Real patient stories: A first-of-its-kind hand transplant

Reminds me of a hand transplant

Hand transplants are still rare. Fewer than 80 patients worldwide have had a hand transplant, and only 23 of them have been in the US. So only a handful of hand surgeons have ever seen or participated in one of these surgeries.

Why is a hand transplant difficult?

A hand transplant surgery is demanding and time-consuming. Every single structure in the donor and the recipient hand has to be dissected out, identified, isolated, and tagged. Then all the structures have to be lined up and reattached, one by one. Let’s suppose that the transplanted hand is reattached just before the level of the wrist. This would mean dissecting, tagging and reattaching 2 bones, 2 arteries, 4 or more veins, 8 nerves, and 25 tendons. The reattachment isn’t a piece of cake either:

  • The blood vessels and nerves have to be repaired with a microscope. The microsurgical sutures are so thin, they will waft away if you breathe on them.
  • If the nerves aren’t lined up perfectly, they will never work well. But you won’t know this until months after the surgery.
  • The tendons have to be repaired at just the right amount of tension, like a stretched rubber band. If they are a bit too tight or a bit too loose, the hand won’t work well.

But it’s not just that the surgery is difficult and requires attention to detail. From the moment the donor hand is removed, it is starved of oxygen. So the surgery is a race against the clock to restore blood flow and circulation to the donor hand. If it takes too long, there can be irreversible damage to the muscles and nerves in the donor hand, and it may never work well.

This combination of time pressure and the large number of individual steps in the surgery makes for high stakes.

Jonathan’s story

During my time at UCLA, I was fortunate enough to be a part of the team taking care of a remarkable patient named Jonathan Koch. Jonathan Koch’s amazing resilience, and the hard work of Dr. Kodi Azari (one of my mentors at UCLA), were critical for his transplant to take place successfully. His story was recently highlighted in a pair of TV specials, on ABC News Nightline and on 20/20.

Click here to watch the Nightline special

Click here to watch the 20/20 special

What made this particular surgery special?

The surgery Jonathan Koch underwent was a first of its kind. Most patients have their hand amputation surgery in emergency situations. Severe car crashes, industrial accidents, or fast-spreading infections can all lead to emergent amputations. Jonathan was different – before his amputation, he had already met with Dr. Azari, and they had discussed a potential hand transplant. So the amputation surgery was done in an unusual way, preserving more of Jonathan’s own tendons, blood vessels and nerves. This technique would not be ideal for a person who was going to use a prosthetic. But it allowed a better hand transplant to be performed. As a result, Jonathan’s transplant has been incredibly successful. For example, he began moving his new fingers as soon as he woke up from surgery! He is now able to play tennis with his new hand, less than a year after his transplant.

Hand transplant vs. high-tech prostheticsWill we ever have robotic arms like Luke Skywalker?

What does the future hold?

Hand transplantation is still in its infancy. As with other organ transplants – like kidneys or livers – patients have to be on life-long medications to prevent the transplanted hand from being rejected by their bodies. Researchers around the country are working on many avenues to advance the science of restoring working hands to amputees. This includes work on

  • minimizing the immunosuppressive drugs patients must take,
  • reducing the initial hit to the immune system that a transplant can cause,
  • finding new ways to allow prosthetics to be controlled by your nerves,
  • making prosthetics with “skin” that can feel.

Hand and upper extremity reconstruction is an exciting area of Plastic Surgery. A world where robotic prosthetics are as good as the ones in Star Wars or limbs can be regenerated as in The Avengers may come about within our lifetimes.