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Measuring the Utility of Hand Composite Tissue Allotransplantation in Hand Amputee Patients
Noor Alolabi, MD1; Jennifer Chuback, MD1; Sharon Grad, MD, FRCP(C)2; Achilles Thoma, MD, MSc, FRCS(C)3
1Division of Plastic Surgery, McMaster University, Hamilton, ON, Canada; 2Division of Physical Medicine and Rehabilitation, McMaster University, Hamilton, ON, Canada; 3Department of Surgery, Division of Plastic Surgery, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada

Introduction: Composite tissue allotransplantation (CTA) of the hand is becoming a reconstructive treatment option for a hand amputation, restoring sensation and intrinsic muscle function. Whether the functional, psychological, and cosmetic benefits are worth the risks associated with the required lifelong immunosuppression is still not known. The purpose of this study is to measure the health utility of and expected quality-adjusted life years (QALYs) gained with a hand transplant using hand amputee patients and the general public. This is in an effort to assist surgeons with the decision of whether to adopt this procedure.

Materials and Methods: Using the time-trade off (TTO) and standard gamble (SG) techniques, health utilities were obtained from 30 general public participants and 15 hand amputee patients (12 traumatic and 3 congenital). The health utility and net expected QALYs gained with hand CTA were computed. A sensitivity analysis was conducted to account for the effect of lifelong immunosuppressive medications on the life expectancy of hand transplant recipients.

Results: Hand amputation mean health utility was 0.72 (TTO) and 0.80 (SG) for the general public group, 0.69 (TTO) and 0.70 (SG) for the traumatic hand amputees group, and 0.73 (TTO) and 0.94 (SG) for the congenital hand amputees group. In comparison, hand CTA mean health utility was 0.74 (TTO) and 0.82 (SG) for the general public group, 0.83 (TTO) and 0.86 (SG) for the traumatic hand amputees group, and 0.70 (TTO) and 0.79 (SG) for the congenital hand amputees group. Hand CTA imparted an expected gain of 0.9 QALYs in the general public, and 7.0 (TTO) and 7.8 (SG) QALYs in the traumatic hand amputees group. Congenital hand amputees displayed an expected loss of 1.7 (TTO) and 7.5 (SG) QALYs.

Conclusions: Hand amputee patients did not show a preference towards hand CTA with its inherent risks. In fact, a loss of QALYs was demonstrated when the life expectancy of a hand CTA was altered in the sensitivity analysis. With this procedure being increasingly adopted worldwide, the potential benefits must be carefully weighted against the risks of life-long immunosuppressive therapy. This study does not show clear benefit to advocate CTA of the hand.

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