Sandra Amaral1, L Scott Levin. 1. aDepartment of Pediatrics, Division of Nephrology bCenter for Clinical Epidemiology and Biostatistics cDepartment of Orthopaedic Surgery, Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Abstract
PURPOSE OF REVIEW: We review the approach and challenges associated with pediatric hand transplantation, including new knowledge gleaned from our recent case of bilateral hand-forearm transplantation in an 8-year old child. RECENT FINDINGS: Bilateral heterologous hand-forearm transplantation was performed in a child with a prior kidney transplant in July 2015. The initial surgery necessitated a large team of experts in microvascular surgery, transplant surgery, orthopedics and plastic surgery as well as pediatric anesthesia. Medical management has highlighted the need for extensive multidisciplinary support with pediatric expertise in transplant medicine, occupational therapy and rehabilitation, neurology, and neuroradiology. The clinical course has been complicated by the need for robust immunosuppression to control ongoing, even though low-grade, and intermittent rejection. Neurological findings have demonstrated cortical neuroplasticity with reorganization of the somatosensory cortex. SUMMARY: Heterologous hand-forearm transplantation in a child is feasible and has the potential for functional benefit to improve quality of life; however, immunological and ethical concerns warrant proceeding with caution. More data are needed to inform patient and family selection to achieve optimal functional and quality of life outcomes.
PURPOSE OF REVIEW: We review the approach and challenges associated with pediatric hand transplantation, including new knowledge gleaned from our recent case of bilateral hand-forearm transplantation in an 8-year old child. RECENT FINDINGS: Bilateral heterologous hand-forearm transplantation was performed in a child with a prior kidney transplant in July 2015. The initial surgery necessitated a large team of experts in microvascular surgery, transplant surgery, orthopedics and plastic surgery as well as pediatric anesthesia. Medical management has highlighted the need for extensive multidisciplinary support with pediatric expertise in transplant medicine, occupational therapy and rehabilitation, neurology, and neuroradiology. The clinical course has been complicated by the need for robust immunosuppression to control ongoing, even though low-grade, and intermittent rejection. Neurological findings have demonstrated cortical neuroplasticity with reorganization of the somatosensory cortex. SUMMARY: Heterologous hand-forearm transplantation in a child is feasible and has the potential for functional benefit to improve quality of life; however, immunological and ethical concerns warrant proceeding with caution. More data are needed to inform patient and family selection to achieve optimal functional and quality of life outcomes.