Elsevier

The Journal of Hand Surgery

Volume 34, Issue 5, May–June 2009, Pages 808-814.e2
The Journal of Hand Surgery

Scientific article
A Survey of North American Hand Surgeons on Their Current Attitudes Toward Hand Transplantation

https://doi.org/10.1016/j.jhsa.2009.01.021Get rights and content

Purpose

Although composite tissue allotransplantation (CTA) is unparalleled in its potential to reconstruct “like with like,” the risk–benefit ratio and clinical indications are difficult to determine. We examined current attitudes regarding the emerging field of CTA from those who treat complex hand injuries.

Methods

A web-based survey regarding CTA was sent to members of the American Society for Surgery of the Hand, which identified their demographic data and practice profiles. Respondents' support for CTA and their assessment of the level of risk associated with these procedures were addressed. Additional questions focused on the clinical application of CTA with current immunosuppression, ethical issues surrounding CTA, and the indications for hand transplantation. Finally, 2 clinical situations that closely mirrored past hand transplantations were presented, and members evaluated their suitability for allotransplantation.

Results

A total of 474 surgeons responded to the survey (22% response rate), who were divided in their opinion of hand transplantation with 24% in favor, 45% against, and 31% undecided. The majority (69%) consider this surgery to be a high-risk endeavor; however, a large percentage (71%) still believe it to be an ethical procedure when performed on properly selected patients. The most accepted indications for hand transplantation were loss of bilateral hands (78%) and amputation of a dominant hand (32%). Only 16% were in favor of performing transplants with the immunosuppression available today. In response to the clinical situation, 66% would offer transplantation to a bilateral hand amputee, whereas only 9% would offer transplantation to a patient with diabetes who had lost his or her dominant hand.

Conclusions

This survey demonstrates support for hand allotransplantation as a solution for dominant-hand and bilateral hand amputees. However, surgeons continue to be concerned about the adverse effects of immunosuppression and the risks of acute and chronic rejection, and many want to wait for the development of better immunologic treatment options.

Section snippets

Materials and Methods

In 2007, a survey was devised to determine current attitudes toward the evolving field of CTA from hand surgeons in the United States. This web-based survey was sent to all active members of the American Society for Surgery of the Hand (ASSH) via e-mail. The survey consisted of 18 questions (see Appendix, which can be viewed at the Journal's Web site, http://www.jhandsurg.org) and was blinded to enhance the response rate, ensure that each response remained anonymous, and minimize bias.

The

Demographics and practice profile

Of the 2,150 ASSH members contacted, 474 responded to the survey (22% response rate). The respondents averaged 15 years in practice, and most had residency training in orthopedic (N = 298, 63%) or plastic surgery (N = 104, 22%), with the remainder having trained in general surgery (N = 40). Three hundred forty (72%) subsequently completed a hand fellowship (Fig. 1). They performed on average of approximately 10 upper extremity replantations per year and 1 functional free tissue (such as

Discussion

The traumatic amputation of a patient's hand is a disfiguring event with immeasurable personal, psychological, financial, and social implications in addition to the obvious functional limitations. The ability to safely transplant a fully integrated and functional hand to these amputees would be of tremendous reconstructive value. Currently, clinical hand transplantation remains an experimental procedure, and the outcomes of this innovative procedure are still being determined. In the current

References (32)

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