January 29, 2013

In Focus: Replacing both lost arms

After an explosion in Iraq takes all his limbs, a soldier receives a rare double arm transplant.

By MICHAEL E. RUANE The Washington Post

A U.S. Army soldier who became a quadruple amputee after surviving an explosion in Iraq three years ago has undergone a rare double arm transplant at Johns Hopkins Hospital in Baltimore, the hospital is expected to announce Tuesday.

Brendan Marrocco, Todd Love, Juan Dominguez
click image to enlarge

Army Sgt. Brendan Marrocco, 26, of Staten Island, N.Y., wears a prosthetic arm at an event at the 9/11 Memorial in New York last July 4. He is the first soldier from the wars in Iraq and Afghanistan to survive losing all four limbs.

The Associated Press

Brendan Marrocco, 26, of Staten Island, N.Y., who underwent the marathon surgery last month, was the first service member from the wars in Iraq and Afghanistan to survive the loss of four limbs, officials have said.

He lost both legs above the knee, his left arm below the elbow, and his right arm above the elbow when the military vehicle he was driving was struck by a powerful roadside bomb on Easter Sunday, April 12, 2009.

The hospital says he is one of only seven people in the United States who have undergone successful double arm transplants. The complex operation was performed on Dec. 18.

Later, in a new anti-rejection procedure, he received an infusion of bone marrow, derived from vertebrae harvested from the donor's lower spine. The infusion allows doctors to reduce the number of powerful anti-rejection drugs they use from three to one.

That is beneficial because the anti-rejection drugs can have harmful side effects, such as infection, organ damage and cancer.

The surgery was done by a special team of transplant experts headed by W.P. Andrew Lee, professor and chairman of the department of plastic and reconstructive surgery at the hospital.

It was the first limb transplant by his newly established group at Hopkins, the hospital says.

"He's doing well," Marrocco's father, Alex, said Monday. "Doing well. It's been a little over a month now."

The hospital said it would detail the operation at a news briefing Tuesday.

Lee, in an interview, said there have been about 80 arms transplanted in about 60 patients around the world.

Among the hundreds of military amputees around the country, there are four others who have lost four limbs.

Many, like Marrocco, have been treated at the old Walter Reed Army Medical Center in Washington, now the Walter Reed National Military Medical Center in Bethesda, Md.

Marrocco was there for several years, and two other quadruple amputees still are recovering there.

Most such patients have been fitted with -- and mastered -- sophisticated mechanical prostheses. But Lee said in a recent interview that research has suggested younger amputees don't always use them.

"The nonacceptance rate of prosthetics is highest among young people in their 20s and 30s," he said.

So the possibility of limb transplantation, despite its enormous medical, psychological and logistical complexity, holds great promise for the future.

Lee said results so far have been good, although the arms are never going to return to 100 percent of their former function.

But he said patients have learned to tie shoes and use chopsticks.

Aside from the physical outcome, "I think it also has additional advantage for the patient to be restored whole," he said. "Once they're transplanted, they regard the arm as theirs. And I think they're more comfortable going out on social occasions, as opposed to wearing a prosthetic."

After recovering at Walter Reed after the surgery, Marrocco returned to Staten Island, where a special home was reportedly constructed for him by charitable organizations.

He has endured numerous surgeries, return trips to the hospital and has been anticipating a transplant since 2010.

Lee, speaking generally and not about the specifics of Marrocco's case, said the operation requires four surgical teams -- two to prepare the donor's arms and two for the recipient's arms. Each team has three surgeons.

Little thus far is publicly known about Marrocco's donor, but Lee said the donor arms often are brought from another hospital, another city or state.

Donor and recipient do not necessarily have to be of the same gender, but the limbs should match in size, skin color, and tissue and blood type. About two years ago, he said, at a California hospital, a female recipient successfully received a transplanted hand from a male donor.

Time is critical.

In a double transplant, all four arms must be carefully readied, with the skin peeled back and the bone ends often cut at angle, as a good carpenter might, for a solid connection, according to a textbook on transplantation Lee and his colleagues are writing.

Inside the arm, individual muscle-tendon units, nerves and blood vessels are identified. They are then tagged with pieces of light blue sterile bandages that are sewn in place and labeled in permanent black marker to ensure proper connection.

The connecting sequence begins with the bones, which are joined with metal plates. "It's not as easy as fixing a fracture," Lee said, "because the two ends of the bone belong to different people."

Next, he said, "we typically connect the muscles and tendons."

After that, "we put together the blood vessels," he said. "That's the critical part, where we need to restore circulation to the transplanted limb by connecting the arteries and the veins. And they're typically done under a microscope."

Finally, the skin is sewn together.

Lee said war injuries have often resulted in amputations higher up the arm.

That is more problematic, in part, because nerves in the donor arm are dead and must be replaced by the recipient's nerves, which regenerate down the arm at a rate of about an inch a month.

Rejection, and especially the drugs used to combat it, pose other problems.

"We want the best of both worlds," Lee said. "We want to do the transplant, improve the quality of life, but not incur the side effects of the traditional anti-rejection regimen."

Experimenting in the laboratory with pigs, he said, the team discovered that infusions of bone marrow cells from the donor can reduce the amount of anti-rejection drugs required.

He said experts must use care in approaching donors' families about arm transplants.

"We typically relay through (the organ-procurement organization) the story of the recipient," he said. "For that reason, I think, we were very rarely turned down by the grieving family," he said.

 

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