Orthopedic surgeon Eric Sides initially laughed off Reggie Cook’s idea. Too crazy.
“I don’t understand why you can’t take my left elbow off and put it on my right side,” said the 37-year-old Cook, who lost use of his arms seven years ago after a car accident.
But then Sides thought about the suggestion, and it actually made sense. Cook’s left arm was paralyzed by nerve damage, but the joint was undamaged. The right arm had movement, but the elbow joint had been shattered beyond repair in the accident.
Sides’ thoughts then went to his friend, Lisa Lattanza, considered one of the world’s leading elbow experts. Training together at the University of Missouri-Kansas City School of Medicine led to their close kinship and prominent surgical careers.
Though their orthopedic residencies ended two decades ago and Lattanza is in California and Sides is in Texas, the two remained close. Sides talked to Lattanza about Cook’s unusual request and they came to a conclusion: Why can’t we do this?
They recently joined forces in what’s thought to be the world’s first elbow-to-elbow transplant. The groundbreaking surgery offers a new hope for Cook to live an independent life.
A desperate request
Cook approached Sides, one of the most sought-after orthopedic surgeons in El Paso, Texas, when no other doctor offered options.
In January 2009 after a long night at work, Cook fell asleep at the wheel and crashed. He was in a coma for months. He suffered brain trauma, broke 14 bones in his neck and was left practically a quadriplegic.
Cook’s legs are partially paralyzed and he uses a wheelchair to get around. But his biggest challenge was the loss of mobility in both arms. A nurse came to his house each day to help him change, shower, use the restroom, make him something to eat, brush his teeth. Cook lives with his sister and her family. He credits her, his daughter and dark humor for keeping his spirit lifted.
There have been glimmers of hope before. His left arm is permanently nerve damaged and paralyzed, but an attempt to rebuild his shattered right arm showed promise. In 2013, an artificial joint made of metal and plastic gave him his right arm back —for a few weeks. The delicate joint ripped, a blood clot formed and became infected.
So doctors removed the joint to treat the infection, then reinstalled it. Another infection. Each time the joint was taken out, doctors had to scrape away part of the bone to get rid of the infection, until he had only a few inches of bone in the upper arm, and not much more of the bones in his forearm.
Doctors told him the artificial joint wouldn’t work. They didn’t know what else to do. That’s what led to Cook’s unusual request of Sides that brought in Lattanza, chief of hand, elbow and upper extremity surgery at the University of California, San Francisco.
UMKC School of Medicine Residency
Residents, then and now, divide their time among Children’s Mercy, Saint Luke’s Hospital and Truman Medical Center.
“Through UMKC, the surgeons we worked with were incredible,” said Lattanza, who completed her residency in 1998. “That’s where I learned how to perform surgery. Now I teach residents.”
She and Sides, who was two years ahead of her, were members of a tightknit group. The four-year program had three residents annually.
“We built such a close camaraderie as trainees because it could be so stressful at times,” Lattanza said. “We did battle together.”
“She’s like a sister to me,” said Sides, who completed his residency in 1996. “We would do anything for each other.”
Lattanza and Sides share a similar approach: they love surgery but detest bureaucracy. That the prospect of this surgery was completely out of the ordinary did not deter them.
“We’re doctors and we really want to help other people,” Lattanza said.
Sides accompanied Cook to San Francisco for an array of consultations and for the surgery on April 15 of this year.
A novel surgery
Planning the 12-hour surgery took more than six months. While it might seem like Cook had nothing to lose from the surgery, Lattanza said the surgery actually could have made things even worse for him. He could have lost his right arm. He could have lost the use of his right hand.
On the plus side: a transplant of Cook’s tissue meant no risk of the rejection that might occur with a donor elbow. And actual bone would hold up better than an artificial joint.
On the challenging side: elbows are among the most complicated joints in the body. Knees, shoulders and hips have only one connection where bones meet; elbows have three. And all of the nerves and blood vessels that serve the hand run over the elbow.
Another major complication in this surgery: Moving Cook’s own elbow from the left to right is the mirror image – or reverse – of the one it would replace.
Planning included simulated 3D computer surgery. They then practiced on cadavers to figure out the obstacles when moving the elbow from left to right.
“A big issue was making sure that we did not injure any nerves, which would have altered his hand function and made him worse,” Lattanza said. “Everything was very scarred from his first four surgeries.”
Lattanza compared the surgery and its preparation to choreographing a complex ballet where everyone had precise moves to execute at specific points in time. The troupe was a team of more than a dozen surgeons, nurses and medical technicians. Surgeons performed simultaneously on both sides of Cook.
Due to state licensing restrictions, Sides did not get to scrub in to the surgery, but he participated.
“It was great to be in the operating room again with Eric again,” Lattanza said. “Everyone on the team performed flawlessly and I don’t think I have ever used all my skill and brainpower to this extent. It was exhilarating.”
Although there will have to be a follow-up surgery to reconstruct ligaments, the elbow transplant is so far a success. Cook remains in San Francisco with Lattanza examining him routinely and Sides checks in by phone.
As planned, Cook’s left arm was amputated during the procedure and he nicknamed the stump “Mighty.”
“He’s doing quite well,” Lattanza said. “After 10 days, he bent his arm and he hadn’t done that in seven years. He was quite emotional.”
“We are cautiously optimistic, but he has a long way to go. If the elbow heals and works, he definitely will be better off than when we started.”
Sides, who specializes in adult reconstructive surgery and sports medicine, hopes to team up with Lattanza again.
If Cook’s transplant is successful, it could be a useful example for other patients. Sides said similar procedures could be used on legs or other parts of the body. One application might be a war-wounded veteran.
News of Cook’s unusual surgery has received national media attention. UMKC School of Medicine faculty and their former residency colleagues have celebrated the medical advance.
“It makes me and all of us very proud, because this really is a first,” said Mark Bernhardt, chair of the UMKC School of Medicine Department of Orthopaedic Surgery. “I worked closely with each of them each during their four years, and they were both bright, inquisitive, talented, committed residents.
“Look what teamwork did here. It proved it is a crucial part of patient care.”
Bernhardt announced that Lattanza will be the annual Dr. Rex L. Diveley visiting professor in April 2017 at the UMKC School of Medicine. She will interact and lecture with students and faculty for two days.
In an email, Lattanza wrote to Bernhardt and other UMKC faculty and colleagues.
“Every one of you was there in the operating room with us. We could not have even dreamed or attempted this without the fabulous training and confidence that you all gave us during residency.”