Hand transplantation, or simply a hand transplant, is a surgical procedure to transplant a hand from one human to another. The donor hand, usually from a brain-dead donor, is transplanted to a recipient amputee. 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 (VCA).
The operation is quite extensive and typically lasts from 8 to 12 hours. In 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.
Use of immunosuppressive drugs afterward
For a hand transplant to succeed the recipient is required to take immunosuppressive drugs,[1] as in other organ transplants such as kidney or liver, to minimize rejection, or risk destruction of the hand by the recipient's natural immune system. These drugs risk weakening the recipient's immune system, which may increase the risk of infections and some cancers. Many recent advances in solid organ transplantation have made these medications more tolerable.
A period of extensive hand therapy/rehabilitation after transplantation helps the recipient gain function of the transplanted hand.[2] Compliance with immunosuppressive medications and intensive physical therapy after hand transplants is associated with significant success in regaining the function of the new hands/arms.
A hand transplant was performed in Ecuador in 1964, but the patient experienced transplant rejection after only two weeks due to the primitive nature of the immune-suppressing medications at that time.[3]
September 23, 1998 hand transplant
The first short-term success in human hand transplant surgery occurred with Clint Hallam,[4] from New Zealand. Hallam lost his hand in an accident while in prison.[5][6][7] The operation was performed on September 23, 1998,[8] in Lyon, France, by a team assembled from different countries around the world led by French Professor Jean-Michel Dubernard, including Professor Nadey Hakim, from the UK.[7][5][9]
A microsurgeon on the team, Earl Owen from Australia, was privy to the detailed basic research, much of it unpublished, that had been carefully gathered by the team in Louisville.[8] After the operation, Hallam wasn't comfortable with the idea of his transplanted hand and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 regime.[6][8] His inaccurate expectations became a vivid example of the necessity of a fully committed team of caregivers, including psychologists, who 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.[6][5][4]
Hallam's transplanted hand was removed[10] at his request by the transplant surgeon Nadey Hakim on February 2, 2001, following another episode of rejection that was, at least in part, caused by his stopping the anti-rejection medication.[11][8]
Other hand transplantation surgeries
The first hand transplant to achieve prolonged success was directed by a team of Kleinert Kutz Hand Care surgeons including Warren C. Breidenbach, Tsu-Min Tsai, Luis Scheker, Steven McCabe, Amitava Gupta, Russell Shatford, William O'Neill, Martin Favetto and Michael Moskal 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 12 hand transplants in ten recipients as of 2016.[citation needed]
In contrast to the earlier attempts at hand transplantation, the Louisville group had performed extensive basic science research and feasibility studies for many years before their first clinical procedure (for example, Shirbacheh et al., 1998).[12] There was also considerable transparency and institutional review board oversight involved in the screening and selection of prospective patients.[citation needed]
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.[citation needed]
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.[13]
On 14 January 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, encouraged other transplant operations of such organs as the face, abdominal wall, and larynx.[citation needed]
On 4 May 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.[14]
On 18 February 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.[15]
On 22 June 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.[citation needed]
On 8 March 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.[16][17]
On 12 March 2011 Linda Lu became the recipient of a hand transplant, performed at Emory University Hospital,[18] from a donor Leslie Sullivent.[19]
On 27 December 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.[21][22]
On 27 February 2013, 38-year-old Eskandar Moghaddami received hand transplant surgery by the 15th of Khordad Hospital plastic surgery team in Tehran, Iran.[citation needed]
On 13 January 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 man, who had lost both his hands in a train accident, received the hands of a 24-year-old accident victim.[23]
On 28 July 2015, doctors at the Children's Hospital of Philadelphia performed the first successful bilateral hand transplant on a child.[24] At the age of 2, Zion Harvey lost his hands and feet to a life-threatening infection. Six years later, at age 8, he had both of his hands replaced in a double hand transplant.[25]
On 2 August 2016, the reconstructive transplantation team at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, performed the first intergender hand transplantation in India on a 16-year-old boy who had lost both his hands in an electrocution injury. The donor was a 54-year-old lady who was brain dead following a road traffic accident.[26][27]
On 26 October 2016, the Director of hand transplantation at UCLA, Dr. Kodi Azari, and his team,[28] performed a hand transplant on 51-year-old entertainment executive from Los Angeles, Jonathan Koch at Ronald Reagan UCLA Medical Center. Koch underwent a 17-hour procedure to replace his left hand, which he lost to a mysterious, life-threatening illness that struck him in January 2015.[29] On June 23, 2015, Koch had the amputation surgery, also performed by Dr. Kodi Azari, which was designed to prep him to receive a transplanted limb. This included severing the left hand closer to the wrist than the elbow. Azari kept all the nerves and tendons long and extended, which would give him plenty to work with later. Then he sutured them together and attached them to the stump of bone to keep them from retracting.[30] This is the first known hand transplant case in which the hand was amputated in preparation for a hand transplant, as opposed to previous hand transplant patients who have undergone typical amputation surgeries. Azari's theory about prepping the hand for a transplant during the initial amputation surgery would later be supported by Koch when he was able to move his thumb only two hours after he woke up from the 17-hour transplant surgery[31] and move his entire hand only two days after surgery.[32]
On 15 January 2021, Icelander Guðmundur Felix Grétarsson underwent the first double-arm and double-shoulder transplant from doctors in France.[33] The transplant was deemed successful.[34]
Long-term functionality
The long-term functionality varies patient to patient and is affected by several factors including level of amputation and transplant and participation in occupational therapy post hand transplant surgery. Hand transplant recipient Jonathan Koch was able to pick up a napkin and a tennis ball with his newly transplanted hand 7 days after his 17-hour surgery and by day 9, he was able to pick up a bottle of water and take a drink. 3 months after surgery, Koch was able to use his transplanted hand to tie his shoe.[35]
Survival rates
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.[36]
Programs
United States
The Johns Hopkins University School of Medicine Hand and Arm Transplant Program was approved by the Johns Hopkins Medicine Institutional Review Board in July 2011. This is one of only two programs in the United States approved to perform hand/arm transplants using an immunomodulatory protocol, which enables patients to take one drug (instead of three) 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 six Wounded Warriors or civilians who have a hand or arm amputation on one or both sides.[citation needed]
The Southern Illinois University School of Medicine 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.
The UCLA Hand Transplant Program, located in Los Angeles, California, was launched July 28, 2010. At the time, it was the only one on the West Coast and one of only four in the country.[37]
United Kingdom
In 2016, it was announced that NHS patients in England were to become some of the first in the world to benefit from publicly funded pioneering hand and upper arm transplants delivered by a specialist team at Leeds General Infirmary.[38]
Organ transplantation is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ. The donor and recipient may be at the same location, or organs may be transported from a donor site to another location. Organs and/or tissues that are transplanted within the same person's body are called autografts. Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source.
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person (allograft). Liver transplantation is a treatment option for end-stage liver disease and acute liver failure, although availability of donor organs is a major limitation. The most common technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic position as the original liver. The surgical procedure is complex, requiring careful harvest of the donor organ and meticulous implantation into the recipient. Liver transplantation is highly regulated, and only performed at designated transplant medical centers by highly trained transplant physicians and supporting medical team. Favorable outcomes require careful screening for eligible recipients, as well as a well-calibrated live or deceased donor match.
A face transplant is a medical procedure to replace all or part of a person's face using tissue from a donor. Part of a field called "Vascularized Composite Tissue Allotransplantation" (VCA) it involves the transplantation of facial skin, the nasal structure, the nose, the lips, the muscles of facial movement used for expression, the nerves that provide sensation, and, potentially, the bones that support the face. The recipient of a face transplant will take life-long medications to suppress the immune system and fight off rejection.
Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.
Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves which have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Microsurgical techniques are utilized by several specialties today, such as general surgery, ophthalmology, orthopedic surgery, gynecological surgery, otolaryngology, neurosurgery, oral and maxillofacial surgery, endodontic microsurgery, plastic surgery, podiatric surgery and pediatric surgery.
Lung transplantation, or pulmonary transplantation, is a surgical procedure in which one or both lungs are replaced by lungs from a donor. Donor lungs can be retrieved from a living or deceased donor. A living donor can only donate one lung lobe. With some lung diseases, a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis, it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for those with end stage pulmonary disease.
Jean-Michel Dubernard was a French medical doctor specializing in transplant surgery who served as a Deputy in the French National Assembly. He was born in Lyon.
Penis transplantation is a surgical transplant procedure in which a penis is transplanted to a patient. The penis may be an allograft from a human donor, or it may be grown artificially, though the latter has not yet been transplanted onto a human.
A uterine transplant is a surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased. As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile. This phenomenon is known as absolute uterine factor infertility (AUFI). Uterine transplant is a potential treatment for this form of infertility.
Adrian Kantrowitz was an American cardiac surgeon whose team performed the world's second heart transplant attempt at Maimonides Medical Center in Brooklyn, New York on December 6, 1967. The infant lived for only six hours. At a press conference afterwards, Kantrowitz emphasized that he considered the operation to have been a failure.
Transplantable organs and tissues may refer to both organs and tissues that are relatively often transplanted, as well as organs and tissues which are relatively seldom transplanted. In addition to this it may also refer to possible-transplants which are still in the experimental stage.
A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. As of 2018, the most common procedure is to take a functioning heart, with or without both lungs, from a recently deceased organ donor and implant it into the patient. The patient's own heart is either removed and replaced with the donor heart or, much less commonly, the recipient's diseased heart is left in place to support the donor heart.
The University of Louisville School of Medicine at the University of Louisville is a medical school located in Louisville, Kentucky, United States. Opened as the Louisville Medical Institute in 1837, it is one of the oldest medical schools in North America and the 9th oldest in the United States.
Warren C. Breidenbach III is an American hand surgeon most well known for having performed the first long-term successful hand transplant surgery in the world at Jewish Hospital in Louisville, Kentucky. The surgery was performed by Breidenbach and hand surgeon Tsu-Min Tsai, both of Kleinert, Kutz and Associates Hand Care Center, leading a team of surgeons to attach a donor left hand to replace New Jersey native Matthew Scott's left hand. The Louisville hand surgery team went on to perform additional hand transplants between 1999 and 2011, when Breidenbach relocated to the University of Arizona in Tucson, Arizona to start a Composite Tissue Allotransplantation center at the university's medical center.
Brendan Marrocco of Staten Island New York was the first US soldier serving in Iraq or Afghanistan to survive a quadruple amputation and the first person to receive a bilateral arm transplant at Johns Hopkins Hospital and the seventh in the United States.
Earl Ronald Owen AO (1934–2014) was an Australian microsurgeon and classical music specialist who led or assisted in many pioneering achievements in the field of microsurgery, including many "world firsts", such as the world's first finger reattachment, vasectomy reversal, fallopian tubal ligation, hand transplant, double-hand transplant and face transplant.
Jonathan Koch is an American television producer. He is the president and chief creative officer of Asylum Entertainment, a Los Angeles–based television production company that produced the 2011 miniseries The Kennedys. In 2004, Koch co-authored Pitching Hollywood: How to Sell Your TV Show and Movie Ideas, a film and television pitching manual, with Robert Kosberg. In 2016, Koch received a hand transplant.
Wei-Ping Andrew Lee is a Taiwanese-American hand surgeon and medical researcher. He is presently the Dean of the University of Texas Southwestern Medical School and Executive Vice President for Academic Affairs and Provost of UT Southwestern Medical Center. Lee focuses on translational research on immune modulation for vascularized composite allotransplantation (VCA) and the implementation of protocols to minimize immunosuppression in hand transplant and other VCA programs.
Stuart William Jamieson is a British cardiothoracic surgeon, specialising in pulmonary thromboendarterectomy (PTE), a surgical procedure performed to remove organized clotted blood (thrombus) from pulmonary arteries in people with chronic thromboembolic pulmonary hypertension (CTEPH).
Eduardo De Jesus Rodriguez MD, DDS is a Cuban American plastic and reconstructive surgeon, and reconstructive transplant surgeon, who is known for his contribution to the field of facial transplantation and vascularized composite allotransplantation.
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Lanzetta M, Petruzzo P, Dubernard JM, etal. (July 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. PMID17584595.
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