by Curtis L. Cetrulo, Jr., MD, FACS Senior Investigator, Transplantation Biology Research Center Massachusetts General Hospital, Boston, MA
Loss of one or both hands from burn injury affects thousands of people each year, including many wounded American service members from the armed conflicts in Iraq and Afghanistan. Treatment options and methods to optimize functional capacity of these amputees remain limited and compound the difficulties faced by burn survivors recovering not only from a burn, but from the loss of their hand(s) as well.
Most approaches to rehabilitation after hand amputation center on fitting the patient with prosthetics to allow them to function more proficiently at the tasks required of everyday life. Prosthetic technology has advanced significantly over the past decade and many excellent options are available to help make life easier for someone missing one or both hands. Furthermore, at some specialized centers, surgeons can tailor surgeries to the requirements of the prosthetic makers to optimize comfort and fit and therefore maximize the patient’s function. Other more cutting-edge advances include the use of electrodes implanted in the patient’s remaining muscle to help power a robotic hand.
Unfortunately, for some individuals, even the most advanced prosthesis does not provide enough function to permit everyday activities to be completed without undue effort, fatigue and plain old frustration with the prosthetic, which, to some, can be a cumbersome tool. Because of these difficulties, some patients simply do not wear the prosthetic hand enough to justify the expense and training required to use it.
For patients who find the prosthetic less than optimum, hand transplantation may be a reasonable option to improve their lives. Hand transplantation is able to restore the appearance, sensation, and function of a native hand. The first successful clinical hand transplant was performed in 1998 in Lyon, France. This case was a technical success, and heralded the dawn of a new era. The results of over 80 hand transplants over the next 12 years have demonstrated that this is a safe and effective procedure.
While excellent functional results can be achieved through hand transplantation, challenges remain for the patients who undergo this revolutionary procedure. Patients must commit themselves to rigorous daily hand therapy while taking medication to prevent rejection of the transplanted hand. These medications are taken at higher doses in the initial post-transplant period and during this time have numerous short term side effects such as insomnia, appetite reduction, and depression, as well as long term risks, such as infection or a higher risk of some types of skin cancer. As these doses are slowly decreased over time, the hope is that the benefit of the patient’s new hand will soon outweigh the challenges required to adapt after a hand transplant. Patients of courage such as Joe Kinan are leading the way in this effort - and inspiring a new field of research at Massachusetts General Hospital designed to eliminate the need for these medications. Until that time, the risks and benefits of hand transplantation must be carefully considered and must be designed to integrate seamlessly into the holistic picture of a burn survivor’s recovery and journey to a better life.
CURTIS L. CETRULO, JR., MD, FACS is a world renowned reconstructive microsurgeon/hand surgeon and Clinical Director of the Reconstructive Transplantation Program of Massachusetts General Hospital. Dr. Cetrulo is Senior Investigator and Director of the Vascularized Composite Tissue Allotransplantation Laboratory at the Transplantation Biology Research Center, Massachusetts General Hospital. Dr. Cetrulo’s research efforts are directed toward improving transplantation tolerance to hand and face transplants. In addition, the laboratory has developed a preclinical model for temporary coverage of severe burn injuries.
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