RECONSTRUCTIVE Attitudes Regarding Lower Extremity Allotransplantation among Lower Extremity Amputees Matthew J. Carty, M.D. Antoine Duclos, M.D., Ph.D. Simon G. Talbot, M.D. Stefan G. Tullius, M.D., Ph.D. Julian J. Pribaz, M.D. Bohdan Pomahac, M.D. Boston, Mass.

Background: Lower limb allotransplantation is garnering increasing attention in the vascularized composite allotransplantation community as a potential treatment modality for those suffering from lower limb amputations. Little is known, however, about the level of interest among lower limb amputees regarding this procedure. Methods: An online survey regarding lower limb allotransplantation was designed in conjunction with and distributed by the Amputee Coalition to lower limb amputees in the United States. Responses from the survey were blinded, tabulated, and analyzed for significance using chi-square or Fisher’s exact test. Results: A total of 770 respondents completed the online survey. Forty-three percent of respondents stated they would be interested in being evaluated for lower limb transplantation, 36 percent declined, and 21 percent were uncertain. Those respondents who expressed an interest in allotransplantation tended to be significantly younger, better educated, more recently amputated, and less satisfied with prosthetic outcomes than those who were not interested. The most important criterion for transplantation to be considered a success by respondents was restoration of meaningful knee/ankle joint function, followed by restoration of limb sensibility. If immunosuppression were not required, 32 percent of those who initially declined and 88 percent of those who were uncertain would choose to undergo evaluation for lower limb allotransplantation. Conclusion: A significant proportion of lower limb amputees would be interested in undergoing evaluation for lower limb allotransplantation.  (Plast. Reconstr. Surg. 134: 1334, 2014.)

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espite the successes witnessed to date in the field of vascularized composite allotransplantation, the notion of transplantation as a restorative treatment for lower extremity amputees remains controversial. The potential advantages of providing a sensate, biological limb with uncertain motor function must be carefully weighed versus the risks of a prolonged operative procedure and those of lifelong immunosuppression—particularly in light of the increasingly excellent functional recovery witnessed through next-generation lower limb prostheses.1,2 From the Divisions of Plastic Surgery and Transplant Surgery, Brigham & Women’s Hospital; and the Center for Surgery and Public Health. Received for publication February 10, 2014; accepted June 6, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000658

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Although the debate regarding the relative risks versus benefits of leg transplantation continues to rage within the scientific community, little consideration has been given to the opinions of lower extremity amputees themselves. Although studies regarding the attitudes of upper extremity amputees concerning hand transplantation have been published in the scientific literature,3 no similar reports highlighting the perspectives of lower limb amputees have appeared to date. In the interest of better informing discussions regarding lower extremity allotransplantation, we undertook this study to ascertain attitudes

Disclosure: The authors have no conflicting financial interest related to the work detailed in this article, nor do any of the authors maintain a financial stake in any product, device, or drug cited herein.

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Volume 134, Number 6 • Attitudes Regarding Allotransplantation regarding lower limb vascularized composite allotransplantation among lower extremity amputees. This project was conducted as a collaborative venture between our team at Brigham & Women’s Hospital and the Amputee Coalition. The Amputee Coalition is the leading national nonprofit organization that empowers individuals with limb loss through education, support, and advocacy. Membership in the organization is free and is considered to be representative of the U.S. amputee population in general.4

PATIENTS AND METHODS An online multiple-choice survey was developed by the first author (M.J.C.) and vetted with personnel from the Amputee Coalition before activation (Appendix 1). An electronic invitation to complete the survey was then distributed by the Amputee Coalition to all lower limb amputees in the Amputee Coalition database with a valid e-mail address, and willing respondents were provided a Web link to the survey instrument once their identity was confirmed. The survey remained active from March 14, 2013, through April 18, 2013; a single reminder e-mail was sent to eligible recipients on March 24, 2013. On termination of the survey, all responses were collated by the Amputee Coalition into a single database and subsequently blinded to remove all individual identifiers. The blinded database was then provided to the first author, and was analyzed using SAS 9.2 (SAS Institute, Inc., Cary, N.C.) based on chi-square or Fisher’s exact test.

Statistical comparisons were deemed to be significant for values of p < 0.05.

RESULTS The survey was distributed by the Amputee Coalition to a total of 6142 lower limb amputees, of which a total of 770 (12.5 percent) completed the instrument. Among respondents, 334 (43.4 percent) reported an interest in presently being evaluated as a candidate for potential leg transplantation (“yes”), whereas 163 (21.2 percent) reported a possible interest in the future (“maybe”) and 273 (35.5 percent) reported no interest (“no”). No statistical difference was noted between the yes and no groups in terms of geography, sex, income, ethnicity, nature of amputation, cause of amputation, or prosthesis use; however, significant differences were noted between these groups in terms of age distribution, educational background, time since amputation, and satisfaction with prosthetic experience, and similar results were noted when comparing yes plus maybe respondents to no respondents (Table 1). Subgroup analyses of responses stratified by interval since amputation demonstrated an increasing reluctance to consider allotransplantation as a treatment modality with increasing time (Fig. 1). Among those respondents reporting an interest in being evaluated for leg transplantation, 240 (73.4 percent) ranked the possibility of restoring a functional knee or ankle joint as being of cardinal importance, whereas 56 (17.1 percent) considered restoration of sensibility and the remaining 31 (9.5

Table 1.  Survey Respondent Characteristics Interest No. of subjects Demographics  1. Geography    Northeast    Midatlantic    Southeast    Midwest    Pacific Northwest    Pacific Southwest    Puerto Rico/Alaska/Hawaii   Outside United States  2. Age, yr   

Attitudes regarding lower extremity allotransplantation among lower extremity amputees.

Lower limb allotransplantation is garnering increasing attention in the vascularized composite allotransplantation community as a potential treatment ...
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