Process of Obtaining Social Consensus and 3-Year Functional Outcomes of the First Hand Allotransplantation in Korea

Abstract

Background: On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation's first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation.

Methods: W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city's financial and legal support and the university's medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man.

Results: With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed.

Conclusions: Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.

Keywords: Functional Outcome; Hand Transplantation; Korea; Social Consensus.

Fig. 1. Task distribution of three organizations for the first hand transplantation in Korea.

OR = operation room, ICU = intensive care unit, IST = immunosuppression therapy.

Fig. 2. Recipient of the hand transplantation. (A) A preoperative view of the recipient with a traumatic amputation of the left hand, which took place 18 months prior. (B) The preoperative radiograph shows amputation at the distal radiocarpal joint. The figures are published under agreement of the patient.

Fig. 3. Intraoperative dissection. (A) The recipient and (B) donor forearm with tagged anatomic structures for repair and fixation.

Fig. 4. Postoperative view at 36-months post-transplantation. (A) V-sign of the hand shows independent digital motion of flexion and extension. (B) Grasping of the hand.

Fig. 5. The postoperative radiograph shows good alignment with the complete union of the radius and ulna.

Fig. 6. High-resolution Doppler scan of repaired ulnar artery (Samsung RS 85 unit; Medison Healthcare, Seoul, Korea). There are no signs of intimal thickening or arterial narrowing. The RI of the ulnar artery is 0.82.

PSV = peak systolic velocity, EDV = end-diastolic velocity, RI = resistance index, HR = heart rate, LT = left, UA = ulnar artery, DIST = distal, ANA = anastomosis.

Fig. 7. Postoperative neurologic assessment with functional brain MRI and electromyography. (A) The right primary sensorimotor cortices (green arrow) are activated during the left hand movements on 10- and 36-month functional brain MRI results. Activations of the right primary sensorimotor cortex (sky-blue arrow) and the supplementary motor area (red arrow) on 10-month fMRI have disappeared at 36 months. (B) On 10- and 36-month DTTs, the integrities of the CSTs are well-preserved in both hemispheres. The tract volume of the right CST has increased to 2,497 on 36-month DTT compared with 1,210 at 10-month. (C) On 36-month transcranial magnetic stimulation results, the latency of motor-evoked potential decreased from 29.4 m/s to 24.7 m/s, and the amplitude increased from 1.6 mV to 3.1 mV compared with 10-month.

Op = operation, Lt = left, fMRI = functional magnetic resonance imaging, DTT = diffusion tensor tractography, Rt = right, CST = corticospinal tract, A = anterior, TV = tract volume, ABP = abductor pollicis brevis muscle, MEP = motor-evoked potentials, MRI = magnetic resonance imaging.