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Hand Transplant vs. Prosthesis

Posted Apr 04 2011 11:01am
I took this photograph.

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My friend Ramona , recently posted about the Orlando, Florida student, Linda Lu , who has just received a hand transplant in her blog Suture for a Living .  Dr. Bates is a surgeon and also a phenomenal quitter.  So you see she certainly understands how important her hands are, yet she noted, “Just because we can do a procedure, doesn’t mean we always should.” I share her sentiments.

As a life care planning expert in amputation injury and limb loss, I find hand transplantation somewhat disturbing.  I can appreciate the technology and biological advances that have allowed transplantation to occur.  I certainly understand the desire the patient has to obtain a flesh and blood hand.  It’s just that I personally don’t feel this is an appropriate answer for most individuals and particularly not those who seem to have adapted well without. I wonder just how many of the 14 transplants done thus far were performed because the patient wanted a flesh and blood hand rather than weighing the risks and benefits concerning what the functional outcome would be.

According to the Fox News story , Ms. Lu lost her hand at one year of age secondary to Kawasaki disease .  A small child who grows up without a limb is very adaptive and typically does not wear a routine hand prosthesis.  Most single limb loss individuals will adapt and use a prosthesis for cosmetic reasons or on occasion, a body powered device for specific tasks.  While I do not know Ms. Lu, nor have I obtained any information outside of this news article, I am surprised she was accepted for this procedure with limb loss at such a young age.  I wonder what expectations she has for her life moving forward. I would certainly hope that the work up for a hand transplantation included a psychological evaluation to determine if her expectations were realistic.

One need only to review the case of Mr. Jeff Kepner , a bilateral hand transplant patient, to understand the concerns of such a procedure.  One year after his transplant he still regretted his life changing decision. In his words…

Mr. Kepner sits in therapy for six hours a day…every day.  As of the report, he was unable to bend his fingers or distinguish textures. He is no longer as independent as he was with his bilateral prosthetics; requiring help to dress and bath.  The former culinary chef lost 60 pounds following the transplantation surgery which tells me he isn’t spending his time in the kitchen any longer. I would like to think he has improved and has made much progress since this news story, but his website hasn’t been updated since last summer. I take that as bad news.

Advances in medicine gave us the ability to perform hand transplantation, but tremendous advances have also been made in prosthetics. In upper limb loss prosthetics we now have transhumeral and shoulder disarticulation amputees able to wear a prosthesis which is controlled by activating muscles in their chest using a procedure called targeted muscle reinnervation. The i-Limb by Touch Bionics is a prosthesis which has five individually powered digits allowing the wearer to open and close the hand while articulating the fingers to close tightly around objects. Bebionic hands moves and grips in a natural and coordinated way and features individual motors for each digit of the hand. Otto Bock is developing the Michelangelo hand which features multiple grip functions and a flexible positionable wrist joint for a more natural shape and movement. This hand is expected to increase grip force and reliability without compromising speed seen in other prostheses. Even functional partial hand prostheses are possible with ProDigits by Touch Bionics .

The advantages of hand transplantation over prosthetic use is that of sensation. The expectation is that the transplanted hand will eventually be able to distinguish some textures and temperature changes.  A below the elbow amputee (BEA) patient of mine recently attended an appointment with his prosthetic provider.  He was looking into a new technologically advanced prosthetic to replace his old one.  He broke down crying and stated, “I just want to be able to reach over and caress my wife’s cheek as I kiss her or stroke her hair.”  The likelihood of obtaining a prosthesis with tactile sensation won’t be possible until we have cyborg ability to be both machine and flesh and blood.

When one compares the cost of surgery, therapy, immunosuppressive medications, psychological evaluation, follow up, and other necessary care, the medical costs for hand transplantation are higher than even the most highly advanced arm prosthesis.  The question becomes is the transplanted hand more functional than our most sophisticated prosthesis?  I think not, at least not at this time.  Regardless of the choice between hand transplant surgery or the most highly advanced prosthetic hand, the replacement is never going to be an adequate replacement for the God given hand. Any patient who thinks otherwise is going to be sorely disappointed.

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