Reconstructive Vascularized Composite Allotransplantation: Qualitative Approach to Enhance Patient-Reported Outcome Metrics and the Candidate Screening Process

Since combat operations began in 2001, more than 300 United States Service members have had upper-extremity amputations. Due to improvements in medicine, many more people can survive with these wounds, yet these individuals face many unique challenges. Artificial limbs help some people, but many others remain unable to care for themselves independently.

Hand transplantation (also known as vascularized composite allotransplantation, or VCA) can potentially restore function and improve quality of life for these individuals. Over the last two decades, science has focused on improving this procedure, and people are finding more success with this surgery. However, the science is less clear on who are the best candidates for this type of surgery. In addition, so far, doctors have focused mostly on the medical aspects of the surgery, but have focused less on how recipients feel about their quality of life with their new hand(s).

Hand transplantation is very different from solid organ transplantation (such as kidney or liver transplant). Hand transplant recipients have to work very hard after the surgery to get the new hand(s) to heal and start working. This often means going to rehabilitation for 4-6 hours every day for many years. The emotional experience of hand transplant is also very different from solid organ transplant. Patients who want hand transplants must be resilient, highly motivated, and determined to succeed in ways that are not required of solid organ transplant recipients. Psychological evaluation before the surgery is important, but scientists do not yet know the most important questions to ask patients. The proposed research intends to take what we know from studying amputees and other organ transplant patients to study people who receive hand transplants. This will also help doctors know what makes someone a good candidate for hand transplantation.

The purpose of this project is to understand quality of life before and after hand transplant and to understand which factors make someone a good candidate for this surgery. This project addresses the Fiscal Year 2017 Reconstructive Transplant Research Program (RTRP) Qualitative Research Award Focus Area: 'Psychosocial considerations and challenges associated with VCA.'

The impact of this study is anticipated to be significant, in both the short and long term. In the short term, this study will create a framework for understanding the quality of life of individuals in the VCA process, which will lead to the creation of patient-reported outcome measures that are meaningful to these individuals. In addition, this will help doctors ask people considering hand transplant the right questions to help understand each person's individual risks for a poor outcome. In the long term, this study will help scientists understand which factors are important for patients who receive hand transplants and will help improve the screening of future hand transplant patients, so that people who are expected to benefit the most will receive transplants. There are currently more than 185,000 upper-extremity amputees in the United States alone who could potentially benefit from this research.

We will be able to complete the aims of this project within 3 years, which will allow us to begin making a difference very quickly. This research will immediately affect the lives of all Service members and civilians with upper-limb amputation who are potential VCA hand transplant candidates by improving clinicians' awareness of the most important issues affecting their quality of life. Additionally, we believe that this study, if funded, has the potential to help more people receive hand transplants by bringing together the transplant community in a cooperative effort. This collaboration will serve to advance the science in the area of hand transplant more quickly. We are hopeful that within the next 5 years, directly because of this research, hand transplant surgeries will be more successful due to better screening. We are additionally hopeful that, within the next 5 years, the patients who receive transplanted hands will have improved quality of life.