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      Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study

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          Abstract

          Background

          Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands.

          Methods

          Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36).

          Results

          Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in “role-physical” (p = 0.006), “vitality” (p = 0.008), “role-emotional” (p = 0.035) and “mental-health” (p = 0.003).

          Conclusions

          The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient’s best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.

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          Most cited references38

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          A performance test for assessment of upper limb function in physical rehabilitation treatment and research.

          R C Lyle (1981)
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            A standardized approach to performing the action research arm test.

            The study of stroke and its treatment in human subjects requires accurate measurement of behavioral status. Arm motor deficits are among the most common sequelae after stroke. The Action Research Arm Test (ARAT) is a reliable, valid measure of arm motor status after stroke. This test has established value for characterizing clinical state and for measuring spontaneous and therapy-induced recovery; however, sufficient details have not been previously published to allow for performance of this scale in a standardized manner over time and across sites. Such an approach to ARAT scoring would likely reduce variance between investigators and sites. This report therefore includes a manual that provides a highly detailed and standardized approach for assigning ARAT scores. Intrarater reliability and interrater reliability, as well as validity, with this approach were measured and are excellent. The ARAT, when performed in a standardized manner, is a useful tool for assessment of arm motor deficits after stroke.
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              Human hand allograft: report on first 6 months.

              Long-term survival of animal limb allografts with new immunosuppressant combinations and encouraging results of autologous limb replantations led us to believe that clinical application of hand transplantation in human beings was viable. On Sept 23, 1998, we transplanted the right distal forearm and hand of a brain-dead man aged 41 years on to a man aged 48 years who had had traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with UW organ preservation solution at 4 degrees C, amputated 5 cm above the elbow, and transported in a cool container. We dissected the donor limb and the recipient's arm simultaneously to identify anatomical structures. Appropriate lengths of viable structures were matched. Transplantation involved bone fixation, arterial and venous anastomoses (ischaemic time 12.5 h), nerve sutures, joining of muscles and tendons, and skin closure. Immunosuppression included antithymocyte globulins, tacrolimus, mycophenolic acid, and prednisone. Maintenance therapy included tacrolimus, mycophenolic acid, and prednisone. Follow-up included routine post-transplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. The initial postoperative course was uneventful. No surgical complications were seen. Immunosuppression was well tolerated. Mild clinical and histological signs of cutaneous rejection were seen at weeks 8-9 after surgery. These signs disappeared after prednisone dose was increased (from 20 mg/day to 40 mg/day) and topical application of immunosuppressive creams (tacrolimus, clobetasol). Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress (Tinel's sign) was excellent and reached the wrist crease (20 cm) on day 100 for the median and ulnar nerves, and at least 24 cm to the palm by 6 months when deep pressure, but not light touch sensation, could be felt at the mid palm. Hand allotransplantation is technically feasible. Currently available immunosuppression seems to prevent acute rejection. If no further episode of rejection occurs, the functional prognosis of this graft should be similar to if not better than that reported in large series of autoreconstruction.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                2 September 2016
                2016
                : 11
                : 9
                : e0162507
                Affiliations
                [1 ]Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
                [2 ]Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
                [3 ]Department of Physical Medicine and Rehabilitation, Medical University of Vienna, Vienna, Austria
                [4 ]Department of Physical Medicine and Rehabilitation, Danube Hospital Vienna, Vienna, Austria
                [5 ]Center for Advanced Psychology in Plastic and Transplant Surgery, Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
                [6 ]Department of Physical Medicine and Rehabilitation, Medical University of Innsbruck, Innsbruck, Austria
                [7 ]Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Innsbruck, Austria
                [8 ]Departments of General and Transplant Surgery, Medical University of Innsbruck, Innsbruck, Austria
                [9 ]Department of Traumatology, Medical University of Innsbruck, Innsbruck, Austria
                [10 ]Hand Trauma Center, St. Hedwigs’s Hospital, Trzebnica, Subdepartment of Replantation of Limbs, Trzebnica, Poland
                [11 ]State Higher Medical Professional School, Opole, Poland
                University of Toledo, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: S. Salminger AS MK MN GP AC JJ OCA.

                • Data curation: S. Salminger AS LAH TP MK MN GP S. Schneeberger MG AC JJ.

                • Formal analysis: S. Salminger AS ADR LAH MK MN.

                • Investigation: S. Salminger AS LAH MK MN GP S. Schneeberger MG AC JJ.

                • Methodology: S. Salminger AS LAH TP MK MN OCA.

                • Writing – original draft: S. Salminger ADR AS LAH MK AC OCA.

                • Writing – review & editing: S. Salminger AS ADR LAH TP MK MN GP S. Schneeberger MG AC JJ OCA.

                Article
                PONE-D-16-16337
                10.1371/journal.pone.0162507
                5010226
                27589057
                e8cebadd-d629-46dd-9eec-cc47ca521efa
                © 2016 Salminger et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 April 2016
                : 1 August 2016
                Page count
                Figures: 0, Tables: 3, Pages: 13
                Funding
                This work was supported by the Christian Doppler Research Foundation a subdivision of the Austrian Federal Ministry of Economy, Family and Youth, the Austrian Council for Research and Technology Development.
                Categories
                Research Article
                Biology and Life Sciences
                Biotechnology
                Medical Devices and Equipment
                Prosthetics
                Medicine and Health Sciences
                Medical Devices and Equipment
                Prosthetics
                Biology and Life Sciences
                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Arms
                Hands
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Arms
                Hands
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Immunology
                Transplantation Immunology
                Transplant Rejection
                Biology and Life Sciences
                Immunology
                Clinical Immunology
                Transplantation Immunology
                Transplant Rejection
                Medicine and Health Sciences
                Immunology
                Clinical Immunology
                Transplantation Immunology
                Transplant Rejection
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Immunology
                Transplantation Immunology
                Biology and Life Sciences
                Immunology
                Clinical Immunology
                Transplantation Immunology
                Medicine and Health Sciences
                Immunology
                Clinical Immunology
                Transplantation Immunology
                Biology and Life Sciences
                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Arms
                Forearms
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Limbs (Anatomy)
                Arms
                Forearms
                Biology and Life Sciences
                Biotechnology
                Medical Devices and Equipment
                Medicine and Health Sciences
                Medical Devices and Equipment
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Medicine and Health Sciences
                Health Care
                Patients
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