Boston surgeons who have successfully transplanted donor faces and hands onto badly disfigured patients are now evaluating several amputees for leg transplants, a highly experimental operation believed to have been done just twice around the world, and never in the United States.
Brigham and Women’s Hospital approved the leg transplant protocol in February. Surgeons initially would perform double-leg transplants only, because patients with one leg usually are able to walk well with a prosthesis.
Doctors already had started screening candidates for the transplants when the April 15 Boston Marathon bombing sadly created another group of badly injured patients, who are now struggling to return to normal life. The bombs tore off the legs of 16 spectators; two of them lost both legs.
Some of the Marathon victims could eventually be considered for the procedure, said Dr. Matthew Carty, surgical leader of the Brigham program. For now, though, doctors are focusing on three patients who each lost their arms and legs when infections ravaged their bodies.
Dr. Bohdan Pomahac, director of plastic surgery transplantation at the Brigham, said amputees who have lost all four limbs, or two legs and an arm, can end up in wheelchairs, particularly if their legs were amputated above the knee, because it can be difficult to function normally with so many prostheses.
“If we can get those people to walk, that is a big deal,’’ he said.
It is unknown when the Brigham would do its first leg transplant, because it depends on finding a candidate who meets the hospital’s criteria and then a suitable donor.
‘In a way it’s bigger than my individual problem. . . . Maybe doctors can learn from the procedure for the next person.’ - William Lautzenheiser, an amputee considering a leg transplant
Unlike hand and arm transplants, which now number nearly 70 operations, leg transplants are controversial among medical professionals. One reason is that the alternative — lower limb prostheses — are constantly improving and allow many amputees not only to walk, but to run, play sports, and swim. Most people remove them to sleep and shower, though, and they must be replaced every three years or so.
Dr. W. P. Andrew Lee, chairman of plastic and reconstructive surgery at Johns Hopkins University School of Medicine, said leg transplants are a natural progression for the specialty. But “if we are going to do a transplant, we want to be better than prostheses,” he said. That is “a higher hurdle to overcome” for leg transplants than for arm transplants, he added, because leg prostheses are more advanced than those for arms.
Doctors also expect rehabilitation after a leg transplant to be longer — Brigham surgeons estimate two years — and more arduous than for an arm transplant. In both cases, the patient’s nerves must grow through the newly transplanted limb for the patient to move it. With a leg, “it’s a very long distance,’’ Lee said. Nerves regenerate at a rate of about one inch per month, he said.
William Lautzenheiser is one of the amputees considering a leg transplant. The 39-year-old contracted a severe group A streptococcus infection nearly two years ago, soon after he began teaching film production and screenwriting at Montana State University.
He spent five months in a hospital intensive care unit fighting for his life, and when his heart stopped pumping blood to his arms and legs, doctors had no choice but to amputate the limbs.
He returned to Massachusetts in early 2012 to undergo rehabilitation at Boston Medical Center. Last summer, a surgeon there introduced him to the Brigham team. Lautzenheiser completed an evaluation for transplant surgery at the hospital earlier this month, and is weighing the benefits and risks of the procedure.
He said that he is struck by how the outcome for him would be “totally unknown.’’ At the same time, he thinks maybe that is not the whole point. “In a way it’s bigger than my individual problem,” he said. “Maybe doctors can learn from the procedure for the next person.’’
If he decides to go forward, Brigham surgeons would do two separate operations to ease the stress on his body — one to give him new arms, and then later, another to attach legs. He said he is nearly certain he will go ahead with the arm transplant.
His left arm was amputated above the elbow and he cannot attach that prosthesis by himself. His body keeps changing shape as he gains back weight and he has had to replace his arm prostheses several times.
“The process requires a lot of patience,’’ he said.
His decision on a leg transplant will hinge in part on how well he learns to walk with his prosthetic legs, he said. He got the metal legs last November and is just beginning to practice walking, by leaning his prosthetic arms on a large, heavy walker.
It is grueling work, especially since his left leg was amputated above the knee. The longer the prosthesis, the heavier it is, and the more tiring it can be to walk.
During physical therapy at Spaulding Rehabilitation Hospital last week, Lautzenheiser required help from two therapists and a friend to attach his prostheses, stand up, and walk the length of the outpatient gym and back. Lautzenheiser, who lives in Brookline, said he would like to be able to walk from his house to the Coolidge Corner Theater. It is one short block, which he said would be a “tremendous accomplishment.’’
He also is considering the risk of taking immunosuppressant drugs for the rest of his life. Transplant patients must take the drugs to prevent their immune systems from attacking the donor tissue, but the medications increase the chances of infections and cancer.
Brigham surgeons proposed the leg transplant program to a hospital ethics committee last year, but they were unsure whether amputees would want to undergo the procedure. Carty worked with the Amputee Coalition, a nonprofit group based in Virginia, to survey members who had lost legs. The level of interest surprised Carty. Of the 770 amputees who responded, 43 percent said they would be “interested in being evaluated as a candidate for potential leg transplantation,’’ he said. There was no difference between amputees who have lost one leg and those who have lost two.
Their biggest concern was having a functioning knee or ankle, but respondents also wanted to have feeling in their limbs, something a prosthesis cannot provide.
Doctors have reported in medical journals that the two patients known to have received leg transplants so far are doing fairly well.
In Spain, in July 2011, Dr. Pedro Cavadas transplanted two legs from a female donor onto a 22-year-old man who lost both his legs above the knee in a car crash. One year after the surgery, the patient, who has not been identified publicly, could extend his knees, flex his feet, and walk while supporting himself between parallel bars, Cavadas reported earlier this year in the American Journal of Transplantation. At one point, his immune system began attacking his new legs, but doctors were able to stop the rejection with medication.
In another case in Toronto that involved two conjoined newborns, the leg of one of the infants, who did not survive, was transplanted onto the sibling. Six years later, the child can walk with a brace, run short distances, and hop, doctors wrote in another article earlier this year.
At the Brigham, leg transplant candidates will have to undergo extensive physical and psychological screening during several months. They will have to wait at least six months from the time of their injury and report less than optimal results using prostheses, based on an evaluation by an experienced physical therapist. The hospital is developing a special rehabilitation program for these patients with Spaulding.
“We are going to be cautious about patients early on,’’ Pomahac said.
Who will pay for the transplants is uncertain, but the Brigham will consider covering the cost if outside sources are not available.
Lee, of Hopkins, said leg transplants are promising but agreed it is best to move ahead gingerly. “We need to be careful about patient selection, and set realistic expectations for the patient, particularly considering the alternatives,’’ he said.