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 8–12 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 mediations at that time.

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 including Prof Nadey Hakim who represented the UK, and Professor Jean-Michel Dubernard from France. A microsurgeon on the team, Earl Owen from Australia, was privy to the detailed basic research, much of it unpublished, that had been carefully gathered by the team in Louisville.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. 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 and Tsu-Min Tsai 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 nine hand transplants in eight recipients as of 2008.

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).^[1] 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.^[2]

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.^[3]

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.^[4]

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.^[5][6]

March 12, 2011 Linda Lu became the recipient of the first hand transplant in the Southeast, performed at Emory University Hospital,^[7] from a donor Leslie Sullivent.^[8]

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.^[9]

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.^[10]

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 youth, who had lost both his hands in a train accident, received the hands of a 24-year-old accident victim. ^[11]

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.^[12]

Programs

United States

Johns Hopkins University School of Medicine Hand and Arm Transplant Program - Led by W. P. Andrew Lee, MD. Located in Baltimore, MD, the program was approved by the Johns Hopkins Medicine Institutional Review Board in July 2011. This is one of only 2 programs in the United States approved to perform hand/arm transplants using an immunomodulatory protocol, which enables patients to take 1 drug (instead of 3) after the transplant to maintain the hand or arm. The program is funded by the US Army Medical Research and Materiel Command (MRMC)Armed Forces Institute of Regenerative Medicine (AFIRM) to transplant up to 6 Wounded Warriors or civilians who have a hand or arm amputation on one or both sides.

Southern Illinois University School of Medicine Hand Transplant Program - Led by Dr. Michael W. Neumeister, MD, FRCS(C), FACS, the SIU hand transplant program is located in Springfield, Illinois. The program was officially launched in January 2014 after receiving IRB approval and grant funding to transplant five patients, unilateral or bilateral, at minimal cost to the patients.

References

Further reading

• Amirlak B, Gonzalez R, Gorantla V, Breidenbach WC, Tobin GR (Apr 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. (Jul 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.  CS1 maint: Explicit use of et al. (link)
• Jones JW, Gruber SA, Barker JH, Breidenbach WC (Aug 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. 

External links

• www.handtransplant.org
• www.siumed.edu/handtransplant
• World's first successful hand transplant
• New York Times, December 6, 2005, "A Pioneering Transplant, and Now an Ethical Storm"
• CNN, May 8, 2009, "Pastry chef receives double hand transplant"