In early February, a team of doctors performed a double hand transplant and forearm replacement at the University of Pittsburgh Medical Center (UPMC). The 11-hour surgery was the nation’s second double hand transplant and first total forearm replacement. The patient, 41 year-old Chris Pollock, lost his left hand at the wrist and right hand and forearm in a farming accident near his home in Harrisburg, Pa.
“He is doing very well,” W. P. Andrew Lee, MD, chief of UPMC’s division of plastic and reconstructive surgery told O&P Business News. “He received the donor marrow infusion, which is part of our protocol designed to minimize the anti-rejection medication.”
According to the UPMC Web site, the anti-rejection medication must be taken for as long as the patient retains the transplanted tissues. This prolonged usage of medication could lead to side effects including hypertension, diabetes, increased risk of infection, kidney dysfunction and the increased risk of developing certain types of cancers.
Although the risk of infection and rejection is always a possibility, the infusion of donor bone marrow appears to eliminate the need for multiple anti-rejection medications. The bone marrow cells help re-educate the immune system into thinking the transplanted hand is not a foreign object, thus not attacking the hand.
In May 2009, a team of doctors at UPMC were the first to perform a double hand transplant. UPMC doctors have performed a total of three hand transplants, two double hand transplants and a single hand transplant. In all three cases, the patients have done well with just a single anti-rejection medication, according to Lee.
Additional surgery is not anticipated for patients post-transplant. Following surgery, patients require regular and rigourous therapy to regain function and sensation.
“Hand therapy consists of mobility exercises and eventually strengthening exercises,” Lee said. “He will be working with our hand therapist up to 6 hours a day for 6 months or more.”
Lee explained why he believes hand transplants are the new frontier for amputees.
“Hand transplants have a significant advantage over prostheses because a transplanted hand can have sensations and feelings and the hand can also be used for social interactions and expression of emotion, which is difficult for prostheses to do,” Lee said.
Although sensory and neuroprosthetics are being developed, Lee considers hand transplants a safe and effective option for amputees. He receives frequent inquiries regarding hand transplants and patients are put through a vigorous screening process in order to determine their suitability for surgery.
“I do not think we will replace prostheses completely, but we think hand transplants for some patients will be an attractive alternative, particularly as we continue to be successful in minimizing the amount of anti-rejection medication necessary,” Lee explained.
— by Anthony Calabro
Hand transplantation is possible as a result of the lessons learned in both reconstructive surgery as well as transplantation. After receiving a hand from a donor, recipients have regained sensation to all of the fingers and the majority have returned to work. Similar to other solid organ transplant recipients, all patients who receive a hand from a donor need to take anti-rejection medications for as long as they have the transplant(s). Essentially all patients have experienced rejection after receiving a hand, and rejection has been able to be controlled with treatment in most patients.
The observations to date, specific to hand transplantation, suggest that the same amount of medications are needed to sustain a hand without rejection as with most solid organs. Current experience in the United States suggests that minimal immunosuppression is not sufficient to prevent rejection in long term even with the use of other agents at the time of the transplant.
To date, a patient in the United States was treated with an agent during the week of transplantation, and one immunosuppressive medication as a long-term treatment. The patient lost the hand due to low levels of anti-rejection therapy in the system. Hand transplantation is a procedure under active investigation and we look forward to continuing to study this field to provide patients with another option for limb reconstruction.
—Linda Cendales, MD
Assistant professor of surgery, Emory University School of Medicine