TECHNOLOGY IN MEDICINE
Upper limb
amputation
has been a
common and
profoundly
disabling injury
throughout
history. Conventional
amputation treatment
uses prostheses crafted for cosmetic or functional purposes. However,
their functional capabilities are severely limited, resulting in
a high abandonment rate by users. An ideal prosthesis exists only
in the mythology of Star Wars, where robot surgeons replaced Luke
Skywalker’s amputated hand with a device having perfect function
(figure 1).
16 LOUISVILLE MEDICINE
Figure 1 - In the Star Wars saga, Luke Skywalker received
a prosthetic hand that restored perfect function
NEW TECHNOLOGY IN UPPER LIMB REPLACEMENT: WILL ADVANCED
PROSTHESES PAIRED WITH STRATEGIC NERVE TRANSFERS REPLACE
HAND TRANSPLANTATION?
AUTHORS Gordon R. Tobin, MD, Christopher M. Jones, MD & Christina L. Kaufman, PhD
In the late 20 th century, advances in immunosuppression, especially
calcineurin inhibitors and induction agents, allowed hand
transplantation, which brought substantial functional improvement
in upper extremity replacement. 1 More recently, advances in prosthetic
technology promise improved functional outcomes by using
“targeted muscle reinnervation (TMR),” in which amputated limb
nerves are transferred to selected muscle segments. A microprocessor
receives electromyographic signals from these muscles to control
a myoelectric prosthesis. 2 In this paper, the progress and challenges
of this new technology will be compared with transplantation for
upper limb replacement.
HAND TRANSPLANTATION
In the mid-1990s, Drs. Warren Breidenbach, Jon Jones and Gordon
Tobin organized a research initiative to explore allotransplantation
of the hand, face and other composite structures of skin, muscle
and bone. Our considerations focused on immunologic barriers
and the ethics of experimental procedures not yet successfully done,
including benefit-to-risk comparisons with alternatives. 3 We noted
and weighed poor function of prosthetic reconstructions.
This initiative then led to formation of a clinical hand transplantation
team involving our colleagues at Jewish Hospital, the University
of Louisville and the Kleinert Kutz Hand Care Center. This
team produced the world’s first long-term success of a skin-bearing
transplant, a hand allograft done at Jewish Hospital in January 1999
for recipient Matthew Scott (figure 2). Scott’s allograft reached a
high level of function, which was far beyond that of a prosthesis.
Now at 21 years, Mr. Scott’s transplant remains healthy and highly
functional, as are many that followed. 1,4 For example, Mr. Donald