a patient with hand
therapy, medications, and follow-up
screening appointments. Every preoperative screening is critical because these
screenings may both predict patient
compliance and identify other medical
risk factors for failure.
The psychological assessment is
likely the most critical component of
transplant screening, and most patients
have been found to have at least one
psychological disorder.29 The success
of a kidney, liver, or heart transplant
depends only on a patient’s compliance
with medications, but relatively high
rates of medication noncompliance occur among patients who depend on the
transplant(s) for life.
bined heart and heart/lung transplant
population, the only risk factor for graft
30, 31
Among a com-
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
410
loss between 6 and 12 months was being unmarried or not living in a stable
relationship. The social support for an
individual candidate must be identified,
and a transplant should not occur if the
surgeon is not comfortable with a patient’s support system.
13
Preferred Surgical
Technique of This
Chapter’s Authors
Donor Procurement
Procurement is performed on donors
with brain death declarations whose
families have consented to donation.
Donor activation and procurement
specifics have been reported in more
detail elsewhere and are briefly summarized here.32 Hand procurement is
performed in a coordinated fashion with
all other organ procurement teams (for
example, kidney, liver, heart, and lungs).
The hand(s) may be procured before
solid organ procurement or during solid organ procurement, although they
must be perfused with preservation
solution after procurement. Organ donation patients are heparinized before
aorta cross-clamping. For a transplant
at the hand/wrist/distal forearm level,
procurement by means of elbow disarticulation is rapid and provides ample
tissue. For procurements at the midforearm level, an elbow disarticulation
also may suffice, although if concerns
for adequate vessel or nerve length or
the quality of the soft-tissue envelope
are present, a supracondylar humerus
procurement provides extra tissue as
necessary. For proximal forearm transplants, a lower to middle humerus procurement is performed (Figure 2). For
supracondylar to midhumerus transplantation, procurement is performed
as high on the humerus as possible to
obtain adequate blood vessel, nerve, and
soft tissue.
Procurement is typically performed
under tourniquet control, and a guillotine incision is made medially to
expose the brachial vessels, which are
Chapter 33: Hand Transplantation
Figure 2
proximal level (A) and the amputated donor limb being perfused with preservation solution (B).
(Copyright Jaimie T. Shores, MD, Baltimore, MD.)
controlled with proximal clips or ligatures. Distal to the ligatures, an arteriotomy is made, and a cannula is
inserted to allow perfusion. After the
cannula is in place, the superficial and
deep veins are divided, and perfusion
with the desired preservation solution
is performed. Clinical examination of
the vessels determines the dominance
of the deep versus superficial venous
system for outflow drainage. The soft
tissues, including the nerves, are
Intraoperative photographs of the setup for procurement of a donor limb at the
gauze and then placed into a sealed plastic bag. This bag is placed into another
sealed bag, immersed in an ice and water
slurry bath in a third bag, placed in a
cooler, and then transported immediately. The residual limb is closed after all
organ and tissue donation has ceased.
A cosmetic prosthesis that is skin tone
matched is then applied to the donor
residual limb to permit postmortem
family viewing and open casket burial,
if desired.
sharply divided. For disarticulations,
the elbow joint is sharply opened and
separated. For transhumeral procurement, a saw is used for the humeral
osteotomy.
To improve coordination among all
organ procurement teams, the limb can
be rapidly removed and perfused on the
back table in the surgical suite or it can
be perfused immediately prior to amputation. The limb is wrapped in moist
Transplantation
The recipient is prepared by anesthesia
with arterial and large central venous access. Peripheral large-bore venous access
is obtained, if possible. Premedication is
administered using immunological induction therapy. Peripheral block nerve
catheters may be placed but should not
be dosed with medication during the
initial surgery.
33
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