Special Considerations for Secondary Surgery after Upper Extremity Transplantation.
Pathik Aravind, M.B.B.S, Christopher Frost, MD, Vidhi Javia, BS, Jaimie Shores, MD, Carisa Cooney, MPH.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.
BACKGROUND: Hand and arm transplantation is a complex undertaking that may require emergent or elective secondary surgery days to years following transplant. Patient comorbidities, pre-existing conditions, and level of transplantation may help determine the secondary surgeries needed. Being able to appropriately anticipate potential complications and follow-up procedures needed over time is important when comparing the cost-effectiveness of upper extremity (UE) transplantation with other reconstructive options. We undertook the current study to characterize the secondary surgeries needed by our UE transplant patients.
METHODS: We retrospectively reviewed 6 patients who underwent hand and upper extremity transplantation by one of the authors (JTS). Medical information and operative details were obtained from electronic patient medical records. Hand and arm function was quantified both subjectively (patient-reports) and objectively [Disability of the Arm, Shoulder and Hand (DASH); Carroll test; Action Research Arm Tests (ARAT); Box and Block test].
RESULTS: Six (n=6) patients (four bilateral and two unilateral) underwent transplantation for a total of ten transplanted limbs. Five (n=5) transplants were performed below and five (n=5) above the elbow. Mean time post transplantation at last follow-up was 5 years (Range 1-9 years). 4 out of 6 patients (66.67%) had secondary surgery at the time of last follow-up. 2 surgeries were secondary to trauma/medical indication and 3 were elective.Of our above elbow transplants, one patient developed significant ulnar clawing managed with Extensor Carpi radialis longus tendon transfer to lateral bands and a Camitz opponensplasty. One patient opted for an elective brachioplasty to reduce redundant skin. The most common elective procedure for above elbow transplants was nerve decompression at the elbow (cubital tunnel), forearm (radial tunnel), and wrist (carpal tunnel, ulnar tunnel), performed in 2 patients at 1 and 2 years since transplantation. Both nerve decompression patients reported improvement in hand function both subjectively and through a mean improvement of 15 points in Carroll score. For the below elbow transplants, 1 patient required multiple I&D procedures for a recurrent abscess and another required an open reduction and internal fixation a both-bone forearm fracture after a fall.
CONCLUSIONS:Patients receiving UE transplantation often require one or more secondary procedures, which may be urgent or elective. Secondary surgeries may vary with level of transplantation and should be included in determining cost-effectiveness of UE transplantation. The need for secondary surgery over the life of the transplant should be a part of pre-transplant planning and patient counselling.
Back to 2019 Abstracts