Rev. bras. ortop. vol.48 número6

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w w w . r b o . o r g . b r

Case

report

Experience

of

a

Brazilian

surgeon

in

a

hand

transplant

case:

“What

I

saw,

what

I

learned”

夽,夽夽

João

Bosco

Rezende

Panattoni

Filho

a

_,

_Tsu-Min

_Tsai

b

_,

_Huey

_Tien

b

_,

_Joseph

_Kutz

b,∗

a_Department_of_Orthopaedic_Surgery,_Saint_Louis_University,_St._Louis,_USA

b_Kleinert_Kutz_Hand_Care_Center,_Christine_M._Kleinert_Institute_for_Hand_and_{Microsurgery,}_Louisville,_Kentucky,_USA

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Articlehistory:

Received30August2012 Accepted9November2012

Keywords: Amputation Hand Therapy Transplantation

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TheLouisvilleVCA(VascularizedCompositeAllograft)Programisoneofthelargesthand transplantprogramsintheworld.DuringmyhandsurgeryfellowshipattheChristineM. KleinertInstitute,theteamperformedtheeighthhandtransplantontheseventhrecipient inLouisville.TheLouisvilleVCAProgramhasdone9handtransplantsin8recipientswith onebilateralcase.Amongthesearethefirst5handtransplantcasesintheUnitedStates. Thefirstcasewasdonein1999andhastheWorld’slongestfollow-up.Theseventhcasewas performedina36-year-oldmaleonJuly10,2011.Theresultachievedsofarcanbe consid-eredexcellentwithaverygoodpatientsatisfaction.Thereisalargemultidisciplinaryteam involvedinsuchprocedureswithallmembersplayingacrucialrolefortheachievementof thebestresultpossible.Thepresentpaperfocusesonthesurgicalprocedureforthe sev-enthrecipient,whichwasuniqueduetothelevelofamputationoftherecipient’shand, withpreservationofnervetothethumb.

Experiência

de

um

cirurgião

brasileiro

em

cirurgia

de

transplante

de

mão:

“O

que

vi,

o

que

aprendi”

Palavras-chave: Amputac¸ão Mãos Terapia Transplante

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e

s

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OProgramadeEnxertoAlográficoVascularizadoComposto(VascularizedComposite Allo-graftouVCAProgram)deLouisvilleéumdosmaioresdetransplantedemãonomundo. DuranteomeufellowshipemcirurgiadamãonoChristineM.KleinertInstitute,ogrupofez ooitavotransplantedemãonosétimoreceptoremLouisville.OVCAProgramdeLouisville jáfeznovetransplantesdemãoemoitoreceptores(umcasobilateral).Entreessesestãoos primeiroscincocasosdetransplantedemãonosEstadosUnidosdaAmérica.Oprimeiro foifeitoem1999,oqueteveomaislongoseguimentoemtodoomundo.Osétimocasofoi feitoemumpacientedosexomasculinode36anosem10dejulhode2011.Oresultado

夽

Pleasecitethisarticleas:PanattoniFilhoJBR,TsaiT-M,TienH,KutzJ.Experiênciadeumcirurgiãobrasileiroemcirurgiadetransplante demão:“Oquevi,oqueaprendi”.RevBrasOrtop.2013;48:567–573.

夽夽

WorkperformedattheChristineM.KleinertInstituteforHandandMicrosurgery,Louisville,Kentucky,USA. ∗ _{Corresponding}_author_.

E-mail:[email protected](J.Kutz).

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seráfocadonoprocedimentocirúrgicofeitonosétimoreceptor,quefoiconsideradoum casoespecial,porcausadoníveldaamputac¸ãodamãodopaciente,compreservac¸ãodo nervoparaopolegar.

Introduction

Transplantationhasagreatfutureinthefieldofhandsurgery andreconstructivemicrosurgery.Sofar,72handtransplants havebeenperformedonatotalof51patientsaroundtheworld (30patientshadonehandtransplantedand21hadboth trans-planted)(www.handregistry.com).

Handtransplantationsurgeryisstillconsideredtobean experimentalprocedure but isa rapidlyexpanding typeof treatment.Itisnowperformedsuccessfullyinmorethan a dozenspecializedcentersworldwide1 _and_in_five_centers_in theUnitedStates.2

Thepostoperativeresultsarevery promising,withgood patientsatisfaction,especially because ofrecoveryofgood functioninthetransplantedhand.Themainadvantagesof handtransplantation,incomparisonwithaprosthesis,are therecoveryofsensitivity,thecosmeticaspectandthe“heat” ofthetransplantedhand.3

Thefirstcaseofhand transplantation performedinthe modern era ofimmunosuppressionwas inFrance in 1998. Thetransplantedhandhadtobeamputatedtwoyearslater, afterthepatientdecidedtostoptakingimmunosuppressant drugs.4

Less than a year later, the Louisville VCA (Vascularized CompositeAllograft)Programperformedthefirsthand trans-plantationintheUnitedStates,inJanuary1999.Therecipient continuestobewelltothepresentday,withgoodrecoveryof functioninthetransplantedhand.Thelong-termfunctional resultexceededtheinitialexpectations.5

The Louisville VCA Program is a collaboration between thesurgeonsandteamsofKleinertKutzHandCareCenter, Jewish Hospital(now part ofKentucky One Health), Chris-tine M. Kleinert Institute and the University of Louisville. Thegrouphasnowperformedhandtransplantationsurgery on eight patients (one bilateral case) and hashad to deal withcomplicationssuchashiposteonecrosis,diabetes(due touse ofsteroids) and onecaseof graft lossnine months after the transplantation, due to vasculopathy.6 _Despite theseproblems, sevenofthe eightpatientscontinue tobe very well. Even the patient who lost the graft wishes to undergoasecondtransplantation.Complicationsrelatingto immunosuppressionhavebeencontrolleduptothepresent day.

Inthefuture,itcanbeexpectedthatmoreandmore cen-terswillstarttoperformhandtransplantationsurgery,and that this procedure willcease tobe experimentaland will becomestandard.Moreover,withtheeconomicgrowththat Brazilisundergoing,webelievethatitisimportantforsurgery ofthistypetobeperformedinthiscountry,whichwouldmake

BrazilthelocationforthefirsthandtransplantationinSouth America.

Itisimportanttoemphasizethathandtransplantationis aprocedurethatdependslargelyonamultidisciplinaryteam forafavorableresulttobeobtained.Thisteamiscomposedof handsurgeons,transplantationsurgeons,psychiatrists,social workers,occupationaltherapists,nurses,immunologistsand coordinators.However,thepresentarticlefocusesonthe sur-gicaltechniqueusedinthecaseofpatientnumbersevenand howtheteamwasorganizedatthesurgicalcenter. Informa-tionontheimmunosuppressiontherapy(requiredfortherest ofthepatient’slife)andthepostoperativeoccupational ther-apyprotocolwillbediscussedinaseparatearticle.

TheseventhLouisvillepatientreceivedhishandtransplant on July10,2011.Therecipientwasa36-year-old manwho hadsufferedanindustrialaccidentonMarch9,1998.Inthe accident,bothofhisarmsbecametrappedinapress(chopping machine).Hisrighthand(dominanthand)wascrushedand hislefthandwaspartiallyamputated,distallytothewrist.The patientwasleftwithpartofhisleftthumbandleftwristwith adequatemovement(Fig.1).Therighthandsufferedsequelae ofmusclehypotrophybecauseofinjurytotheulnarnerve,but amputationwasnotrequired.

Thesurgical teamwas composedof16 surgeons (seven chiefsandninefellows).Oneofthechiefs(Dr.Kutz)wasthe leadingsurgeon:hefollowedupeverystepoftheprocedure andalsoorganizedhowthesurgicalteamswouldrotate.The firstauthor,Dr.JoãoPanattoni,fromCampinas(SP),Brazil,was presentandparticipatedintheproceduresasoneofthesenior fellows.

The anesthesia team was composed ofone anesthetist and one nurse who was an anesthesia specialist. General anesthesia was induced, with additional regional brachial plexusblock,forgreatervasodilatationandpostoperativepain control.Thenursingteamcomprisedthreenursesandtwo instrumenttechnicians.

Atthestartoftheoperation,twosurgicalteamsworked concomitantlyinthesamesurgicalroom.Theteamworking ontherecipientstartedfirst,whilethesecondteamharvested thelimbfromthedonor.Efficientcommunicationbetweenthe teamsisimportant,inordertoensurethatthelimbfromthe donorisinagoodconditionbeforeanesthesiaisinducedand surgeryisperformedontherecipient.

Surgicaltechnique

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Figure1–Preoperativeappearance.

Source_:_Christine_M._Kleinert_Institute.

Limbharvesting

Withtheaimofreducingthedurationofhotischemia, har-vestingandtransportationofthelimbfromthedonorwere doneasquicklyaspossible.Whenpossible,thehand harvest-ingteamgoes infirstanduses atourniquettoremovethe handorhands beforecross-clampingand organharvesting areperformedonthedonor.

Thebrachialarterywasidentifiedandprotectedandthe limbwas amputated atthe elbow joint.Preservation solu-tion(University ofWisconsin solution)at4degreesCelsius wasinfusedinto thebrachialarteryandtheopenareawas keptmoistusingcompressessoakedinphysiologicalserum. Thelimbwasthenplacedinaninsulatedplasticbag,which was then placed in an insulated box with ice. When the limbarrivedatthesurgicalcenter,wheretherecipientwas, infusionofpreservationsolutionwasstoppedandtheentire procedurewasperformedwiththe transplantpiecekeptat 0–4degreesCelsius(icebagsinsidesterilegloves)(Fig.2).

Surgicalincision

Whilethegraft from thedonorwas beingpreparedonthe surgicaltable,theskinofthedonorwasraisedbymeansoftwo incisions:onemediallyandonelaterally.Adelicatedissection wasperformedinordertoidentifythestructures.Depending onthetypeofinjurypresentedbytherecipient,theskinmay

Figure2–Maintenanceofthelimbinicewhilethe structureswerebeingidentified.

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Figure3–Identificationandlabelingofthestructures.

beraisedsoastoformaninterpositionflapwithfourstitches (twoonthedonorandtwoontherecipient).7

Oneveryimportantinitialstepwastoidentifythe struc-tures by stitching labels onto them. This is a very valid investmentofsurgicaltime,sinceitmakestheprocedureless confusingafterthelimbhasbeenconnectedbythebone.A goodwaytodothisishavetwosetsofsterileplasticatedlabels (oneforthedonorandonefortherecipient)withallthenames ofthestructures(tendons,nervesandvessels)(Fig.3).

However,dependingontherecipient’soriginalinjurythat causedtheamputation,identifyingthestructuresmaybevery challenging,whichmaycauseconfusionandleadtodelayed dissection.Thisisparticularlysoincasesofpatientswhoare victimsofburnsorinjuriescausedbyexplosives.Inourcase, delicateexplorationofthestructureswasdone,withspecial attentiontopreservationofthevessels(volaranddorsal ves-sels),whichpotentiallycouldbeusedinanastomoses.

Bone

Theboneneedstobestabilizedrapidlyandefficiently.Bone fixationwasdoneafterfinishingidentifyingallthestructures. Ifthetimelimitforthetourniquetisapproaching,itcanbe releasedaftergoodexposureofthebonehasbeenachieved, andtheplateisthenappliedwiththetourniquetdeflated.

Apediatricnasogastriccannulacanbeusedtoconnectthe recipient’sarterytothedonatedlimb,soastoenablegreater timeforperformingbonefixation.IntheseventhLouisville case,thiswasnotdonebecausebonefixationwascompleted

Figure4–Measurementoftheosteotomylocation.

withinagood timeand theteam judgedthatashunt was unnecessary.

Amicrosawwasusedtocutthebonetransversallyinthe recipientandinthedonor.Oneadvantageinthispatientwas that hestillhad hiswristjoint.Thisgreatlyfacilitated the measurements:6cmwassubtractedfromtherecipientand thesamelengthwasobtainedinthepartofthedonorlimb thatwastobeconnected(Fig.4).Incasesinwhichthepatient haslostpartoftheforearm,carefulmeasurementsaremade based on the contralateral forearm and elbow joint before proceedingwithosteotomy.Itisimportanttonotethatthe ideaofcuttingoneforearmboneatatimedoesnotworkwell. Itispreferabletocuttheradiusandulnaonbothlimbsand then performbonefixation. Another optionistoplace the plateonthedonorbeforeperformingtheosteotomy,butthis wasnotdoneontheseventhLouisvillecase.

A3.5mmplate(LowContact-DynamicCompression Lock-ing Plate, Synthes) was used for both bones.8 _In _cases _of transplantation moredistally, a 2.7mm plate forthedistal ulna and radiuscanbeused.Amini-image intensifierwas usedthroughoutourprocedure,inordertocheckforadequate platepositioningandbonereduction.

Vessel1

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lactate,inaninfusionpumpat20mL/h.Dextranwasnotused, eitherduringoraftertheprocedure.

Thefirstarterydonewastheulnar.Thetechniqueusedwas “backwallfirst”, with8–0 monofilamentsuturing(Ethilon). The vena comitante was then done using 9–0 suturing (Ethilon),bymeansofthesametechnique.

Theteam’sopinionwasthatoncethetourniquethadbeen released afterarterial anastomosis had been performed, it couldnotbeinflatedagain,sincethiscouldputthe anasto-mosisatriskthroughformationofthrombi.Fromthattime onwards,thelimbwaskeptwarmed,withdampcompresses, andwasintermittentlyirrigatedwithwarmedphysiological serum.

Aftertheanastomosis ofthe first arteryhad been com-pleted,itwasimportanttoallowsomebleedingofthelimb foraround15min,soasto“washout”thepotentiallytoxic preservationsolutionthathadbeeninfusedduring harvest-ing.Duringthis waitingtime, theulnar nerve wassutured undermagnificationusingasurgicalmicroscope,using8–0 suturingthread(Ethilon),withoutusingfibringlue.Lastly,the radialarteryanditsvenacomitantewereanastomosedusing thesametechniqueandsamesizeofsuturingthreadasthat usedfortheulnararteryanditsvenacomitante.Thelargest ofthevenaecomitanteswasusedforeachartery(radialand ulnar),atthedistalleveloftheforearm.Thevenaecomitantes shouldnotbereliedonaloneforvenousdrainage,but they certainlyhelppreventcongestion.

Itwasimportanttotakecareregardingwristpositioning duringtheanastomosis.Giventhat,uptothatpoint,no ten-donshadbeenrepaired,thewristcouldeasilyhavebeenleft inahyperextendedposition,therebycausingtheanastomosis toberedundant,withtheriskofkinking.

Atthismoment,themicroscopewasremovedandthe ten-donrepairswerestarted.Specialattentionwasgiventothe patient’s vital signs, especially considering that the dorsal veins(whichhadnotyetbeenanastomosed)couldbe poten-tialsitesofmajorbloodloss.Itispreferabletomaintainthe patient’sarterialblood pressurehigherthan100×60mmHg

and the temperature of the operating theater above 25◦_C.

Tendon

Theflexorandextensortendonswere connectedbymeans ofthePulvertafttechnique.10_All_the_tendons_were_repaired proximallytotheretinaculum,inordertoavoidlimitations ofmobilityand“bowstring” deformity.Aninterwoven con-nection wasstabilized using X-format sutures withTycron 4.0 thread (Fig. 5). Since immediate aggressive postopera-tive therapy was envisaged, the suturing was reinforced usingFiberloop4.0thread(Arthrex),similarlytotheBecker technique.11_Calibration_of_the_tendons_may_be_difficult_and, here,the assistant’srole isimportantformaintaining ade-quatetensioninthetendonsandcorrectlypositioningthem onthefingersandwrist.

Theextensortendonswereconnectedafterfinishingthe nerveanastomoses(seebelow).Justlikewiththeflexors,the same Pulvertaft technique with Becker reinforcement was usedfortheextensortendons.10,11

Figure5–Pulvertafttechniqueontheextensortendon.

Nerve

The median nerve was anastomosed after connecting the flexortendons.Forthispatient,oneadvantagewasthathestill hadpartofthisthumb.Therefore,itwassoughttomaintain themaximumlengthofmediannervepossibleinthe recip-ient. Themotorbranchwasanastomosedveryclosetothe thenarmuscles(targetmuscles),soastoenablerapid reinner-vation.Microscopicsurgerywasusedforthisprocedure,which wasdoneusing9–0monofilamentsuturingthread(Ethilon).

Asmentioned earlier,the ulnar nervewas repairedjust afterperformingthefirstarterialanastomosis,whilewaiting forthepreservationsolutiontobe“washedout”.Following this,thevolarskinwasbroughttogetherwithouttensioning it and,inordertoprotecttherecentlyrepairedvessels,the forearmwaspronated.Adorsal-radialaccessenabled anas-tomosisofthesensorybranchoftheradialnerve,whichwas doneusingsuturingthreadofsize9–0(Ethilon).Theextensor tendonswerethenconnected.

Vessel2

As many venous anastomoses as possible should be per-formed,inordertopreventgraftcongestion.Afterfinishing the extensor tendons,attention was giventorepairing the veins.Thismaybeoneofthebiggestchallengesofthehand transplantationprocedure.Theconditionoftherecipientand themechanismoftheoriginalinjurywilldefinehowdifficult thispartoftheoperationwillbe.

Atthistime,skinflapsweredeveloped.Theincisionsfor theskinflapsweremadecarefully,soastopreserveasmany veins as possible,even the small subcutaneousveins. The veinsthatpotentiallycouldbeusedweremarkedwith vas-cularclips.

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volarvein).

Allthevenousanastomoseswereperformedunder mag-nificationusingasurgicalmicroscope,usingthe “backwall first”techniqueandmonofilamentsuturingthread(Ethilon). Asstated earlier, the venaecomitantes were anastomosed using9–0suturingthread.Becauseofthesmallersizeofthe subcutaneousveins,10–0suturingthreadhadtobeused.For thecephalicvein,8–0suturingthreadwasgoodenough.

Lastly,theskinwasclosedcarefullyinordertoprotectthe recentlyanastomosedveins.Non-compressivedressingswere appliedwithgauze,sterilecolonwoolandaplaster-castsplint extendingfromtheaxillatothepalmofthehand.

Theoperationtook14.5handtherewerenointraoperative complications.Therewere nosignsofarterialinsufficiency orvenouscongestion aftertheoperationandthereforethe patientdidnothavetobetakenbacktothesurgicalcenter (Fig.6).

Postoperativecare

Thepatienttoleratedtheoperativeprocedurewelland,after post-anesthesiarecovery,wastakentotheward.Theroom waskeptheated(at least25degreesCelsius).Theflapwas monitoredthrough observationson its color, capillary per-fusioninthefingersandtemperature.Theintervalbetween checkswashourlyonthefirstpostoperativedayandspaced outonsubsequentdays.Furthermore,anoximeterwasplaced ononeofthefingersofthetransplantedlimb,withcontrol doneonthecontralateralside.12

Thepatientwaskeptinhospitalfor14daysafterthe oper-ation, in order to control the pain and continue with the immunosuppressant medication.The occupationaltherapy servicestarted itswork withthepatient whilehewas still inthehospital.Thefirstchangeofdressingswasperformed threedaysaftertheoperation.

Discussion

Thepossibilityofobservingandparticipatinginhand trans-plantationsurgeryisarareeventandwasaspecialfeature ofthehandsurgeryfellowshipprogramattheChristineM. KleinertInstitute.Theseventhpatienttoreceiveatransplant (eighthtransplantedlimb)atthiscentercanbeconsideredto havebeenagreatsuccess.Patientselectioncertainlyhadan importantroleinthisresult.Thepatientwaswell-motivated anddisciplined.Moreover,theamputationlevelcanalsobe consideredtohavebeenanadvantage.Sincethe transplanta-tionwasdoneatwristlevel,therecipient’snerveswerekept aslong aspossible.Inaddition,the amputationlevel facil-itatedthe bonework andenabled fasterrecoveryofmotor function.

OnekeycomponentinthesuccessoftheLouisvillegroup is the availability ofa large group of well-trained special-ized surgeons. Thisenabledrotation duringthe procedure, so as always to have a surgeon resting for a different part of the surgery. Another advantage is that a surgeon

Figure6–Immediatepostoperativeresult.

who was more specialized and had an interest in a cer-tain stage of the operation could perform his part and leaveanothersurgeontocontinuewiththenextstepofthe surgery.

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thesuccessofthesurgery.Beingtheleaderwascertainlya verydifficulttask,sinceheneededtobepresentthroughout theprocedure,whichwouldnotnecessarilyapplytotheother surgeons.

Conclusion

Hand transplantation surgery produces very promising results. Therefore, it can be expected that this procedure willstarttobeperformedmoreandmoreoftenaroundthe world.

Withregardtothesurgicaltechnique,itisimportanttobe attentivetorefinementsandtechnicaladvancesofthe surgi-calprocedureandmakeacriticalanalysisinordertoassess whetheragivensurgicalservice/countryhastheconditions requiredtoperformit.

WiththecurrenteconomicgrowthoftheBrazilian econ-omy, the chances that this will be the location for the first hand transplantation in SouthAmerica are becoming greater.

Funding

Thepresentarticlewasbasedonworkthatwaspartlyfunded by the Medical Research Department of the UnitedStates Army,throughfundsW81XWH-07-2-0092and W81XWH-07-1-0185,andbytheNavyResearchDepartment,throughfund N000140610084. The opinions, interpretations, conclusions andrecommendationsare thoseoftheauthors anddonot necessarilyrepresentthose ofthe UnitedStatesArmyand Navy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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