About reconstructive hand transplants
A reconstructive transplant, also called a composite tissue transplant or composite tissue allograft, is an operation that involves transplantation of bone, tissue, muscle and blood vessels. A reconstructive hand transplant is an operation tailored to each patient’s individual needs, type of injury and anatomy. This transplants an upper extremity, usually at the level of the forearm and wrist, but sometimes above the elbow, to help restore function after the loss of a hand or arm.
Anatomy of the hands
The hand is one of the most complex parts of the body, providing humans with the ability to communicate with each other. The hand is also our main method of interacting with our surrounding physical world. The hand and wrist have 27 main bones and the hand has 19 “intrinsic” muscles, or muscles which begin and end only in the hand. In addition, there are 24 “extrinsic” tendons that run from muscles in the forearm into the hand or fingers that, when combined with the 19 “intrinsic” muscles, create the complex movements that normal hands are capable of. The movement, or “motor” function of the hand as well as its ability to sense the world it interacts with, are possible because of three major nerves that tell the muscles what to do and relay sensed information from the hand back to the brain. Most people have two main arteries and several veins that take blood into and then away from the hand to make sure that all of the bones, nerves, tendons, muscles, skin, and other soft tissues get enough oxygen and nutrients to function normally.
Reasons for the procedure
Not every person who is missing a hand or upper limb might be eligible to receive a transplant. Many people are able to live full lives and accomplish everything they desire with the aid of a prosthetic device and sometimes without the aid of anything. However, some people find prosthetics difficult to use and the lack of sensory “feedback” from their prosthesis can significantly limit their function. These persons may consider reconstructive transplantation. We find that those patients who have either bilateral (both hands) amputations or those who have had their dominant hand amputated are likely to receive the most benefit from the procedure. However, we will provide information to any interested person regardless of the nature of their amputation.
Risks of the procedure
There are both short-term and long-term risks associated with this procedure, as well as risks associated with the immunosuppressant protocol that is used to prevent rejection.
Short term risks
- Long, complex operation
- Blood vessels may become “clotted off,” stopping blood flow to the hands. This is one reason why patients are monitored so closely in the intensive care unit (SICU) after surgery so that if this complication occurs, we detect it early and have the best chance to correct it.
- Wound healing problems
- The development of other medical problems
Long term risks
- Rejection of new limb. This begins at the time of surgery and remains for the rest of a recipient’s life.
- Occasional problems with bone healing, which may require a second surgery and could develop later problems with blood flow, though this appears to be rare.
Risks associated with immunosuppression
- Development of cancers
- Kidney damage
- Heart disease
Because of the risks associated with immunosuppression medication, Johns Hopkins has devoted our research and clinical program into minimizing the amount of immunosuppression necessary for hand transplantation. Our goal is to lower the risks of immunosuppression and favor the benefits of reconstructive transplant to the recipient.
Before the procedure
- Patients arriving for transplantation will undergo an examination by the transplant team to make sure they are healthy enough to tolerate surgery. Blood samples will be taken, IV’s will be placed and IV fluids and some “pre-treatment” medications will be given. Note: Significant medications or procedures will not occur until after the transplant team has confirmed that one or both hands from a donor have been “procured” and that the limbs are suitable for transplantation.
- Small plastic catheters used to “numb” or “block” nerves are placed into the shoulder of the side to be transplanted to help with pain during and after the surgery.
- An ultrasound machine is used to mark out veins to be connected on the recipient’s skin and medications used to help tolerate immunosuppression are started.
- The patient goes to the operating room before the start of the procedure so that any invasive lines or monitors they require can be placed after they are asleep without taking the critical minutes needed to attach the transplanted limbs away.
- Once the limb(s) arrive, two teams of surgeons simultaneously operate for each limb to be transplanted. One team prepares the patient’s amputated site to accept the transplant, and the other team prepares the donor’s limb that will become the recipient’s new hand. If both hands are being transplanted, then this requires two times the amount of surgeons.
- Once all recipient sites and donated limbs have been prepared, the bones are connected with rigid plates and screws. Then, most of the tendons are connected before bringing in surgical microscopes to connect the arteries, veins and nerves using microsurgical techniques.
- Once blood is circulating throughout the transplanted hand, any remaining tendons, muscles or nerves are connected and the skin and soft tissues are then closed.
- Protective dressings and splints are applied as well as monitoring devices that help the surgeons ascertain the level of blood flow going into and out of the hands.
- The patient is then taken to the surgical intensive care unit (SICU) for close monitoring.
After the procedure
In the hospital
- Immediately following surgery, the patient will stay in the Surgical Intensive Care Unit (SICU). Here, the new hands will be closely monitored and the patient will recover from surgery. During this time, the patient will be watched very closely by the nursing staff and checked every hour. The number of visitors will be limited.
- Therapy begins almost immediately within the first days after surgery. While we may not want the patient to try to move the fingers, hand, or wrist themselves right away, we will start “passive” motion within the first several days by having a certified hand therapist come to the patient’s room. As time goes on, the patient can eventually try to move the fingers and hand on their own and they will be allowed to meet the hand therapist where the therapist works in the rehabilitation department.
- After a few days, the patient will begin physical therapy and start to move the joints of the new hand. The patient will also move to a regular (non-ICU) hospital room and begin to work with other types of physical therapy. The patient will continue to take medications and have blood tests to monitor the immune system. Over the next week or so of the patient will have less monitoring and perform more therapy until they are ready to leave the hospital.
- The patient will be attached to several different types of monitors to check on their vital signs as well as the blood flow to the new hands. These will be checked very frequently at first and less often over time. The monitors will be removed before the patient leaves the hospital.
- The patient will be cared for by many different members of the hand transplant team. This will include intensive care nurses, hospital floor nurses, and therapists, physical therapists, nutritionists, psychiatrists, and medication experts. Different kinds of physicians will also check on the patient including hand surgeons, plastic surgeons, infectious disease doctors, psychiatrists and residents.
- Every patient is different, and so discharge dates are not always the same. Some may go home by four weeks after transplant; others may stay for three months or more. This is determined by the type of injury, preexisting comorbidities, degree of healing the patient demonstrates, consideration of any complications or unexpected problems with their recovery, the amount of help they have available to them at home, and the amount of distance from Johns Hopkins to their home.
- All patients will have very specific and detailed instructions given to them at discharge. It is imperative that patients follow these instructions exactly at all times. At any time, if a patient has a problem or concern, they should call the hand transplant team immediately so that we may help them find a remedy or have them return to see one of our team members. Patients should remember that their ultimate functional outcome is MOST DEPENDENT upon their ability to follow and comply with instructions with regards to hand therapy and immunosuppression. The two most important instructions to follow regard performing physical therapy to rehabilitate their transplant AND taking their medications every time and on time.
- Every patient’s rehabilitation program and schedule will be personalized to their requirements and anatomical site of transplantation. Most patients can expect to perform 6 hours or more of rehabilitation with a certified hand therapist 5 days per week and then home exercises on the weekends.
The recipient’s immune cells encounter the newly transplanted hand as “foreign” and follow their natural response similar to the one against bacteria or viruses to attack/reject the graft. This can result in a noticeable inflammatory reaction. Such acute rejection episodes can occur within days to months after transplant. A scoring system for rejection was established similar to the Banff classification for solid organ transplants.
Rejection can be controlled/prevented using specific medications called immunosuppressants. After the transplant patients need to take such medication for the rest of their lives. No patient taking his/her immunosuppression drugs on time and as advised has lost a transplanted hand/arm
At the Johns Hopkins Comprehensive Transplant Center, we offer a specialized treatment protocol that uses bone marrow cells to minimize conventional maintenance medication, favoring the risk-benefit balance of the surgery. Our laboratory specializes in basic and translational research, and has a long-standing experience using small and large animal models for composite tissue allografting as the scientific foundation of the program.
Signs of rejection
The skin component is the main target of rejection in hand transplantation:
- Clinical sign is usually a rash which can be spotty, patchy or blotchy, usually painless
- Unlike solid organ transplants such as a kidney or liver, the skin can be watched and monitored continuously by the patient
- This allows for early detection of rejections, diagnostic skin biopsies, timely intervention and treatment
- All rejection episodes after hand transplantation could be reversed with medication
Contact us for more information on reconstructive transplants.