Hand transplantation

Hand transplantation is a surgical procedure to transplant a hand from one human to another. The donor hand usually comes from a brain-dead donor and is transplanted to a recipient who has lost one or both hands/arms. Most hand transplants to date have been performed on below elbow amputees, although above elbow transplants are gaining popularity. Hand transplants were the first of a new category of transplants where multiple organs are transplanted as a single functional unit, now termed "Vascularized Composite Allotransplantation" or VCA.

The operation is quite extensive and typically lasts from 8 to 12 hours. By comparison, a typical heart transplant operation lasts 6 to 8 hours. Surgeons usually connect the bones first, followed by tendons, arteries, nerves, veins, and skin.

The recipient of a hand transplant needs to take immunosuppressive drugs similar to other transplants such as kidneys or livers, as the body's natural immune system will try to reject, or destroy, the hand. These drugs cause the recipient to have a weaker immune system which may lead to an increased risk of infections and some cancers. There have been many advances in solid organ transplantation over the years that have made these medications quite tolerable.

After the transplant, there is a period of extensive hand therapy/rehabilitation which helps the recipients regain function of the transplanted hand. Those patients who are dedicated to taking the medications and performing the physical therapy following a hand transplant have had remarkable success in regaining function of the new hands/arms.

History

A hand transplant was performed in Ecuador in 1964, but the patient suffered from transplant rejection after only two weeks due to the primitive nature of the immune-suppressing medications at that time.^[1]

The first short-term success in human hand transplant occurred with New Zealander Clint Hallam who had lost his hand in an accident while in prison. The operation was performed on September 23, 1998, in Lyon, France, by a team assembled from different countries around the world led by French Professor Jean-Michel Dubernard, including Prof Nadey Hakim, who represented the UK. A microsurgeon on the team, Earl Owen from Australia, was privy to the detailed basic research, much of it unpublished, that had been carefully gathered by the team in Louisville. After the operation, Hallam wasn't comfortable with the idea of his transplanted hand and failed to follow the prescribed post-operative drug and physiotherapy regime. His inaccurate expectations became a vivid example of the necessity of a fully committed team of caregivers, including psychologists, that can correctly select and prepare the potential transplant recipients for the lengthy and difficult recovery and for the modest functional restoration of a transplanted hand to be expected. Hallam's transplanted hand was removed at his request by the transplant surgeon Nadey Hakim on February 2, 2001, following another episode of rejection.

The first hand transplant to achieve prolonged success was directed by a team of Kleinert Kutz Hand Care surgeons including Warren C. Breidenbach, Tsu-Min Tsai, Luis Scheker, Steven McCabe, Amitava Gupta, Russell Shatford, William O'Neill, Martin Favetto and Michael Moskal in cooperation with the Christine M. Kleinert Institute, Jewish Hospital and the University of Louisville in Louisville, Kentucky. The procedure was performed on New Jersey native Matthew Scott on January 14, 1999. Scott had lost his hand in a fireworks accident at age 24. Later in 1999, the Philadelphia Phillies baseball team asked him to do the honors of throwing out the ceremonial first pitch. The Louisville group went on to perform the first five hand transplants in the United States and have performed 12 hand transplants in ten recipients as of 2016.

In contrast to the earlier attempts at hand transplantation, the Louisville group had performed extensive basic science research and feasibility studies for many years prior to their first clinical procedure (for example, Shirbacheh et al., 1998).^[2] There was also considerable transparency and institutional review board oversight involved in the screening and selection of prospective patients.

In March 2000, a team of surgeons at the University of Innsbruck in Austria began a series of three bilateral hand transplants over six years. The first was an Austrian police officer who had lost both hands attempting to defuse a bomb. He has completed an around-the-world solo motorcycle trip using his transplanted hands.

University of Louisville doctors also performed a successful hand transplant on Michigan native Jerry Fisher in February 2001, and Michigan resident David Savage in 2006.^[3]

On January 14, 2004, the team of Professor Jean-Michel Dubernard (Edouard-Herriot Hospital, France) declared a five-year-old double hand transplant a success. The lessons learned in this case, and in the 26 other hand transplants (6 double) which occurred between 2000 and 2005, gave encouragement to other transplant operations of such organs as the face, abdominal wall and larynx.

On May 4, 2009 Jeff Kepner, a 57-year-old Augusta, Georgia resident underwent the first double hand transplant in the United States at the University of Pittsburgh Medical Center by a team led by W.P. Andrew Lee, who also had been performing careful basic research on such transplants for many years. A CNN story on his follow up demonstrated the limited functional restoration to be expected, particularly following bilateral transplantation.^[4]

On February 18, 2010, the first female in the United States underwent hand transplantation at Wilford Hall Medical Center in San Antonio, Texas. The procedure was performed by surgeons from The Hand Center of San Antonio and US Air Force.^[5]

On June 22, 2010, a Polish soldier received two new hands from a female donor, after losing them three years earlier while saving a young recruit from a bomb.

On March 8, 2011, 26-year-old Emily Fennell underwent an 18-hour surgery to attach a right hand. This was performed in the Ronald Reagan UCLA Medical Center.^[6][7]

March 12, 2011 Linda Lu became the recipient of a hand transplant, performed at Emory University Hospital,^[8] from a donor Leslie Sullivent.^[9]

In the fall of 2011, 28-year-old Lindsay Ess received a double hand transplant at the Hospital of the University of Pennsylvania in an 11 1/2 hour surgery.^[10]

On December 27, 2012, 51-year-old Mark Cahill received a right hand transplant at Leeds General Infirmary in the UK. The recipient's hand was removed during the same 8 hour operation, reportedly allowing very accurate restoration of nerve structures, believed to be an international first.^[11]

On February 27, 2013, 38-year-old Eskandar Moghaddami received hand transplant surgery by the 15th of Khordad Hospital plastic surgery team in Tehran, Iran.

On January 13, 2015, doctors at the Kochi-based Amrita Institute of Medical Sciences and Research Centre (AIMS) successfully conducted India's first hand transplant. A 30-year-old man, who had lost both his hands in a train accident, received the hands of a 24-year-old accident victim.^[12]

On July 28, 2015, doctors at the Children's Hospital of Philadelphia performed the first successful bilateral hand transplant on a child.^[13] At the age of 2, Zion Harvey lost his hands and feet to a life-threatening infection. Six years later, at age 8, he had both of his hands replaced in a double hand transplant.^[14]

On August 2, 2016, the reconstructive transplantation team at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, performed the first intergender hand transplantation in India on a 16 year old boy who had lost both his hands in an electrocution injury. The donor was a 54 year old lady who was brain dead following a road traffic accident.^[15][16]

Kodi Azari

On October 26, 2016, the Director of hand transplantation at UCLA, Dr. Kodi Azari, and his team,^[17] performed a hand transplant on 51-year-old entertainment executive from Los Angeles, Jonathan Koch at Ronald Reagan UCLA Medical Center. Koch underwent a 17-hour procedure to replace his left hand, which he lost to a mysterious, life-threatening illness that struck him in January 2015.^[18] On June 23, 2015, Koch had the amputation surgery, also performed by Dr. Kodi Azari, which was designed to prep him to receive a transplanted limb. This included severing the left hand closer to the wrist than the elbow. Azari kept all the nerves and tendons long and extended, which would give him plenty to work with later. Then he sutured them together and attached them to the stump of bone to keep them from retracting.^[19] This is the first known hand transplant case in which the hand was amputated in preparation for a hand transplant, as opposed to previous hand transplant patients who have undergone typical amputation surgeries. Azari's theory about prepping the hand for a transplant during the initial amputation surgery would later be supported by Koch when he was able to move his thumb only two hours after he woke up from the 17-hour transplant surgery^[20] and move his entire hand only two days after surgery.^[21]

Long-term functionality

The long-term functionality varies patient to patient and is affected by several factors including level of amputation and transplant and participation in occupational therapy post hand transplant surgery. Hand transplant recipient Jonathan Koch was able to pick up a napkin and a tennis ball with his newly transplanted hand 7 days after his 17-hour surgery and by day 9, he was able to pick up a bottle of water and take a drink. 3 months after surgery, Koch was able to use his transplanted hand to tie his shoe.^[22]

Survival rates

Although the one-year survival rate of transplanted hands has been excellent at institutions that are fully committed to the procedure, the number of hand transplants performed after 2008 has been small due to drug-related side effects, uncertain long-term outcome, and the high costs of surgery, rehabilitation and immunosuppression.^[23]

Programs

References

Further reading

• Amirlak B, Gonzalez R, Gorantla V, Breidenbach WC, Tobin GR (April 2007). "Creating a hand transplant program". Clin Plast Surg. 34 (2): 279–89, x. doi:10.1016/j.cps.2007.01.002. PMID 17418677.
• Lanzetta M, Petruzzo P, Dubernard JM, et al. (July 2007). "Second report (1998–2006) of the International Registry of Hand and Composite Tissue Transplantation". Transpl Immunol. 18 (1): 1–6. doi:10.1016/j.trim.2007.03.002. PMID 17584595.
• Jones JW, Gruber SA, Barker JH, Breidenbach WC (August 2000). "Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team". N Engl J Med. 343 (7): 468–73. doi:10.1056/NEJM200008173430704. PMID 10950668.