Complications of Hand Transplantation: the Johns Hopkins-Pittsburgh Experience
W P Andrew Lee, MD1, Jaimie T. Shores, MD1, Carisa Cooney, MPH1, Stefan Schneeberger, MD2, Joseph E. Losee, MD3, Gerald Brandacher, MD1.
1Johns Hopkins University, Baltimore, MD, USA, 2Innsbruck Medical University, Innsbruck, Austria, 3University of Pittsburgh, Pittsburgh, PA, USA.
Since 1998, about 120 hand transplants have been performed worldwide. However, few systematic reports regarding complications exist. As hand transplant experiences accumulate, we report complications from our patient series in order to help inform future practice.
Following IRB approval, eligible candidates were transplanted using an immunomodulatory protocol involving donor bone marrow cell infusion, enabling minimum immunosuppression with tacrolimus monotherapy.
Since 2009, 11 hand/arm transplants have been performed in 7 patients, including 4 bilateral transplants, at Johns Hopkins and University of Pittsburgh. Good-to-excellent function was achieved in all but one recipient. Infrequent rejection episodes were treated with topical clobetasol, tacrolimus dose adjustment, and/or IV solumedrol. Complications included: -Intraoperative coagulopathy (n=2 patients) with significant bleeding -Limited skin flap necrosis (n=3) requiring wound care and/or skin graft -Bony nonunion (n=2) requiring revision -Delayed DVT (n=2) requiring temporary systemic anticoagulation -Systemic inflammation (n=4) leading to skin rejection episodes from thermal burn, cellulitis, appendicitis, periprosthetic forearm fracture -Poor hand function (n=1) with poor therapy engagement -Transient creatinine rise (n=4) which generally returned to normal range after tacrolimus adjustment -Non-compliance with medical regimen (n=2) following attainment of excellent function, resulting in allograft rejection and eventual explantation
Hand transplantation has restored motor/sensory function and body image in ways not achievable with prosthetics, leading to autonomous and productive lives in compliant patients. Recipients maintained on tacrolimus monotherapy encountered few adverse effects. This experience has focused efforts on pre-transplant psychosocial screening to select patients most likely to comply with medical regimen and hand therapy.
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