What to Expect From a Hand Transplant

Emily Fennell, UCLA's first hand-transplant recipient

Ann Johansson / Corbis / Getty Images

 

Hand transplants, also known as vascularized composite allotransplantation (VCA), are a total replacement of the hand. Another common abbreviation is composite tissue allotransplantation, or CTA. Both terms refer to the various structures within the hand which must be united during a transplant. This includes blood vessels, nerves, cartilage, bone, tendon, skin, and muscle.

A hand transplant may take place after complicated injuries and illnesses which result in severe structural, functional, and cosmetic deficits. These deficits cannot be treated or rehabilitated in any of the traditional reconstructive ways. This severity makes hand transplants the only viable method allowing an individual to regain function.

Important issues which accompany hand transplants include bioethics, immunosuppression, and the need for adequate nerve regeneration. The transplanted hand will undergo rehabilitation treatment much the same as any other hand injury with nerve involvement.

Reasons for a Hand Transplant

While hand transplants are revolutionary advances in the field of medicine, not everyone qualifies as a good candidate for this procedure. The best candidates for a hand transplant are individuals between the ages of 18 and 69 years old who are in good overall health and able to tolerate immunosuppressive drugs. Being in a good state of health will increase the likelihood the individual’s body will accept the hand(s), rendering the procedure successful. A good candidate will also be free of cancer for the past five years and free of major infections such as hepatitis or human immunodeficiency virus (HIV).

Another important factor in candidacy for a hand transplant is the reason for the hand transplant. Hands which are absent due to full limb amputations are good candidates for this procedure. Your doctor may recommend a hand transplant when an evaluation determines all these criteria have been met and deficits are severe enough that traditional reconstructive surgery will not suffice.

Who Is Not a Good Candidate?

Individuals who lack hand(s) due to cancer or a birth defect are not good candidates for hand transplants. Likewise for individuals who have lost some or all of their fingers to an injury or illness. Individuals with some or no fingers who still have a relatively intact base of the hand would qualify for traditional reconstructive surgery. Individuals who have lost the entire arm are not candidates for hand transplants, as they are lacking the structures to support newly transplanted hands.

Due to the chance of becoming immunocompromised, women who are currently pregnant are not good hand transplant candidates. It is also required that women agree to refrain from trying to get pregnant one year after the transplant.

Donor Recipient Selection Process

Unlike the donor process for vital organs such as the liver and lung, the process is a bit different for transplants which are external and visible. As with all donated organs, blood and tissue types must match to be considered. The selection process then gets more detailed with additional emphasis being placed on matching ethnicity, skin tone, gender, and sizing 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.

Once being recommended and approved for a transplant by a doctor, your name is added to the waiting list. The time someone spends on a waiting list is highly variable from several weeks to several years. Around 85 people have received hand transplants worldwide by 2019, with numbers growing each day as more transplant programs are evolving. Despite the number of active and established transplant programs, the length of the waiting list is dependent on how many donors are available and are good matches for the 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 assists potential recipients in entering their names on the waitlists at several different hospitals nationally to ensure they have the best possible chance of matching with a donor. They assist in managing the review of records to determine which donor is the best match for which recipient on the list.

The waiting list approval process for any transplant can be long and difficult for anyone to cope with. An effective way to increase function and maintain high motivation is to participate in rehabilitation therapies and continue to stay engaged in medical followup. This will assist with the maintenance of a healthy lifestyle and increase engagement in functional performance. Therapies can also assist with productive leisure activities which can help cope with difficult emotions which may come along with the waiting process.

Types of Donors

Understandably, the only donors for hand transplants are those who are decreased. It assists in the donor process if genetic material matches, but only if the donor is of the same blood and tissue type as the recipient. It is also important to factor in cosmetic considerations. This can potentially be received from family members; however, the chances are unlikely family members will be able to provide an acceptable match.

Before Surgery

Before surgery, it is important to begin working with rehabilitation therapies to strengthen your upper extremities in preparation for the transplant. This will help start the rigorous rehabilitation process which will take place after the transplant surgery.

Preparation for the surgery will also include regular transplant clinic visits to keep all diagnostic tests are up to date. This will ensure the recipient is still eligible for the transplant. At this time, recipients are also started on a regimen of immunosuppressive medications to prepare the body for receiving the transplanted hand(s). Your tolerance of these medications will also be monitored at clinic check-ins.

Due to the complexity and length of a hand transplant, doctors recommend a recipient stays within several hours of the hospital where they will be receiving their transplant. These accommodations should be made ahead of time to secure a convenient placement. Recipients are often required to remain in these accommodations for several months after their transplant to ensure they can regularly check-in with their team of doctors.

Surgical Process

Surgery typically takes eight to 10 hours in instances where there are no complications. This is the time it will take for surgeons to connect the blood vessels, followed by intensive testing to ensure the blood vessels are in working order. Once blood vessels have been secured, surgeons will connect nerves, bones, tendons, and muscles. Two surgical teams are needed, as one will work on removing and preserving the hand(s) from the donor while the other team prepares the recipient’s arm for the transplant.

After Surgery

Patients stay several days in the intensive care unit (ICU) immediately following transplant to ease the transition process and closely monitor the recipient for any signs of rejection. After the second day, the recipient will begin rehabilitative services such as physical therapy and occupational therapy to strengthen the hands and increase the function of the recipient. Patients will then be moved to a standard post-operative room for observation as long as there are no serious concerns. In these rooms, doctors will continually check in on the recipient to ensure motor and nerve function is present.

Pain will also closely be monitored as extreme pain is a sign of possible rejection. Pain will be managed by your health care team, so it is important to ensure patients accurately report pain levels. Patients will eventually be weaned off pain medication as their pain levels decrease.

Patients will continue on immunosuppressive medications for the rest of their life following the transplant. This will increase the chances of the body accepting the transplant.

It is important to follow the instructions of an occupational or physical therapist closely, as they will guide patients toward recovery and the safe use of the new hand. Therapists often recommend patients wear a splint to protect the mechanisms of the hand while at rest. Splints also provide sensory input to the new hand, which gradually lessens some of the sensitivity and pain a patient may be experiencing.

Acute and chronic rejection are the highest risks associated with hand transplants. Acute rejection is often visible immediately and can be seen in a drastic immune system response. Skin rashes which appear shortly after the transplant are typically the first sign of acute rejection. Chronic rejection may not happen until years later; however, there is an excellent recovery rate for individuals who receive immunosuppressive medications in response to chronic rejection.

The good news is there have been no reports of rejection occurring after hand transplant surgery. This is an excellent sign that the procedure currently followed is effective enough to ensure functional use.

Prognosis

Since there are no known cases of rejected hand transplants, it is safe to say the prognosis for individuals who receive transplanted hands is excellent. This prognosis is due in large part to the consistent use of immunosuppressive medications following the transplant.

Support and Coping

The addition of a new hand is a major step toward living a full and independent life. This is not only a large milestone for you, but also a big change. Much of the monitoring after surgery will focus on appropriate coping and psychological response to the patient’s new hand(s). Normal reactions associated with a hand transplant may include a feeling of disconnect with the body, changes in self-esteem, and difficulty re-entering roles you naturally have assumed such as mother or caretaker.

It is important to discuss these feelings to prevent abnormal psychological reactions which limit function and impact quality-of-life. Depression is a risk after any major surgery, so you and your friends and family should be alert for any symptoms and report them to your medical team.

Recent hand transplant recipients should seek support in whichever way they see fit. This may include joining support groups, speaking with close friends, engaging in activities you enjoy, and taking the time to properly manage stress. Normal reactions to this procedure should subside after a couple of months, so be sure to seek help if these psychological symptoms persist.

Maintaining a healthy diet will support the healing process. Your transplant medical team may include a dietitian, or you can ask them for a referral to one to get personalized advice.

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