Doctor's Review: Medicine on the Move

September 22, 2017
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Hand transplants push science forward

Gratifying results for recipients and surgeons

The first moderately successful hand transplant quickly became an embarrassment for the surgeons not long after they performed it. The procedure was attempted in Ecuador in 1964, but due to the primitive nature of anti-rejection medication, the hand failed after only two weeks.

Almost 25 years went by before the next attempt. In 1998, an international team led by French surgeon Dr Jean-Michel Dubernard in Lyon, France, seemed to be going better with the hand showing promising results. The glory of the operation, though, was soon tainted by reports that the recipient, Clint Hallam, had a criminal record and had lost his hand in prison during an accident with a circular saw. Before the operation, he’d said he lost it in “an industrial accident” which, to give him the benefit of the doubt, was not far off the mark considering that he was serving time for fraud. But things soon went from bad to worse. Hallam seemed put off by the new hand, even uncomfortable with the idea of transplantation. Rumours had it that he refused to take the prescribed drugs to prevent rejection of the graft and failed to do regular exercises to train his new appendage.

In late 2000, Hallam claimed that the hand, which had belonged to a motorcyclist who was killed in a crash, had stopped functioning after the first 12 months. Then, he said, it began to break out in scabrous “pockets of rejection,” and he tired of its presence, admitting that he had stopped taking the medication. All he wanted now — “enough is enough,” he said — was to have the hand amputated. In February 2001, Dr Nadey Hakim of St. Mary’s Hospital in London obliged him, saying that his life was in danger due to rejection. Dr Dubernard did not wish to comment.

A team approach

The disappointing outcome of the Hallam transplant provided an important lesson: the success of the next transplant would depend on a committed team of caregivers, including psychologists who could help the patient adjust to the eeriness of adopting such a personal part of another person’s body. In addition, it would be necessary to be more straightforward about what transplanted hands could be expected to do. While generally capable of slight movement soon after being attached, the new hands only become capable of doing the things one expects hands to do only after months, even years, of hard, focused work.

Transplantation, as with most medical innovations, begins with trial and error. A case in point is that of Dr Kodi Azari who recently launched the first hand transplant program in California at the UCLA Medical Center. He found inspiration from the considerable advances made in liver transplantation since its early days. When he was in high school, a family friend sent him an article about young liver transplant pioneer Dr Thomas Starzl. Up to then, the lad who considered himself a risk taker had hoped to become a fighter pilot. After reading Dr Starzl’s profile, he did an about-face and from that time on he tried to learn everything he could about transplants.

The first operations he read about were so bloody that blankets had to be placed on the floor by the doors of the operating room so that the blood wouldn’t seep out into the hospital hallway. In Pittsburgh, where Dr Starzl practiced, liver transplants required so much blood that all elective surgeries had to be cancelled that day for lack of blood. Moreover, many of the early patients died, either on the table or in the ensuing weeks. Now, Dr Azari notes, the hospital where he interned, routinely performs three liver transplants a day.

Building on the past

Hand transplantation may be on a similar trajectory. After the botched 1998 transplant, a team at the Jewish Hospital in Louisville, Kentucky became the first to achieve prolonged success. Preparing for years in advance with extensive basic science research and feasibility studies, they took great care in selecting their donor. The recipient of the hand was Matthew Scott, from New Jersey, who lost his dominant left hand in 1984 at age 24 in a blast from an M-80 firecracker. He received the new hand in 1999 and now, 16 years later, Mr Scott is considered the most successful hand transplant patient in the world.

“His range of motion can touch things, he can almost read braille, which is down to four millimetres apart,” says Dr Joseph Kutz, a surgeon at the Kleinert Kutz Hand Care Center where Scott’s transplant was performed. “We’ve had patients who’ve had their own hands put on who haven’t even reached that point.”

Dr Jean-Michel Dubernard, however, was not to be outdone. In January 2000, he and a 50-member surgical team performed the world’s first double hand transplant, again in Lyon, France. This time, the operation was a success. Two single hand transplants were also performed the same month in Guangxi, China. Two months after that, an 18-member Austrian surgical team performed the world’s second double hand transplant. Theo Kelz, a 45-year-old policeman who lost both of his hands in a pipe bomb explosion in 1994, was adamant about wanting new hands. “I was, from the beginning, absolutely convinced about getting new hands. So it’s not been a problem at all to accept these beautiful new hands. I will learn to seize life again,” he explained passionately to Austrian reporters.

Icy hands

Hand transplantation is a long, slow operation; it can take anywhere from 13 to 50 hours. By contrast, a heart transplant takes six to eight hours. First, the bones of the recipient’s arm are joined to the bones of the donor’s hand, followed by the tendons, arteries, nerve veins and skin. If the arteries are poorly attached, a clot will form and the graft will fail. What’s more, all of this is done on ice to preserve the hand. Dr Azari recalls desperately wishing someone could pour warm water on his hands during his first operating session.

It takes about six months for new nerves to grow all the way to the tips of the fingers — and that’s the easy part. The hard part is regrowing the neural connections that allow the hand and the brain to work together. This is where Clint Hallam, the recipient of the first hand transplant, made such a bad candidate. Kelz, the Austrian policeman, called the 1700 hours of cognitive therapy that were required of him a “huge task of concentration.” Kelz spent 1700 hours with his eyes closed, patiently absorbing tactile information while a cognitive therapist moved his thumb and fingers across a variety of textured surfaces and asked him questions about his sensations.

Therapy isn’t the only challenge faced by a hand transplant recipient, of course. While new immunosuppressive drugs are better tolerated these days, they still carry an increased risk of infection and some cancers. In 2000, surgeons in Malaysia had a rare opportunity to perform a transplant without immunosuppressant drugs. The recipient was Lih Ying, a one-month-old baby girl born with a missing arm whose identical twin sister died moments after birth of brain damage. Despite their confidence that the drugs would not be necessary, the microsurgeons at Kuala Lumpur’s Selayang Hospital breathed a sigh of relief when the arm showed clear signs of taking.

Easy choice?

Getting a new pair of hands isn’t a matter of survival — it’s a choice, not a necessity. So far only about 85 of the transplants have been performed around the world and some surgeons have expressed doubts about continuing. But to many, especially those who have lost their hands and gained them back, the choice is obvious. Dr Azari speaking on NPR’s show “The Moth,” said he considers the work he does restoring hands to servicemen and women who have lost them in action to be an experience beyond compare. He recalls meeting his first transplant patient, a young marine, later at the Pentagon for a photo-op.

“Outside of family events, this was one of the really most incredible events of my life,” he says. “I looked at his face and I shook his hand. And the hand was warm. It was strong. And it was sweaty. Human hands are sweaty if they have nerve function.” The most recent recipient of a new set of hands in the limelight is Zion Harvey, an eight-year-old from Baltimore, MD who lost his hands and feet to an infection at age two. He’s the first child in the world to get two new hands. He was, it would seem, the perfect candidate. Not only was he already taking immunosuppressants for a kidney transplant he received from his mother when he was four, but he has the attitude consistent with other hand transplant recipients who have met with success. He’s relentlessly positive and unstoppable in his determination to function with ease — and he’s not afraid.

“When I get these hands,” he’s said, “I will be proud of what hands I get. And if it gets messed up, I don’t care because I have my family.”

Hand transplants have yet to be performed in Canada, in spite of the nearly 18,000 citizens living with amputations. Dr Steven McCabe, director of the University of Toronto hand and upper extremity program, was one of the team of surgeons who performed the first hand transplant in Lyons, and he’s determined to bring the operation to Canada. Ethical concerns, he says, have kept the health care system from approving the procedure, such as the need to take the immunosupressive medication for life. But for some, says McCabe, the transplant is the right choice, because, he says, “it recreates a sense of wholeness for the person.”

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