THE GOOD THE BAD AND THE UGLY: A REVIEW OF SPLINTS USED IN THE LOUISVILLE HAND TRANSPLANT PROGRAM

Ashley Buren Emrich¹, Laurie Newsome¹, Anne Hodges¹, Selena McGill¹, Christina Kaufman¹, Brenda Blair¹.

¹Christine M. Kleinert Institute, Louisville, KY, USA.

Purpose: Over the last 12 years, our center has performed hand transplantation on six patients (5 unilateral and 1 bilateral) for a total of 7 grafts. The purpose of the review was to clearly identify factors guiding splint selection, implementation, and resulting outcomes throughout the rehabilitation process.

Methods: A retrospective chart review of custom made splints used in the first six hand transplants in the Louisville program was conducted. A Bledsoe hinged elbow splint and alumafoam splints were reviewed in addition to the custom braces. The splints were examined in the context of current treatment protocols in hand therapy. Data was collected on the rationale for each splint used, as well as reasons a particular splint did not perform as required. Two splints used universally in all 7 grafts were forearm based crane outriggers, and anti-claw splints.

Results: Primary factors for splint use were found to be: protection of healing structures, positioning of anatomical structures, maximization of function for current and future performance. The greatest challenges in managing the orthotics were edema fluctuations due to both post-operative edema and rejection episodes, wound healing, pressure areas, and maximization of functional performance at every stage of rehabilitation. The average number of splints used per graft was 7.14 with a range of 4 to 10. The recent bilateral transplant was an exceptional challenge due to multiple complications in the early post transplant period, resulting in manufacture of 18 braces in the first 120 days post transplant.

Conclusions: In order to achieve good functional outcomes post hand transplantation, correct positioning of the MP joints and protection of healing structures is critical and achieved through proper splinting. The forearm based crane outrigger is paramount in biomechanically balancing the hand and allowing early protected motion. The anti-claw splint is critical to rehabilitation through the first year post transplantation to position the hand until intrinsic shortening, scarring or innervation has taken place.