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Tendon Tensioning In Hand Transplantation: Emerging Principles From The First Successful Full Face And Bilateral Hand Transplant
Jorge Trilles, BS, Gustave K. Diep, MD, Jacques H. Hacquebord, MD, Bachar F. Chaya, MD, Zoe P. Berman, MD, Ricardo Rodriguez Colon, BS, Daniel Boczar, MD, Sheel Sharma, MD, Eduardo D. Rodriguez, MD, DDS.
NYU Langone Health, New York, NY, USA.

PURPOSE: Hand transplantation can restore form and function when conventional reconstruction falls short, but few technical details on tendon tensioning are reported in the literature and improper tensioning may lead to postoperative functional limitations. We report our approach for tendon tensioning at the distal forearm level and present some emerging principles to expand the current understanding of tendon tensioning in hand transplantation.
METHODS: The recipient, a 22-year-old right hand-dominant male, sustained an 80% total body surface area burn injury in a motor vehicle accident. Prior to presentation, he underwent more than 30 surgeries including distal digital amputation in both hands, severely limiting his independence and quality of life. Checklists of key steps for the procedure were created, informed by a systematic review of the existing literature. The operative technique was then refined over a series of 11 high-fidelity cadaveric rehearsals. Checklists were revised throughout and finalized prior to transplantation.
RESULTS: Donor and recipient preparation occurred simultaneously, with 21 tendons individually tagged and divided in each hand. The right hand was transplanted first, and after confirmation of adequate perfusion, the left hand. The overall sequence of repairs was wrist extensors, wrist flexors, digital flexors, and digital extensors. A prefabricated positional splint maintained the wrist in 30° extension for wrist extensor repairs. Only superficial digital flexors and extensors were repaired en masse. Two-weave Pulvertaft technique was preferred throughout for its strength. Our approach for individual repairs was to set tension, place a clamp, and suture in the ensuing position. Upon clamp release, tension was assessed via tenodesis and if adequate, the second weave was performed in the usual fashion, but if the repair was loose, we tightened the second weave. Six-month post-transplant functional outcomes reflect substantial improvements, including range of motion, grip strength, Carroll’s test (right, 61 vs. 20 pre-transplant; left, 58 vs. 13 pre-transplant), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire (37 vs. 90 pre-transplant). One-year post-transplant functional outcomes are forthcoming.
CONCLUSION: Hand transplantation is an evolving practice, but there remains a lack of consensus on tendon tensioning, which is critical to optimize patient outcomes. We describe our approach, its development, and accompanying rationale. It was successfully executed in the context of a full face and bilateral hand transplant. The initial wrist extensor repairs are foundational, and sequential repair of opposing tendon groups facilitates balanced tensioning. Finishing with the digital extensors, which have the shortest excursion, is recommended.


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