Hand transplant

Overview

Hand transplant is a treatment option for people who have had one or both hands amputated. In a hand transplant, you receive one or two donor hands and a portion of the forearms from a person who has died. Hand transplants are performed in a small number of transplant centers worldwide.

Although not guaranteed, a hand transplant may help you regain some hand function and sensation. While a hand transplant can improve your quality of life, getting the surgery involves making a lifelong commitment to treatment. You'll need to take special medications (immunosuppressants). You'll also have routine physical therapy and health care appointments to check on the condition of your donor hands.

Why it's done

A hand transplant is performed in selected cases in an attempt to improve quality of life and give you some function and feeling in your new hands.

When matching you with a donor hand for a hand transplant, surgeons consider:

• Blood type
• Tissue type
• Skin color
• Ages of donor and recipient
• The sex of the donor and recipient
• Hand size
• Muscle bulk

Risks

Surgical risks

A hand transplant is a major operation and carries all the risks typical of transplant surgery. Potential risks include infection, bleeding and blood clots. A clot would cause decreased blood flow to your hand, a serious complication that requires immediate surgery to repair.

Rejection risks

Rejection of a donor hand happens when your body's immune system treats your donor hand as foreign to your body. Your immune system may try to destroy your donor hand the same way it attacks viruses or bacteria.

Rejection can happen two ways:

• Acute rejection. Acute rejection happens when your immune system tries to quickly destroy the tissues in your donor hand. It can also happen when your immune system sends special proteins (antibodies) to attack blood vessels and tissues in your donor hand.

  If you have acute rejection, you may notice a rash, swelling, or change in skin color of your hand or arm. You may or may not have pain.

  Acute rejection usually can be controlled with medications, but in rare cases, you may need to have your donor hand or hands removed. Having a previous acute rejection doesn't disqualify you from having another hand transplant, but it may make it more difficult to match you with a donor.

• Chronic rejection. Chronic rejection happens over a longer period of time. Your hand may become painful and lose function. You may notice a loss of hair on your hand or changes in your fingernails.

  It's important to watch for early signs of rejection. Report any changes in the appearance or feeling in your hand to your transplant team. If your transplant team suspects your body is rejecting your donor hand, you may need to begin taking more anti-rejection medications. Your transplant team will likely order tests to be done on your hand, including a biopsy of the tissue in your donor hand.

Immunosuppressant risks

Immunosuppressants are medications you take to prevent your body from rejecting your donor hand or hands. Immunosuppressants are powerful medications that you will need to take for the rest of your life.

Major side effects of immunosuppressants include:

• Increased risk of serious infections, including from the virus cytomegalovirus (CMV)
• Increased cancer risk
• Kidney damage
• Increased risk of developing diabetes
• Osteoporosis
• Increased cholesterol, increasing the risk of heart disease

Other immunosuppressant side effects include:

• Acne
• Weight gain
• Sleeplessness
• Hair loss
• Bruising
• Diarrhea
• Headaches
• Nausea

How you prepare

Evaluating whether to have a hand transplant

Before you can receive a hand transplant, carefully consider the risks of the procedure and whether you're committed to intense follow-up care that will last the rest of your life. Also consider what benefits you hope to gain from a hand transplant.

Post-transplant care includes:

• Regular appointments with transplant doctors and surgeons
• Regular physical therapy
• Taking immunosuppressant medications daily and managing the medications' side effects
• Follow-up care with your primary health care provider for routine health screenings

You'll be evaluated by a transplant team. People with amputation at the mid-upper arm or below may be considered for transplant. To be considered for a hand transplant, a candidate must:

• Pass a comprehensive physical exam that includes X-rays, blood tests and other measures of physical health
• Pass a mental and emotional health evaluation that examines coping skills, family and social support, and ability to manage post-transplant care
• Have no history of chronic nerve conditions, such as peripheral neuropathy
• Have no serious medical problems, such as diabetes, kidney disease, heart disease or untreatable cancers
• Have had no recent serious infections
• Be a nonsmoker
• Not abuse alcohol or illegal drugs
• Complete a financial evaluation of post-transplant care expenses with a member of the transplant team

Getting ready for your hand transplant

Once you're approved for a hand transplant, you'll be placed on a waiting list for a donor hand or hands. Your wait time can be unpredictable, since it's usually not known when a donor hand or hands that will match your needs will be available.

In the meantime, prepare as much as possible for a transplant. Preparations include:

• Transplant clinic visits. You'll need periodic appointments with your transplant team for blood tests and ongoing evaluations of your transplant readiness.
• Strengthening exercises, if recommended. Physical therapists may work with you to increase the strength and flexibility in your arms before your transplant.
• Arranging for travel and lodging. Your transplant team will ask that you stay at a location that's within 10 hours of travel time to the hospital where you'll have your transplant. Following your transplant, you'll usually need to stay near your transplant team for several months. Your transplant team may have recommendations for long-term lodging if you need it.
• Communicating with your transplant team. If you have any changes to your medical care — including changing medications, having a blood transfusion or being diagnosed with a chronic medical condition — let your transplant team know immediately. Also be sure to communicate any changes to your address, phone number or family contact information.

What you can expect

During the procedure

Hand transplant surgery is a complicated operation that can take 18 to 24 hours to perform. A team of surgeons will perform your surgery and provide your family with periodic updates on how your surgery is progressing.

Once the donor hand is ready to be attached to your arm, your surgeons will first attach your bones to the bones of the donor hand using small metal plates. Your surgeons will then use special sutures (stitches) to attach the blood vessels, nerves and tendons. Surgeons use a special operating room microscope to place the sutures. Once all the parts of the donor hand and recipient's arm have been attached, the skin is closed.

After the procedure

After your surgery, you'll be placed in an intensive care unit (ICU). Your health care team will check for function in your donor hand or hands, and you'll be asked to try to move your fingers. It's possible the room that you stay in will be kept at a higher temperature to promote blood circulation in your donor hand or hands.

Once you're stable enough to leave the ICU, you'll move to a different hospital room. You can expect to stay in the hospital for 7 to 10 days following your transplant.

Your health care team will help you manage your pain following your transplant. It's important to communicate to your team how serious your pain is, since managing your pain can speed up your recovery.

A special hand therapist also will work on physical therapy with you while you're in the hospital. He or she will teach you exercises to get your hand functioning. In between exercise sessions, you'll wear a splint on your hand to keep it stable. You'll also be taught exercises to perform on your own.

It's normal to have some emotional concerns soon after your surgery. You may have trouble sleeping and adjusting to your new routine of caring for your donor hand or hands. Talk to members of your transplant team if you have any emotional concerns.

Immunosuppressants

Immunosuppressant medications can help stop your immune system from destroying your donor hand or hands. Following your procedure, you'll begin to take immunosuppressant medications and will continue to do so for the rest of your life.

To decrease the risk of side effects from immunosuppressant medications and the risk of rejection, you should:

• Take your immunosuppressants at the same time and in the same way every day (with or without food)
• Never stop taking the medications unless directed to do so by a health care provider
• Expect side effects from the medications, and work with your transplant team to minimize the side effects
• Have regular blood tests to check the effectiveness of your immunosuppressants

While immunosuppressants can help reduce your risk of rejection, they can also lower your body's ability to fight off infections. If you have any signs that you're becoming ill with an infection — such as fever, rash or swelling — contact your transplant team or your health care provider.

Results

Because hand transplants are a relatively new procedure, it's difficult to predict what the results of your procedure will be. Following your post-transplant care plan carefully can increase your chance of regaining as much function as possible.

Although there's no guarantee on how much hand function you'll gain, hand transplant recipients have been able to:

• Pick up small objects, such as nuts and bolts
• Lift heavier objects with one hand, such as a full milk jug
• Use a wrench and other tools
• Take change into an outstretched palm
• Use a knife and fork
• Tie shoes
• Catch a ball

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