Correspondence

Successful Hand Transplantation — One-Year Follow-up

N Engl J Med 2001; 344:65January 4, 2001

Article

To the Editor:

Jones et al. (Aug. 17 issue)1 describe transplantation of a hand and provide one year of follow-up data on the recipient. Although one can applaud the technical accomplishment, their use of the term “successful” must be challenged. The authors have demonstrated the technical ability to transplant composite tissue, but until there is the recovery of sensation in the hand and demonstration of useful function, including bimanual use, we would not consider this result a success.

At this time, it is the position of the American Society for Surgery of the Hand2 that it is premature to undertake hand transplantation in a patient with no hands, let alone one. The hand is a complex set of tissues with tendons, muscles, joints, and nerves. The society believes that although surgeons possess the skills to perform hand and limb transplantation, it is important to alert the medical profession and the public to the potential health risks and unpredictable outcomes with respect to both survival and function of a transplanted limb. More evidence is needed to prove that current methods of immunosuppression used in conjunction with transplantation would put the patient at only minimal risk and that the benefits outweigh the risks.

W.P. Cooney, M.D.
Mayo Clinic, Rochester, MN 55905

Vincent R. Hentz, M.D.
Stanford University Medical Center, Palo Alto, CA 94304

2 References

1. 1

   Jones JW, Gruber SA, Barker JH, Breidenbach WC. Successful hand transplantation: one-year follow-up. N Engl J Med 2000;343:468-473
   Full Text | Web of Science | Medline

2. 2

   The American Society for Surgery of the Hand. Position paper on hand and forearm transplantation. (See http://www.hand-surg.org.)
   

Author/Editor Response

The authors reply:

To the Editor: We described the hand transplantation in our patient as successful for several reasons. The patient perceives his hand function to be good. He has protective sensation and uses both hands at work and during play. He underwent a Carroll test (an objective test of sensory and motor function of the hand), and the score for the transplanted hand was 56 of 99 possible points, demonstrating that the hand has half-normal function and twice that achieved with an average prosthesis.1 The patient also reports a psychological benefit in the form of a better body image and quality of life than he had when he had a prosthesis.

We agree with Drs. Cooney and Hentz about the need to inform the public and the medical community of the risks of immunosuppression and the unpredictability of the functional outcome of this new procedure. We described in our article the steps we took to discuss hand transplantation with physicians and the public and the review process that was completed before the procedure was performed.

Finally, we disagree with the position of Cooney and Hentz that hand transplantation should not be done. Rather we recommend that qualified programs proceed cautiously, using an approved experimental protocol. At least nine hand transplantations have been performed to date in the world, with one clear failure almost certainly resulting from the patient's noncompliance. The functional and psychological benefits achievable today indicate that our outlook should be one of cautious optimism. As we gain more information and experience, the results are likely to improve and the risks to become better defined.

Warren C. Breidenbach, M.D.
Kleinert, Kutz and Associates Hand Care Center, Louisville, KY 40292

Jon W. Jones, Jr., M.D.
Carolinas Medical Center, Charlotte, NC 28232-2861

1 References

1. 1

   Graham B, Adkins P, Tsai TM, Firrell J, Breidenbach WC. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg [Am] 1998;23:783-791
   CrossRef | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Wei-Chao Huang, Jeng-Yee Lin, Christopher Glenn Wallace, Wen-Yu Chuang, Fu-Chan Wei, Shuen-Kuei Liao. (2010) Vascularized bone grafts within composite tissue allotransplants can auto-create tolerance via mixed chimerism with partial myeloablative conditioning: an experimental study in rats. Plastic and Reconstructive Surgery1
   CrossRef

2. 2

   Thomas H. Tung, Susan E. Mackinnon, T Mohanakumar. (2005) Combined Treatment with CD40 Costimulation Blockade, T-Cell Depletion, Low-Dose Irradiation, and Donor Bone Marrow Transfusion in Limb Allograft Survival. Annals of Plastic Surgery 55:5, 512-518
   CrossRef

3. 3

   Thomas H. Tung, Susan E. Mackinnon, T. Mohanakumar. (2005) Prolonged limb allograft survival with CD40 costimulation blockade, T-cell depletion, and megadose donor bone-marrow transfusion. Microsurgery 25:8, 624-631
   CrossRef

4. 4

   Thomas H. H. Tung, Susan E. Mackinnon, T. Mohanakumar. (2003) Long-term limb allograft survival using anti-CD40L antibody in a murine model. Transplantation 75:5, 644-650
   CrossRef