The Institute for Plastic Surgery at Southern Illinois University School of Medicine, in partnership with Memorial Medical Center, is conducting a clinical trial of hand and upper extremity transplantation for patients who have previously lost one or both hands/arms. The trial was approved by the Springfield Committee for Research Involving Human Subjects on October 17th, 2013 (IRB protocol # 12-811) and is currently enrolling patients. Click on the tabs above and to the left of the page for more information.
Hand Transplantation Defined
Hand transplantation is the surgical transfer of a hand from an organ donor to a person who has previously suffered an amputation. Hand transplantation is similar to other organ transplants such as a heart, liver, or kidney, in that the tissue comes from a deceased donor and therefore requires lifelong medications to prevent rejection. Hand transplantation also requires an extensive post-operative hand rehabilitation process to regain function of the transplanted limb.
Hand transplantation evolved from hand replantation, or the surgical re-attachment of an amputated hand. The first successful replantation of an arm took place in 1962, which paved the way for hand and arm transplantation. The procedure of transplanting a hand from a deceased donor to a patient was first performed in 1964, but failed two weeks later due to the primitive anti-rejection medications used at the time. With the addition of modern anti-rejection medications in the 1980’s-90’s, the first long-term successful hand transplant took place in 1999 in Louisville, Kentucky. This patient continues to function well with his transplanted hand and has experienced only minor complications from his medications. Since that time until today, close to 100 hand transplants have been performed, some including the upper arm. Although some transplanted hands have required removal due to rejection, this is rare and usually only due to not taking the medications as instructed. The overall graft survival rate for hand transplants at 5 years after transplantation is around 90%, compared to the next highest graft survival rate of 75% in kidney transplants.
1. Foroohar et al. The History and Evolution of Hand Transplantation. Hand Clin 2011; 27:405-9.
2. Petruzzo et al. International Registry on Hand and Composite Tissue Transplantation.
Transplantation 2010;90(12) 1590-4.
Before the Transplant
Once a patient is found to be a good candidate for hand transplantation they will be placed on a waiting list. All organ donors from the surrounding region will then be screened for compatibility with the patient in regards to blood type, tissue type, CMV virus status, as well as hand size, skin color, tone, and hair patterns. Once an appropriate donor is located, the hand transplant team will be mobilized and the patient will be brought to the hospital for the surgery.
Once the final match between the patient and donor is confirmed, the patient goes to surgery and the transplant begins. The donor limbs are delivered to the operating room, and each structure is carefully attached including the bones, blood vessels, tendons, muscles, nerves, and skin. The anti-rejection medications are started during surgery. A bulky protective splint is then placed on the arm along with oxygen monitoring probes. The surgery usually takes around 12 hours. Once the transplant is complete, the patient is taken to the recovery room.
After surgery the patient will stay in the intensive care unit for 1-3 days for close monitoring. They will then move to a regular hospital room where they will stay for 1-2 weeks. Physical therapy will begin within 2-3 days after surgery. Transplant nurse educators will spend time with the patient daily for instruction on the anti-rejection medications. After discharge from the hospital, the patient will stay near the medical center for 3-6 months for close monitoring for signs of rejection and for extensive hand rehabilitation (see separate link to the left for more details). Housing will be provided during this period by the hospital.
According to the International Registry on Hand and Composite Tissue Transplantation, 100% of hand transplant patients reported to the registry so far have regained protective sensation to the transplanted hand. Roughly 90% of people regain tactile sensation, or the ability to sense the texture of objects and how much pressure is placed on the skin. Discriminative touch, or the ability to precisely locate and identify objects based on touch is regained in 84% of patients.
The registry has also reported promising motor, or functional outcomes following hand transplantation. Based on a number of scoring systems such as the DASH score (disabilities of the arm, shoulder, and hand) and the HTSS (hand transplant scoring system), functional outcomes continue to improve over the life of the graft, and with dedication to physical therapy, can reach near normal scores (see figures below).
Both the registry and a recent report by Jensen et al. noted that the vast majority of hand transplant patients report an increased quality of life after the transplant. In addition, most patients are able to return to work, perform their activities of daily living, and participate in hobbies once again. Transplanted hands also restore a near normal appearance to the body although this can vary depending on the match between the donor and recipient.
1. Petruzzo et al. International Registry on Hand and Composite Tissue Transplantation. Transplantation 2010;90(12) 1590-4.
2. Jensen et al. Quality of life considerations in upper limb transplantation: review and future directions. J Hand Surg Am. 2012 Oct;37(10):2126-35.
Because hand transplantation is similar to other organ transplants and requires immunosuppression (anti-rejection) medications, there are a number of potential risks and side effects. In order to prevent the immune system from attacking the transplanted tissue, medications that lower the immune system are used that also make patients more susceptible to infections, metabolic problems (like diabetes), and some cancers. There are also risks that come with any surgical procedure such as allergic reactions to anesthetics, excessive scaring, infections, blood clots in the legs that can move to the lungs, heart attacks, and strokes. Although very rare, some of the complications can be life threatening.
The alternatives to hand transplantation include learning how to live without the lost hand(s) or utilizing prosthetics. Many modern prosthetics can be very functional and can look quite normal. Most patients undergoing hand transplantation are required to use prosthetics for a period of time before being eligible for a hand transplant.