16. Bilateral Hand Transplantation: Long-Term Functional Outcomes in Seven Patients with an Average Follow-Up of 13 Years (Range: 8–25 Years)

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Introduction: Between January 2000 and September 2016, seven adult patients who had suffered a bilateral traumatic trans-radial amputation, received a bilateral hand-forearm allograft. We report the functional benefits achieved over a mean follow-up period of 13 years (range 8 to 25 years). Methods: The level of amputation was distal in all cases except for 3 patients amputated at the mid-forearm level. All recipients received initially the same immunosuppressive treatment including tacrolimus, mycophenolate mofetil, prednisone, and, for induction, antithymocyte globulins. Functional results were evaluated every year using the Carroll upper extremity function test, a 400-point test, and the RAND-36 quality-of-life evaluation. Subjective and overall results were assessed by the Disabilities of the Arm Shoulder and Hand (DASH) score and Hand Transplantation Score System (HTSS). Restoration of motion, strength, and sensibility was specifically analyzed. Results: All recipients showed adequate sensorimotor recovery with protective and tactile sensitivity and partial recovery in intrinsic muscles. Active range of motion, strength, and sensory function remain stable over time after 3 years for patients who retain their grafts, even at 25 years, as demonstrated by the patient with the longest follow-up. Functional outcomes are summarized in table 1. Patients were able to perform most of daily living activities and had a normal social life. We establish two types of functional profile according to the graft length: the best results were obtained at the wrist level with more than 90% for HTSS-score for dominant hand. However, the quality of sensory recovery was not related to the level of amputation. Graft function was not impacted by episodes of acute rejection. Function deteriorates rapidly in one patient (pt2) who developed uncontrollable chronic rejection (graft vasculopathy) with sequential amputations of fingers 11 years after transplantation. For pt3, the grafts were removed 11 years after transplantation at the patient’s request. She developed high incidence of acute rejection episodes and she could no longer tolerate the numerous side effects of immunosuppressive therapy, despite retaining satisfactory analytical performance of her hands. Conclusions: Bilateral hand transplantation is a satisfactory treatment option for trans-radial amputees, with careful selection of candidates. Despite poor analytics results, graft function is good and sustainable on the long-term. Patient satisfaction is excellent despite the risk of rejection and side effects of immunosuppression. Table 1: functional results of the patients at their last clinical follow-up:L: Loss of grafts; (N)DH: (Non) Dominant Hand; P: physical; M: Mental

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