July 24, 2017

This 8-year-old received the first pediatric double hand transplant. Now he can swing a baseball bat.

Daily Briefing

In July 2015, surgeons at the Children's Hospital of Philadelphia successfully performed the world's first pediatric double hand transplant on an 8-year-old boy , according to an article published Tuesday in the Lancet Child & Adolescent Health, Troy Brown reports for MedScape.

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Background

The boy, Zion Harvey, was a good fit for the procedure because, in addition to having faced amputation due to an illness contracted at 2 years old, he also had received a transplanted kidney from his mother—meaning that he was already receiving immunosuppressive therapy to prevent the rejection of the kidney.

"A child psychologist, (pediatric) transplantation pharmacist, and social worker assessed psychosocial readiness to undertake surgery and a prolonged rehabilitation period, history of medical adherence, and the family's ability to provide social and logistical support," said Sandra Amaral, a doctor from the division of nephrology at the Children's Hospital of Philadelphia.

His mother's goals for the surgery were for Harvey to be able to dress himself, brush his teeth, and cut his own food after surgery—all activities that Harvey struggled with as a result of his amputations. Harvey had loftier goals: He wanted to be able to climb monkey bars and swing a baseball bat.

The long road to recovery

Within a year of his surgery, Harvey achieved his goal of swinging a bat. Here's how it happened. 

The 10.5 hour surgery included four teams who conducted two years of "extensive preparation," the researchers wrote. During the procedure, the medical and surgical teams worked simultaneously on the donor and on Harvey's hands and forearms.

Harvey was able to move his fingers within days of the transplant. Six days after the transplant, he started daily occupational therapy that included video games, exercises using finger lights and puppets, writing, and other activities. By six months, he could move his hands and feel touch, allowing him to feed himself and grip a pen; by eight months he could use scissors and crayons; and within a year, he was able to swing a baseball bat with both hands.

But it was not all smooth sailing. Throughout Harvey's recovery he experienced "multiple episodes of graft rejection, minor systemic infections, moderate renal transplant functional impairment, (hyperlipidemia), the need for chronic anticoagulation with low-dose aspirin, the need for more immunosuppression than he required before hand transplantation, months of intensive rehabilitation, and a prolonged period of time until functional recovery to a pretransplantation level," the researchers wrote.

Throughout the process both Harvey and his mother spoke with a psychologist and social worker for emotional support and planned his eventual return to school.

Discussion

Marco Lanzetta of the Italian Institute of Hand Surgery, the University of Canberra, and Ludes University in an accompanying article wrote that hand transplantation in a child should not performed without deep consideration because it is not a life-saving procedure and subjects the child to a lifetime of  antirejection medications.

Further, Lanzetta also noted that advancements in the world of prosthetics complicate the debate on whether hand transplants should be performed. " In view of these developments, one might argue that it is too late to attempt (pediatric) heterologous hand transplantation, since prosthetics are now very sophisticated. Equally, it could be argued that it is too early for such procedures to go ahead without much needed new immunosuppression drugs," he wrote (Brown, Medscape, 7/18; Amaral et al., The Lancet, 7/18).

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