Historic Double Hand Transplant

How OTs and PTs played a pivotal role in the remarkable story of 8-year-old Zion Harvey

Cover Story

Vol. 31 • Issue 12 • Page 8

When Zion Harvey was just a toddler, he developed a case of sepsis that required the amputation of his hands and feet, as well as a kidney transplant. Now 8 years old, Zion hasn’t let those impairments dampen his sunny outlook on life or chase the nearly ever-present smile from his face. That’s part of the reason why he was deemed an ideal candidate to become the world’s first-ever pediatric recipient of a bilateral hand transplant.

The revolutionary surgical procedure occurred in early July at the Children’s Hospital of Philadelphia (CHOP), led by L. Scott Levin, MD, FACS, chairman of the Department of Orthopedic Surgery and professor of surgery (Division of Plastic Surgery) at Penn Medicine, and director of the Hand Transplantation Program at CHOP. In total, a 40-member multidisciplinary team of physicians, nurses and other healthcare personnel from plastic and reconstructive surgery, orthopedic surgery, anesthesiology and radiology conducted the 10-hour operation.

During this transplantation, the hands and forearms of a donor were attached by connecting bones, blood vessels, nerves, muscles, tendons and skin. The surgical team was divided into four simultaneous operating groups, with two focused on the donor limbs and two on Zion. First, the radius and ulna were fused with steel plates and screws. Next, microvascular surgical techniques connected the arteries and veins. Once blood flow was established through the reconnected vessels, surgeons individually repaired and rejoined each muscle and tendon, before reattaching nerves and closing the surgical sites.

“This surgery was the result of years of training, followed by months of planning and preparation by a remarkable team,” said Levin. “The success of Penn’s first bilateral hand transplant on an adult, performed in 2011, gave us a foundation to adapt the intricate techniques and coordinated plans required to perform this type of complex procedure on a child. CHOP is one of the few places in the world that offer the capabilities necessary to push the limits of medicine to give a child a drastically improved quality of life.”

Following the surgery, Zion spent a week in CHOP’s pediatric intensive care unit before being moved to acute care and eventually an inpatient rehabilitation unit. He underwent rigorous occupational and physical therapy several times per day prior to being discharged in late August. Zion now returns to CHOP on a biweekly basis for evaluation, while also undergoing daily therapy in his native Baltimore.

Embracing the Challenge

The rehabilitation team at CHOP embraced the challenges of such a groundbreaking procedure, as well as the rewards of treating a patient as charismatic and inspiring as Zion.

“We started therapy with him at bedside one week post-operatively,” related Deborah Humpl, OTR/L, outpatient occupational therapy supervisor at CHOP. “That included passive and active range of motion, along with extensive splinting for positioning.”

“Much of Zion’s day-to-day management entailed controlling of edema, positioning and dressing changes, assessing his positioning while sleeping, as well as daily rounds with doctors to assess his skin,” added Kelly Ferry, MOTR/L, staff therapist. “I can’t emphasize enough how much time we spent on splinting and changing splints — literally hours each day.”

Beyond the physical concerns, Zion’s therapy also included a significant mental aspect.

“One component that’s ongoing but started very early was making sure he felt comfortable with the idea of having new hands, looking at and connecting with them,” shared Todd Levy, MS, OTR/L, CBIST, clinical specialist. “Thankfully, from the beginning Zion was remarkably comfortable and playful. He really began to look at his hands and touch his face on his own, without much encouragement from us. I think we expected that to be more of a gradual development, but Zion was so mature about it.”

“Yes, he quickly showed an impressive understanding of how extensive this process would be, and adapted really well,” Ferry agreed.

“When we saw Zion for the first time after surgery, the level of compliance he demonstrated was incredible,” added Humpl. “Lying there for 8 hours a day completely immobilized while we stretched him, did range of motion, had him try to move his hands, and adjusted his splints over and over again. I remember saying, ‘We’ve found the most perfect candidate in the world for this.'”

Collaborative Care

Although occupational therapy comprised the majority of Zion’s rehabilitation, physical therapy certainly played an important role as well.

“The interesting thing about Zion from a PT standpoint is I didn’t actually do much with his hands,” related Domenica Platenecky, PT, DPT, PCS, staff therapist, who served as Zion’s sole physical therapist for about five weeks in the acute care setting. “It was more about the secondary effects of the surgery.”

Due to precautions regarding Zion’s hands, he had to hold them in specific positions and could only perform certain movements for set periods of time, Platenecky continued.

“That could be hard on him because of the lower-extremity prosthetics. The new hands completely affected his posture and balance, so we had to conduct significant training and basically teach him how to walk again. We also did a lot of postural education, because he felt very stiff and weak at times. Another factor was poor endurance since he had been immobilized for about a week after surgery, so we worked hard to build that back up.”

When Zion transferred to inpatient rehabilitation in mid-August, Jamie Bradford, PT, DPT, staff therapist, became his primary physical therapist for the approximately two weeks until he was discharged from CHOP.

“Much of our focus in the inpatient setting was on trying to increase what Zion had already been doing in the acute setting,” Bradford told ADVANCE. “So we had him out of his room more frequently, and worked hard on getting him to walk to therapy rather than being taken in a wheelchair. That way it would be more of a normalization of his day-to-day life when he went home. In addition, we really tried to increase his endurance activities and work more on dynamic balance, whereas in acute care he had just been trying to re-learn his balance.”

What kind of progress has Zion made so far?

“I watched him walk down the hall recently with his mom holding his hand and he looked amazing,” said Humpl. “If you saw him in the park, you’d never know he had a hand transplant.”

“We see him now doing fun things like trying to hold a football and that just elevates his motivation to do even more,” added Ferry. “This is an ongoing process and we don’t know yet what the long-term results will be, but Zion continues to make gains and enjoy his progress.”

‘Incredible Experience’

Witnessing that improvement is just as gratifying for the dedicated therapists who have helped Zion along the way, and all feel very humbled to be part of his trailblazing journey.

“It has been such an exciting honor,” related Platenecky. “As the first time this procedure was ever performed on a child, it has also been challenging since there are no norms for pediatrics, no baseline or benchmarks to take guidance from. But that has made it a great learning experience too. Being able to troubleshoot for the first time, figure out what works, what doesn’t work, and how we can do it better in the future.”

“One of the remarkable things about working on this case has not only been Zion himself, but also just being part of something that’s happening for the first time in the history of the world,” concluded Michelle Hsia, MS, OTR/L, outpatient occupational therapy supervisor. “Coming together as a team, and being able to work with the physicians at Penn and CHOP. The amount of energy, dedication, time and pure care given to Zion all day, every day by all of us was spectacular. He has been amazing to work with, and just being on this team has been an incredible experience as well.”

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