Volume 199 - Issue 4
Hand transplantation
Author: Warren C Breidenbach
Med J Aust 2013; 199 (4): 228-229. || doi: 10.5694/mja13.10637
Published online: 2 September 2013
Published online: 2 September 2013
A brief history of hand transplantation, and support for the team that performed Australia’s first successful transplant in what would generally be considered an unlikely recipient.
Unconventional decisions made by the Australian transplant team provided the best overall outcome for their patient
Hand transplantation represents the spearhead of the new field of composite tissue allotransplantation. Since the beginning of time, it has been a medical goal to replace missing tissue with like tissue. The psychological and medical importance of achieving this goal is highlighted by the story of Cosmas and Damian, two 3rd century physician saints who successfully transplanted a leg around the year 1150, long after their deaths.1
Such reports notwithstanding, the ability to transplant composite tissue remained elusive for most of the history of mankind. The modern era of hand transplantation started in 1964, when Roberto Gilbert Elizalde of Ecuador transplanted a hand onto a patient using azathioprine for immunosuppression. The hand survived for 3 weeks.2
The next attempt to transplant a hand was carried out in France on a New Zealander residing in Australia, Clint Hallam, by a team led by Jean-Michel Dubernard in September 1998.3 Earl Owen from Australia participated in the surgery. The transplanted hand survived for 29 months.
The next hand transplant was carried out in January 1999 by the Kleinert Kutz team in the United States.4 The patient, Matthew Scott, is still using this hand over 14 years later, and this surgery represents the first successful long-term hand transplant.
The success of this hand transplant did not signal medical acceptance of hand transplantation. Many were sceptical about the long-term viability of Matthew Scott’s new hand. The spectre of the short survival of the hand in the first French case, along with the belief that skin was too allogeneic to transplant, generated many critics. There were also those who held the position that hand transplantation was unethical, because one was giving immunosuppression that would shorten the patient’s life, for a transplant that did not aim to extend the patient’s life.
In spite of these concerns, pioneers pushed forward. By the end of the first decade of the new millennium, more teams entered this field. Further hand transplants were carried out in France, the US, Belgium, Austria, Spain and China.5,6 International and American societies for composite tissue transplantation were founded. Other teams started transplanting faces, legs, and combinations of face and hands, hands and legs, tracheas and uteruses. The wider field of composite tissue allotransplantation (CTA) had been established.
The first Australian hand transplant is reported in this issue of the Journal.7 In many ways the report challenges conventional wisdom, and demonstrates the value that this new field can bring to an individual.
Hand transplantation was felt to be dangerous because of the complications it would bring to an otherwise healthy recipient. However, the complications of hand transplantation have actually been less than those seen in solid organ transplantation. This is because hand transplant patients are healthy, whereas solid organ transplant patients are often already severely affected by organ failure and they begin immunosuppression treatment in a poorer state of health.
The Australian case challenges this issue. Conventional wisdom states that all hand transplant patients should be healthy, but this patient had a series of concerning medical issues, including splenectomy and diabetes. The Australian team transplanted a patient who was the oldest recipient on record, with significant medical problems. Was this optimal recipient selection? Many experts in the field of CTA would say no. Should older age be an exclusion criterion? In solid organ transplantation, recipients massively outnumber donors, and allocation criteria have to be firm. However, due to the paucity of hand transplant recipients, there is a relative excess of donors, albeit small. This surplus means we do have more leeway to relax some criteria such as age.
To make matters even more controversial, the authors only transplanted one hand. Immunosuppression partially shuts the immune system down for the whole body. Therefore bilateral hand transplants do not need more immunosuppression than single hand transplants. It would have been possible to transplant both hands without any increase in immunosuppression.
By transplanting a patient who had multiple medical problems, and only transplanting one hand in a patient who arguably needed two, this team challenged prevailing beliefs. However, in my opinion, these were appropriate hand transplant decisions, and it was proper not to transplant the recipient’s only functional partial hand.
The most important goal in hand transplantation is to improve quality of life, and this should not be confused with obtaining the best function. This particular patient had poor quality of life, and because he had lost all four of his extremities, he could perform few activities of daily living. His functional appendage that had been fashioned into a partial hand allowed him only primitive pinch.
The authors saw through the fallacy that all hand transplant patients must be healthy, and that all hands need to be transplanted in cases of bilateral loss. They protected the patient in case of early loss of the transplanted hand, by leaving one partially functional appendage. They correctly understood that, even if older and more prone to complications from immunosuppression, the patient’s quality of life was so poor that a single transplanted hand would provide him with a large increase in utility.
The authors should be congratulated for their clarity of thought in transplanting this patient. “Discovery consists of seeing what everyone has seen and thinking what nobody has thought.”8 This transplant has achieved that. It emphasises the importance of utility over function and health. It opens up the debate about where that balance should be. There will be many who will disagree with these authors and with my words. The patient will not be one of them.
Competing interests
No relevant disclosures.
References
- Hamilton D. A history of organ transplantation. Ancient legends to modern practice. Pittsburgh: University of Pittsburgh Press, 2012. 0_i1139888
- Gilbert R. Transplant is successful with a cadaver forearm. Med Trib Med News 1964; 5: 20. 0_i1139890
- Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft: report on first 6 months. Lancet 1999; 353: 1315-1320. 0_i1139892
- Jones JW, Gruber SA, Barker JH, Breidenbach WC. Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team. N Engl J Med 2000; 343: 468-473. 0_i1139894
- Pei G, Xiang D, Gu L, et al. A report of 15 hand allotransplantations in 12 patients and their outcomes in China. Transplantation 2012; 94: 1052-1059. 0_i1139896
- Petruzzo P, Lanzetta M, Dubernard JM, et al. The International Registry on Hand and Composite Tissue Transplantation. Transplantation 2010; 90: 1590-1594. 0_i1139900
- Dwyer KM, Webb AR, Furniss HS, et al. First hand transplant procedure in Australia: outcome at 2 years. Med J Aust 2013; 199: 285-287. 0_i1139901
- Albert Szent-Gyorgi. In: Good IJ, editor. The scientist speculates: an anthology of partly-baked ideas. London: Heinemann, 1962. 0_CHDJAGGA
Provenance: Commissioned; not externally peer reviewed.