Lessons Learned from the Amputation of a Bilateral Hand Grafted Patient due to Psychiatric Disorders

Abstract

Summary: The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients’ assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting.

Hand transplantation: can we balance the risks and benefits?

“…Surgery entails some risk of adverse outcomes. Hand transplant adds the exceptional complexities of immunosuppression, but also of bringing together tissues from two distinct individuals, and success relies upon congruence between the donor and recipient parts in the disposition of skin incisions, of osteosynthesis and of muscle repairs (matching lengths carefully), but also psychological acceptance of the limb(s) by the recipient (Petruzzo et al., 2020).…”

Hand Therapy Regimen for Functional Recovery Following Combined Face and Bilateral Hand Transplantation

“…2,3 A multidisciplinary team effort is essential for the success of this complex procedure because it requires meticulous patient selection, preoperative evaluation and planning, and comprehensive postoperative care. 2,4,5 Hand therapy plays a major role in the favorable outcomes reported in the HT literature. 6 This is especially relevant in the context of long-term side-effects caused by the required immunosuppression therapy.…”

“…2,3 A multidisciplinary team effort is essential for the success of this complex procedure because it requires meticulous patient selection, preoperative evaluation and planning, and comprehensive postoperative care. 2,4,5…”