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Hand transplants to be evaluated


Surgery team with VA, Emory will track outcomes

August 31, 2010

Veteran Donald Michigan resident David Savage,who in 2006 became the third person in the U.S. to receive a hand transplant, works his new hand during a physical therapy session following the procedure.

Veteran Donald Michigan resident David Savage, who in 2006 became the third person in the U.S. to receive a hand transplant, works his new hand during a physical therapy session following the procedure.(Photo: Jewish Hospital/Kleinert Kutz/U. of Louisville)

Hand transplants to be evaluated Surgery team with VA, Emory will track outcomes nly nine patients have ever received a hand transplant in the U.S. It's a staggeringly complex operation that can take up to 16 hours—twice the time of the average heart transplant. Surgeons must painstakingly knit together nerves, tendons and blood vessels—along with skin, muscle, bone and cartilage—into a seamless biological unit that looks just like the patient's natural hand and works almost as well.

The surgery is available at the Atlanta VA Medical Center and its affiliate, Emory University, as well as at a few elite centers nationwide. The VA-Emory surgeon who performs the procedure, Linda Cendales, MD, is now looking to track outcomes among patients through a new study funded by VA, the Department of Defense and other sources.

Who is eligible to take part in the study? "Any upper-limb amputee, below the elbow, who is between 18 and 55," says Cendales. "It doesn't matter how long ago the amputation was—30 or 40 years, or just a couple of months."

Hand transplant facts

  • A hand transplant is an extremely complex procedure, but it is not as difficult as a hand replantation—reattaching a patient's own injured hand—because the latter usually involves severely damaged tissues.
  • When doing a hand transplant, surgeons first fix the bone, and then repair tendons, arteries, nerves and veins.
  • Post-surgery complications can include poor blood flow, infections and rejection.

Cendales has a rare combination of skills: She is trained in hand and microsurgery, as well as in transplant surgery, which includes the immunosuppression techniques that help avoid rejection of a new limb. She took part in the first two hand transplants that were done in the U.S. A few months after his 1999 transplant, the nation's first handtransplant patient, Matthew Scott, from New Jersey, used his new left hand to throw out the ceremonial first pitch at the Philadelphia Phillies' opening-day game.

"A limb transplant is an option to recuperate a human hand," says Cendales. "In my experience with hand transplantation, the patients report that the new hand has been better for them than the prostheses they were wearing."

She explains some of the advantages: "It's a human hand, not a device. For many people body image is important. The hand recovers sensation and the patients are able to perform activities such as turning doorknobs, holding the newspaper, tying their shoes. It's not a life-saving organ—it's a quality-of-life transplant."

Cendales adds that some upper-limb amputees prefer not dealing with the potential inconveniences of prostheses: "They need to take it off and put it on. If it's myoelectric, they need to pay attention to the weather changes." Also, she notes, a person might need to change from one hand prosthesis to another—each designed for a different scope of activity—to do various tasks.

At the same time, she points out that a hand transplant is not the best option for every upper-limb amputee. As with a liver or kidney transplant, patients have to be on anti-rejection drugs for as long as they have the transplant. Side effects from medications can include diarrhea, headache and high blood pressure. Cendales notes that her team minimizes the long-term use of some of the drugs involved, such as steroids, which can cause diabetes and other problems.

The team approach also includes evaluations to explore the potential psychosocial impact of the procedure on patients. Cendales says that to date, all those who have received a hand transplant have come to "consider the new hand as their own, with no problems."

Cendales says she and other surgeons value the role of other disciplines in rehabilitating those who have lost limbs. She acknowledges advances in upper-limb prostheses—such as the DEKA arm, now being tested by VA (see the May 2009 VA Research Currents at www.research.va.gov/ currents)—and says such technology will offer more options for amputees.

"Perhaps a good approach is the model we follow," says Cendales. "We have a multidisciplinary team that is patientcentered. Our program aims to provide another option for a selected group of patients, and to provide the best options overall for our amputees. If it's a prosthesis, the best prosthesis, and if it's a hand, the best-matched human hand."

This article originally appeared in the September 2010 issue of VA Research Currents.