Hand Transplant vs. Prosthesis

Victoria Powell — Mon, 04 Apr 2011 15:01:40 +0000

Image via Wikipedia

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…

“I got it,” he said about the surgery. “And I regret it. It’s over and done with. I didn’t dream there would be this much therapy.”

“When I had the hooks, I worked and drove,” he said. “I did lots of things.”

“I don’t see the light at the end of the process,” Kepner said. “If three or four years later, nothing’s going to happen, yes, I would say take them off.”

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.

Bionic Hand

Victoria Powell — Thu, 16 Apr 2009 18:49:23 +0000

Updated 4/16/09

As many of my readers are aware, I have a personal interest in patients suffering from traumatic amputation. I have had the pleasure of assisting several amputees in their rehabilitation efforts. It is gratifying work.

A Twitter link today directed me to post from the Telegraph in the UK regarding a student who was fit for the i-Limb bionic hand/arm. The post includes a great video. For anyone who has worked with amputation patients, you will recognize the advances in this limb compared with the myoelectric prosthesis. The most amazing advance is the single digit rotary motors which allow for single digit movement.

My brother is a prosthetist with Snell Laboratory in Little Rock. I have had the pleasure of working side-by-side with him on several cases. It has been interesting to see him in a professional role rather than just my little brother. He was involved in the first Arkansas i-Limb placement which took place last November. A short news clip was posted to a local station which can be viewed here.

The i-Limb was developed by Touch Bionics and was made after government monies were made available in response to the lost limbs of our service men and women. It is the worlds first fully articulating bionic hand. It is controlled by highly intuitive control system that uses the traditional two-input myoelectric signal generated by the muscles in the remaining portion of the limb to open and close the life like fingers.

For an even more life like appearance this i-Limb can be covered with silicone “skin.” This “skin” is developed in corellation with prosthetists and artists who sculpt the silicone and custom paint the fearture which are unique to each individual patient. I have had the pleasure of witnessing this process with a hand amputee patient. My husband is an airbrush artist so it was particularly interesting to me to see artists working in the medical field to provide such psychological healing. For an up close photo of the artistry take a look at this nasal prosthetic.

Medical miracles never cease to amaze me.

Video: Real, useful bionic arm testimonial (crunchgear.com)
Surgery improves control of artificial arm, study shows (cbc.ca)
Brave New World of Bionics (thanks to @MedHunters)