What to Expect From a Hand Transplant

Emily Fennell, UCLA's first hand-transplant recipient

Ann Johansson / Corbis / Getty Images

 

A hand transplant (vascularized composite allotransplantation, or VCA), is a total surgical replacement of the hand. The procedure is also sometimes referred to as composite tissue allotransplantation (CTA).

Both terms refer to structures within the hand, including blood vessels, nerves, cartilage, bone, tendon, skin, and muscle, that are united during a transplant.

A hand transplant might be considered when illness or injury results in severe structural, functional, and cosmetic deficits.

In severe cases that cannot be treated or rehabilitated using traditional reconstructive methods, a transplant may be the only way for someone to regain hand function.

After surgery, a transplanted hand needs rehabilitation treatment just as any other hand injury with nerve involvement would.

Bioethics, complications from immunosuppression, and the need for adequate nerve regeneration are other important issues regarding hand transplants.

Reasons for a Hand Transplant

Certain criteria must be met to be considered for hand transplant surgery. In general, the best candidates for a hand transplant are people who are:

  • 18 to 69 years old
  • In good overall health
  • Able to tolerate immunosuppressive drugs

Being in a good state of health increases the likelihood a person's body will accept the transplanted hand(s).

Candidates also need to:

The reason for the transplant is also an important consideration. In many cases, people who have lost a hand or even an entire arm live and function well with help from prosthetics. However, if a prosthesis does not work well, transplantation of a new hand or arm might be considered.

If your injury is severe, cannot be addressed with traditional reconstructive surgery, and you have met all the criteria, your doctor may recommend a hand transplant.

Who Is Not a Good Candidate?

Hand transplants are revolutionary advances in the field of medicine, but the procedure is highly specialized and not widely available.

Additionally, not every person who has lost a hand or arm will be eligible for the surgery. For example, individuals who lack one or both hands due to a congenital (born with) cause or as a result of cancer are not considered good candidates for hand transplants.

If someone has lost their entire arm, they would not be able to have a hand transplant because they lack the bone, tissue, and muscle structures needed to support a newly transplanted hand.

Individuals who lose some or all of their fingers to an injury or illness are generally not considered candidates for hand transplants. However, if they have a relatively intact hand base they may qualify for reconstructive surgery.

Due to the risk of immunocompromise, people who are pregnant are not considered for hand transplants. Furthermore, patients who are selected must agree to refrain from trying to get pregnant for one year after the transplant.

Donor Recipient Selection Process

As with all donated organs, the donor blood and tissue type must match those of the intended recipient. Hands are external and visible, unlike vital organs that can be transplanted (such as the liver and lung), which makes the selection process a bit different.

The process of choosing a donated hand for transplant is more detailed and there is an emphasis placed on matching ethnicity, skin tone, gender, and size to ensure a natural fit.

Another factor to consider in donor selection is the presence of healthy nerves and muscles to assist in nerve regeneration and overall recipient acceptance.

After a doctor has recommended and approved a candidate for a hand transplant, their name is added to the transplant waiting list. How long someone will be on the waiting list is highly variable: they may wait weeks, months, or even years.

According to the data collected in 2017, about 85 hand transplants have been completed worldwide. As global transplant programs evolve, the number of successful procedures is expected to rise.

Despite the number of established and active transplant programs around the world, the length of a waiting list depends on how many donors are available and whether there are good matches for each recipient.

According to the United Network for Organ Sharing (UNOS), there is no priority score specifically measuring the candidacy of someone awaiting a hand transplant.

UNOS also helps potential recipients enter their names on waitlists at several different hospitals (which gives them the best chance of matching with a donor), as well as manages and reviews medical records to match donors and recipients.

The waiting list approval process for any transplant can take a long time, and many people find coping with it challenging.

Participating in rehabilitation therapy and staying engaged with medical follow-up helps people waiting for a hand transplant to maintain physical functioning and stay motivated.

Therapies can also assist with productive leisure activities, which are an important part of coping with the emotional aspects of the transplant process.

Types of Donors

Hands used for transplant come from deceased donors. For the transplant to work, the donor's genetic material (specifically blood and tissue type) must match the recipient.

Genetic characteristics are also important for the cosmetic considerations of a hand transplant. While a high degree of genetic similarity could be achieved through family member donation, a match is not guaranteed.

Before Surgery

If you will be undergoing hand transplant surgery, you will begin preparing with rehabilitation therapy to strengthen your upper extremities. Doing so gives you a head start on the rigorous rehabilitation process that will follow transplant surgery.

Preparation for surgery will also include regular transplant clinic visits to keep all diagnostic tests up to date, which ensures you are still eligible for the transplant.

You will be started on a regimen of immunosuppressive medications that prepare the body to receive the transplanted hand(s). Your tolerance of these medications will be monitored at clinic check-ins.

Due to the length and complexity of hand transplant surgery, recipients are usually advised to stay within several hours of the hospital where the transplant will be done.

If you will be traveling far from home, you'll want to make arrangements for your accommodations ahead of time. You will need to stay at these accommodations for several months after the transplant so you can regularly check in with your doctors.

Surgical Process

Two surgical teams are needed to perform a hand transplant surgery. One works on removing and preserving the hand(s) from the donor while the other prepares the recipient’s arm for the transplant.

During the procedure, surgeons carefully connect the blood vessels, then perform intensive testing to ensure they work. Once the blood vessels are secured and have passed testing, the surgeon will move on to connecting nerves, bones, tendons, and muscles.

When there are no complications, a hand transplant can take anywhere from eight to 16 hours.

After Surgery

When the surgery is over, you will spend several days in the intensive care unit (ICU). This helps ease the transition process and allows the medical team to closely monitor for any signs of rejection.

After the second day, you will begin rehabilitative services such as physical therapy and occupational therapy to strengthen your hands.

You'll still be in the hospital after a few days, but if you are healing well you'll be moved to a standard post-operative room for observation. The medical team taking care of you will continue to check on your hand's motor and nerve function.

Your pain levels will also be closely monitored, as extreme pain can be a sign of rejection. It's important that you tell your health care team about any post-op pain you have so they can manage it.

Initially, this may involve pain medication. You will be weaned off these drugs as your pain levels decrease.

You will need to continue to take immunosuppressive medications for the rest of your life to ensure your body continues to accept the transplant.

You will also need to carefully follow the instructions of an occupational or physical therapist, as they will guide you in using your hand safely as you recover.

Patients often need to wear a splint to protect the mechanisms of the hand while it is at rest.  Splints also provide sensory input to the new hand, which helps to gradually lessen pain and sensitivity you might experience after the transplant.

Following a healthy diet is an important component of the healing process. Your transplant medical team may include a dietitian or your doctor may refer you to one during your recovery.

Transplant Rejection

The highest risk associated with hand transplant is rejection, which can be acute or chronic.

Acute rejection can be visible immediately due to a drastic immune response. Skin rashes that appear shortly after the transplant are typically the first sign of acute rejection.

According to data from the International Registry on Hand and Composite Tissue Transplantation (IRHCTT), around 85% of recipients experience one or more episodes of acute rejection.

Chronic rejection may not happen until years after the transplant. IRHCTT data indicates around 10% of hand transplant recipients experience chronic rejection.

However, if people receive immunosuppressive medications in response, the rate of recovery may improve.

Prognosis

The outcomes for a hand transplant vary and are largely dependent on a patients' consistent use of immunosuppressive medications after the surgery.

Even if the transplant surgery goes well and a patient's medication adherence is good, it's difficult to predict exactly how functional a transplanted hand will be.

The procedure is still new and there are few longterm examples to look to for guidance.

In addition to preventing rejection, the surgery would be considered successful if a person is able to live well and function with their new hand.

Ideally, a person will be able to perform typical everyday tasks with their new hand, such as:

  • Pick up small objects, like nuts and bolts
  • Lift heavy objects (for example, a gallon of milk) with one hand
  • Use a wrench and other tools
  • Accept small coins in their outstretched palm
  • Properly use utensils (cutting with a knife and fork)
  • Tie their shoes
  • Catch a ball

Support and Coping

If you've lost a hand and receive a new one via transplant, surgery marks a major milestone toward living independently, but it's also a big change—physically and emotionally.

After surgery, much of the work you will need to do will be learning how to cope. The psychological response to having a new hand can differ from one patient to the next.

Feeling disconnected from your body, change in self-esteem, and difficulty re-entering roles you naturally assumed before surgery (such as parent or partner) are all normal responses after a hand transplant.

While these feelings are common experiences, it's important that you discuss them. Acknowledging your emotions will help prevent them from developing into reactions that limit your function or decrease your quality of life.

Depression is a risk after any major surgery, especially when the recovery is long and represents a major life change. Communicate with your support network and medical team to let them know how you're feeling emotionally as well as physically.

Focus on taking care of your body, mind, and spirit. This might include joining a support group, confiding in your friends, family, or a trusted therapist, engaging in activities you enjoy (or finding new hobbies), and learning how to manage stress in healthy ways.

The intense emotions and psychological response to a hand transplant will typically begin to improve within a couple of months. However, if you feel you have persistent symptoms of depression after surgery, tell your doctor.

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