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Scott Kozin, MD, poses with his patient, Zion Harvey, as Zion prepares to leave Children’s Hospital of Philadelphia to begin rehabilitation after receiving a bilateral hand transplant.
Courtesy of Children’s Hospital of Philadelphia

AAOS Now

Published 10/1/2015
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Scott F.M. Duncan, MD, MPH, MBA

Giving Zion Two Hands

The surgery made headlines around the world. In June, 8-year-old Zion Harvey became the first child and youngest person ever to receive a bilateral hand transplant. In the hand surgery world, the event was akin to landing a man on the moon—pretty incredible. The surgery was special in many ways—a stunning technical achievement, a unique collaboration among institutions, and a generous humanitarian gesture.

Recently, I had the opportunity to talk with Scott Kozin, MD, chief of staff at Philadelphia Shriners Hospitals for Children, about the surgery. Shriners Hospitals for Children was the referring hospital, and Dr. Kozin was a member of the surgical team. He started by sharing some of the medical background and social history on this unique patient.

Dr. Kozin: We first saw Zion when he was 6 years old. At age 2, Zion became septic and lost all four limbs and his kidneys. At age 4, his mom donated her kidney, and Zion underwent kidney transplantation, which was key to his becoming the world’s first pediatric recipient of a hand transplant.

On a totally separate front, we had started a collaborative effort with L. Scott Levin, MD, and colleagues at the University of Pennsylvania, about 5 or 6 years ago, to build a pediatric microsurgical center. That’s been an ongoing process with increasing case volume, and this collaborative effort opened our eyes to the possibilities of pediatric hand transplantation.

We subsequently referred Zion to Dr. Levin at the Hand Transplantation Center at The Children’s Hospital of Philadelphia (CHOP). It took almost 2 years to bring everything to fruition. The first year was spent just studying Zion to make sure he was an appropriate candidate—psychologically, physically, and mentally. During that time, we also organized a team and practiced multiple times at the tissue lab.

Dr. Duncan: How did you go about planning for such a complicated surgery?

Dr. Kozin: Dr. Levin was the orchestrator and each surgeon practiced on different parts of the proposed procedure. We varied surgical roles between working on the donor or recipient part. We had to be ready to perform all parts of the surgery because we didn’t know who would be in town when it finally happened. The nurses and the Gift of Life Donor Program also participated in the practice sessions.

The cool thing was that the surgeons were from around the city—from Shriners, CHOP, and Penn Medicine. Nobody had any personal agendas—we all just wanted to do what was right for Zion.

We also developed a surgical checklist appropriate for children. After each practice session, we would debrief and work on the checklist, which included about 25 steps. We had tags made for each individual anatomic structure to facilitate their identification during surgery. We also enlisted corporate sponsors, including Materialise (Leuven, Belgium), which is a maker of 3-D prototypes, to produce cutting jigs to ensure that Zion’s arm and the donor’s arm would align. We talked about how and where to make the connection, particularly with respect to the growth plate.

We also discussed acceptable proportions and ultimately decided that plus or minus 20 percent of ideal would be acceptable. Subsequently, the biomedical engineers made prostheses that were plus or minus 20 percent. Hence, when the procurement team assessed a donor, they didn’t have to take any measurements. The team simply took the prostheses and measured them against the donor. We did the same thing with a skin palette to ensure an adequate match.

By April, we had all the steps and the timing down and planned to practice regularly until a match was found. We were told it could take up to 3 years. But on a Sunday morning in June, I got the call from Dr. Levin that a match had been found. Surgeons who were out of town returned and the surgery started on a Monday afternoon. Ten surgeons and probably 40 ancillary staff were involved. It was the coolest thing I’ve ever done.

Dr. Duncan: How long did the entire surgery take? Did you take any breaks or simply push through the entire way?

Dr. Kozin: The surgery lasted about 12 hours. Every limb had a scribe, who could be a resident, a fellow, or a transplant coordinator. We followed the 25-point checklist and the last point was to go back and recheck the first 24 points. Then we took a break and the next team came in. When they were done, we were called back. It was like a big ballet—people moving in and out. No one surgeon operated for the entire 12 hours.

Dr. Duncan: Very impressive; you really thought this through.

Dr. Kozin: Preparation was the key. We analyzed and discussed every part of the procedure—from incision to closure and every part in between. We didn’t post Zion on the transplant list until we were ready. Nobody felt we were ready to tackle the transplant until the surgical technique, anesthesia, nursing, immunology, and rehabilitation were defined.

The greatest thing about the Hand Transplant Center at CHOP was the level and degree of expertise available. For example, there was a dedicated transplant pharmacologist.

Dr. Duncan: It sounds like a unification of multiple centers enabling the talent to work together. It’s nice to see silos break down for the betterment of humankind.

Scott Kozin, MD, poses with his patient, Zion Harvey, as Zion prepares to leave Children’s Hospital of Philadelphia to begin rehabilitation after receiving a bilateral hand transplant.
Courtesy of Children’s Hospital of Philadelphia
The transplant team had tags made for each individual anatomic structure to facilitate their identification during surgery.
Courtesy of Children’s Hospital of Philadelphia
L. Scott Levin, MD, from the Hand Transplantation Center at the University of Pennsylvania, orchestrated the procedure; participating surgeons were from three different hospitals.
Courtesy of Children’s Hospital of Philadelphia
During his rehabilitation after surgery, Zion played soccer with his mother (serving as goalie) and a physical therapist.
Courtesy of Children’s Hospital of Philadelphia

Dr. Kozin: Collaboration is the key; it was a fantastic opportunity. I’d love to see this type of collaboration serve as a model for systems working together to better treat patients.

Dr. Duncan: We all know the pros and cons for hand transplantation in general in adults. As a child, does Zion have essentially the same immunosuppressive regime that any hand transplant patient would get? Or is he on a lower dose due to the previous kidney transplant?

Dr. Kozin: One thing that concerned us was the minute possibility that the additional antigens induced by the hands could lead to rejection of the kidney or full-blown rejection of everything.

Zion is on a lower dose than an adult, but it’s still a slightly higher level than he would take for just the kidney. However, children don’t seem to react to the medications as adults do. To Zion, the medication is part of his life. His personality is unbelievable. At the press conference afterward, we asked Zion if he wanted to say anything else. He said, “Yes, I want my family to stand up.” He had 25 members of his family stand up, and he said, “I want to thank you for all that you have done. If this doesn’t work, don’t worry. I have you to fall back on.” You could have heard a pin drop in that room.

Dr. Duncan: So what’s next for Zion? What about rehabilitation?

Dr. Kozin: He was first discharged to a rehab facility adjacent to CHOP, but the goal is to get him home, back in his own environment. He lives in Baltimore, so the CHOP therapists are working with therapists from the Kennedy Krieger Institute to transition his care. The cool thing about Zion is that he’s bringing all these institutions together with the single goal of making life better for Zion.

We are also analyzing Zion’s brain and its reaction following hand transplantation. We know that if a person loses a thumb, that area of the cortical homunculus will shrink. When the individual subsequently has a toe-to-hand transplant that area increases. We don’t know how Zion’s brain will react to the transplant. Will it react as though it’s a 2-year-old’s hand or an 8-year-old’s hand? So we’re conducting functional MRI studies to assess his development over time. Will the part of the homunculus that represents the hand enlarge? I imagine it will.

Dr. Duncan: Children’s plasticity is amazing, as you know, from your work with them.

Dr. Kozin: The game-changer in Zion’s case is the fact that he had a kidney transplant and was already on the medications. With other pediatric amputees, transplantation requires a real risk/benefit discussion because they’ll be on medications for a lifetime.

Dr. Duncan: Can you share any information about the donor or the donor’s family?

Dr. Kozin: Great question, but the way that Gift of Life and organ procurement works is that there’s no contact between the recipient team and the donor team. All I know is that the child was 2 or 3 years old. I can’t imagine being in those parents’ position; they deserve huge accolades for changing lives, not only Zion’s, but other children’s lives as well because other organs were also donated.

Dr. Duncan: Who else was on the surgical team, other than yourself and Dr. Levin?

Dr. Kozin: We had a transplant surgeon, a few plastic surgeons for their expertise in vascular reconstruction. We also had anesthesiologists, and the other orthopaedic surgeons included Robert Carrigan, MD; David R. Steinberg, MD; David J. Bozentka, MD; and Dan A. Zlotolow, MD.

Dr. Duncan: This is an excellent example of collaboration and getting services to work together. It’s really an incredible story, and I’m sure we’ll be hearing more about hand transplants in the future.

As a society, we’ve accepted liver, kidney, and heart transplants; it’s just a matter of time before composite tissue allografts will be seen as acceptable. One hopes this will spur more research into immunosuppression and alternatives as well as techniques and technologies that will increase application and survival rates for all kinds of transplants.

Dr. Kozin: I think the important message is what we can do with innovation and collaboration. The sky is the limit.

An AAOS Now podcast with L. Scott Levin, MD, chair of the department of orthopaedic surgery at Penn Medicine and director of the hand transplantation program at Children’s Hospital of Philadelphia, is available for download here.

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