Whole again

Veteran amputees are among the first to benefit from groundbreaking work in limb transplants.

Sheila Advento lost her hands and legs to a life-threatening bacterial infection
Sheila Advento lost her hands and legs to a life-threatening bacterial infection

Chris Pollock pleaded with God to take his life in the minutes after his arms were sucked into a mechanical corn picker. No one responded to his screams for help. His right arm was wrapped around a roller. His left hand hung by a thread.

The third time Pollock asked God to let him die, a couple who lived near the rural Pennsylvania cornfield came to his aid. Pollock told them how to shut off the tractor and corn picker. He’d left the machines running when he got down to deal with an overflowing corn wagon and decided to throw a few pieces into the picker. A moving chain caught his coat sleeve and pulled his left arm in. His right arm followed as he attempted to free himself.

It took an hour for emergency workers to disassemble the 1950s-era machine and free his mangled limbs. “I never passed out,” Pollock says. He maintained consciousness throughout the ordeal, including the helicopter ride to Hershey Medical Center in Hershey, Pa.
It happened on the Friday after Thanksgiving 2008. The following Sunday he awoke in a hospital room, his left arm amputated at the wrist, his right arm gone below the elbow. He was surprised he survived at all. “I still call that a resurrection,” he says.

That was not his only miracle. In March, he’ll celebrate two successful years with a transplanted arm and two transplanted hands. Thanks to a University of Pittsburgh medical team whose work – partially supported by the Pentagon – will also help wounded warriors, Pollock can use his new hands to drive a car, pull change from his pocket and tighten his shoelaces.

He remains astonished that such a thing was even possible. “It’s that whole idea of them attaching someone else’s limbs to you, and they work,” says Pollock, 43, who spent 23 years in the National Guard both as a citizen-soldier and a civilian employee.

Regenerative Medicine. The first-ever hand transplant took place in Ecuador in 1964. The recipient’s body rejected the hand two weeks later, and the procedure was deemed a failure, according to the University of Pittsburgh Medical Center. The next transplant was performed in France in 1998, and the patient was treated with an anti-rejection drug regimen commonly used in organ transplants. Doctors performed the first U.S. transplant in Kentucky that year. More than 40 patients have since received hand transplants, most of which involve heavy doses of anti-rejection medication.

A double-arm transplant, the first of its kind, was performed in Germany in 2008.

Pollock’s limb transplants are the work of a team led by Dr. W.P. Andrew Lee, professor and chairman of plastic and reconstructive surgery at Johns Hopkins University School of Medicine, and director of the extremity-injury program for the Armed Forces Institute of Regenerative Medicine (AFIRM)’s Wake Forest-Pittsburgh Consortium. Lee, who moved to Johns Hopkins from the University of Pittsburgh in 2010, has been researching ways to reduce the amount of anti-rejection medication transplant patients need to take for 25 years after the procedure. The medications are expensive and come with harsh side effects.

“As a plastic and reconstructive surgeon with specialized interests in hand surgery, it seemed natural to ‘restore whole’ patients (who’d had) limb amputations,” Lee says. “Prosthetics, even with the latest advances, do not fully replace the multiple tasks of the human hand, including the ability to touch and feel.”

That meant trying to reduce or eliminate the need for anti-rejection drugs. “I want to make sure the benefits outweigh the risks,” Lee says.

Lee’s team has successfully done eight limb transplants on five patients, using just one anti-rejection drug and a technique they call the “Pittsburgh Protocol.” Under the protocol, limb recipients – such as Pollock – receive an infusion of marrow from the limb donor two weeks after the transplant. That helps trick the recipient’s immune system into accepting the arm and hands.

Donor limbs come from the bodies of people who are on life support but not expected to survive. Transplant teams ask families if they will consider allowing the arms or hands of a loved one be offered to patients awaiting them.

Limb transplants have one advantage over organ transplants: rejection is easier to diagnose. The body’s immune system first attacks the skin from the transplanted limb, having interpreted it as a foreign substance.

“If there is any rejection it will be a rash,” Lee says. That rash is treated with a topical steroid cream that does not have the same harmful side effects as the steroids organ-transplant patients often take.

Finding matching limb donors, however, is difficult. Donor limbs have to be the same size, same build, and have the same skin tone, blood and tissue type as the recipient.

Help for Wounded Warriors. Three of the five people Lee’s team has treated are former members of the U.S. military. Josh Maloney, a Marine who lost his right hand in an explosives demonstration, received the first-ever hand transplant using the Pittsburgh Protocol in March 2009. Two months later, Lee’s team performed the first bilateral hand transplant on an Air Force veteran who lost his hands as the result of septic infection.

Pollock became the team’s third transplant patient in February 2010 – and the first in the United States to receive an above-elbow arm transplant. Brendan Marrocco, a soldier who lost both arms and both legs to an armor-piercing roadside bomb on Easter Sunday 2009, has met with Lee’s team and is now a candidate for a bilateral limb transplant. His right-arm transplant would be similar to Pollock’s.

As many as 16 surgeons, including orthopedic, plastic and microvascular specialists, work as long as 12 hours straight from the time they begin to remove the hands or arms from the donor to the time they finish attaching the limbs to the recipient. The final moments, when the recipient’s blood vessels are connected to the new arms and hands, is dramatic, Lee says. “You can see the blood go into the hand. What have been pale tissues turn pink.”

Limb transplants are a key focus of AFIRM, a dual multi-university/medical-center consortia started in 2008. Wake Forest University and the University of Pittsburgh lead one consortium; Rutgers University and the Cleveland Clinic lead the other. The U.S. Army Institute of Surgical Research in San Antonio is the primary military partner, providing research-laboratory resources and guidance regarding military burn patients.

The $280 million initiative was launched with funding from the Army, Navy, Air Force, National Institutes of Health, DoD Public Affairs and VA. Universities, industry and state governments have also contributed. In addition to limb reconstruction, AFIRM is focused on burn repair, scar-free wound healing, craniofacial reconstruction and compartment syndrome – a post-surgical condition where inflammation can impair blood flow, damage nerves and kill muscles.   

“Our intent was to have one therapy in clinical trials after five years,” says Terry Irgens, AFIRM director and a retired Navy captain. “We have 11 clinical trials after three years, and we are enrolling patients in seven of the clinical trials.”

The military is particularly interested in work to reduce the need for anti-rejection drugs. “The goal would be to get patients to accept the donors’ limbs without lifelong immunosuppression,” says Dr. Wendy Dean, a medical consultant to AFIRM. Besides damaging the liver and kidneys, it’s a huge financial burden for patients. “Even with hand transplants, a patient is looking at upwards of $20,000 in immunotherapy,” says Lt. Col. Brian Moore, AFIRM’s deputy director. Reducing or eliminating the need for such drugs will help the civilian and military communities alike.

Blessed Journey. Sheila Advento, a 34-year-old New Jersey resident, is drawing and painting again because of AFIRM’s limb transplant research. In July 2003, Advento contracted meningococcemia, a virulent bacterial infection that can cause gangrene. When she woke up after nine days in the hospital, her hands were black. “They were lifeless, dead,” Advento says. “I was numb from staring at them. I knew they had to go.”

Advento’s hands were amputated at the wrist. Days later, doctors had to remove both legs below the knee. However, a plastic surgeon at Hackensack University Medical Center transplanted muscle from the left side of Advento’s back to her right arm in case she decided to have a hand transplant at some point in the future. That idea took hold. “Throughout all those years, I always wondered how much more I would be able to accomplish with just one hand,” she says.

Advento contacted Lee after reading about his work in late 2009. That led to a week of intense physical and psychological screening. Doctors told her she could change her mind at any time. “I was still determined, no matter what,” Advento says. In September 2010, she became the first woman in the United States to receive a bilateral hand transplant. A month later, she was drawing pictures.

Advento’s ability to feel cold returned while she was washing her hands in mid-November. “I was in shock,” she says. “I must have texted everybody.” By early 2011, Advento could feel texture. She’s still receiving occupational therapy six hours a day, five days a week. But Advento is living on her own, driving again, and has returned to work at Quest Diagnostics two days a week.

“I had my moments, especially when I didn’t have hands,” Advento says. “But I’ve had the greatest support system. I felt myself to be blessed my entire journey.”

It’s a difficult journey that demands a great deal from transplant patients, Lee says. They may need occupational therapy for three years. And because nerves only grow an inch a month, it can take up to three years for a patient to gain maximum function from new limbs.

“There’s no question that patients’ effort and time in therapy correlates with how much function they regain,” Lee said. “(Pollock) has been gaining good function quicker and better than I expected because of his sheer dedication to therapy.”

Pollock is well aware of what that commitment has meant. By his tally, he will have received 1,700 hours of occupational therapy as of mid-January. That’s far from his only challenge. He can no longer work as a mechanic, and he had to move back home with his parents and apply for Social Security disability benefits. But he still considers himself fortunate.

“I don’t see this as being difficult,” Pollock says. “I look back, and it was all a speck of dirt.” 

Ken Olsen is a frequent contributor to The American Legion Magazine.

 

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