In 1998, while working in a factory, Donnie Rickelman had both his hands caught and crushed in a steel splitter machine. As surgeons amputated his mangled hands, Rickelman’s hope of holding anything ever again slowly vanished.
Earlier this year, however, Mr Rickelman had surgery to transplant replacement human hands where his own used to be.
Thanks to an astounding, slightly surreal procedure, it is now possible to take hands from deceased patients and give them to those without.
This process of detaching a dead donor’s appendage at the wrist or elbow, and intricately transplanting onto a recipient, is an emerging treatment for amputees – most of whom have lost limbs after trauma.
Hand transplants have only been performed a few dozen times to date. But they represent a future alternative to upper-limb prosthesis, which often fails to replicate what nature gave us. Prosthetics can be bulky and heavy. This is particularly problematic for arms and hands because gravity tends to pull them off at the crucial moment of trying to lift something.
So, since the first successful attempt in 1998, surgeons have been developing the technique which could someday arm the limbless – a promising venture for the 5,000 amputees a year who are referred to British prosthetic clinics.
Hand transplants are Britain-bound
Now, the hunt is on to bring the technique to the UK. Surgeons all over the United Kingdom were contacted earlier this year by the British Association of Plastic, Reconstructive and Aesthetic Surgeons to start searching for ideal hand donors and recipients for the transplant.
The exact extent of the demand for hands in the UK is unknown, but it could grow if the procedure is deemed more natural-looking, or provides better dexterity and sensation, than prosthetic limb alternatives. Since the procedure is relatively new, however, its long-term usefulness is yet to be determined.
The UK procedure is set to be carried out in a year’s time at Leeds General Infirmary, though it has already taken years to prepare. Bringing together the world’s leading experts from fields as wide-ranging as plastic surgery and psychiatry is no mean feat.
Professor Simon Kay, who is leading Britain’s first hand transplant attempt, said: “Preparing for any new type of transplant surgery takes time…We need to ensure we have all the protocols in place for when the time comes.”
Hand size, colour and hairiness all influence donor hand choice
Hand transplants are trickier to organise than other transplants as they must take into account appearance – as well as significant long-term post-surgery psychiatry, physiotherapy and anti-rejection drug treatment.
The team currently involved in Britain’s hand transplant is made up of 36 medics and researchers from disciplines such as hand surgery, plastic surgery, hematology (blood studies), orthopaedics (bones), anaesthesia, brain-mapping and rehabilitation.
As an American surgeon once said, “the hand transplant surgeons put the hand on, the transplant medicine doctors keep it on, and the therapists make it work”.
A complex procedure
The practical side of the transplant, namely the fusion of donor organ and recipient, is arguably the shortest part of the process. The surgery generally lasts between 8 and 24 hours.
The highly skilled multifaceted procedure begins with preparing each organ and exposing its surface to identify every structure ready to be melded together. Then the painstaking process of attaching each layer in each portion of the human hand commences.
The bones of each hand segment are firstly bolted together using metal plates and screws attaching to both sides of the two main arm bones, the ulna and radius. The delicate procedures which follow then ensure the numerous blood vessels, 23 tendons, three nerves, thick fat layer and overlying skin are all sewed together sequentially.
The donor hand must be delicately sewed onto the recipient
Movement of the hand depends on perfectly balanced tendons, which connect muscle to bone. Tendons must be perfectly adjusted to each other, and the muscles they connect to, in order to allow precise movement.
The principle is somewhat analogous to assembling a wardrobe: if the screws on the door hinges are not correctly positioned, or are tightened too much, the doors will lose alignment and not open and close properly.
Surgeons can test each tendon as they connect it. By pulling a particular tendon and seeing which finger flexes as a result, they can ensure that the tendons are correctly attached to relevant fingers and are moving as freely as they should.
After the procedure, potentially life-long care is required. As well as the limb being set in plaster for a short time, physiotherapy, occupational therapy and possibly electrostimulation all contribute to an intense rehabilitation programme that aims to restore as much function to the transplanted hand as possible.
Rejection of the donor hand is also dealt with using immunosuppressive (anti-rejection) drugs, which are usually taken for years after the operation.
Rigorous candidate criteria
Unlike your heart, liver or kidney, hands are generally on show. Surgeons who are looking for a suitable hand donor need to match it to the prospective recipient on a number of parameters: not just typical ones, such as blood group, but also hand size, colour and degree of hairiness.
This means that finding hands suitable for donation is more difficult: in addition to working correctly, the donor hand has to look good. This is one of the reasons that plastic surgeons have a major role in hand transplant.
Recipients are often subjected to multiple psychological analyses before proceedings begin. Because a hand transplant requires more aftercare than most other organ transplants, recipients must be committed to the hard work of therapy, which one patient described as “relentless pain”.
The case of Clint Hallam is an illustrative one on this topic. Mr Hallam was the first person to have an arm successfully transplanted, in 1998. However, this French-based operation was followed by an English one three years later, when Mr Hallam requested the arm be removed.
Mr Hallam said that after a trouble-free year, he felt “mentally detached” from the transplant, and movement was difficult. The surgeons said this was due to rejection, as a result of him not taking his follow-up medication or doing the physiotherapy prescribed to him.
Hand surgeon Dr Kodi Azari said: “Hand transplant is not for everyone; it’s for unique individuals who are healthy, recovered from [the] drama of injuries, physically and psychologically [and] had to have tried prosthetics for a minimum of 6 months.”
Remapping the hand on the brain
Donnie Rickelman requires hand therapy to master basic tasks
The attached hand is not, however, immediately functional. A small amount of finger wriggling may be possible straight after the operation; picking up small objects could take a few weeks; and feeling hot and cold may be feasible after a several months.
Larger and more precise movement takes much longer to master. Sensation and feeling in the hand can take up to a year, with increasing function as time goes on.
This is partly due to the brain and how it maps movement on its surface. Hands receive a large area on the brain map. However, when a hand is lost, the portion of the map which represents it also disappears. When a hand is replanted, therefore, the brain has to rebuild the map to interpret sensation from the new organ.
Ethics under development
Hand transplants, though an impressive medical advance, aren’t without their ethical issues. As a transplant, they are not life-saving but life-enhancing. Therefore, unlike life-saving transplant procedures, the benefits of limb transplants do not self-evidently outweigh the risks.
As few hand transplants have been carried out to date, little long-term data on risks and benefits exists. The National Institute for Health and Clinical Excellence (NICE) is therefore treating each hand transplant to date like a clinical trial, emphasising there is still much to learn about the drugs and rejection.
“NICE guidelines for hand transplants are essentially the same as other transplants,” explains Professor James Neuburger from NHS Blood and Transplant.
Professor Bruce Campbell, chairman of the Interventional Procedures Advisory Committee at NICE said: “We would welcome the opportunity to review this guidance once further research has been published.”
To begin to compile case studies, NICE advises surgical teams to send information about hand transplants to the International Registry on Hand and Composite Tissue Transplantation and Transplant UK, so the procedure’s efficacy can be charted over time.
What lies ahead for new hands
As it stands, a very small number of people will benefit from hand transplants. This raises issues of how much the NHS can or will spend on developing it – as it will potentially only enhance the lives of few, rather than save the lives of many.
And it won’t be anytime soon that the average Briton will come into contact with the subject: Professor Anthony Warrens, vice president of the British Transplantation Society, has rejected suggestions of adding hands to the British organ donor cards, saying “the demand [for hands] is so rare that donor cards would not be changed…[and instead will be] dealt with on an individual basis by asking family”.
Main photo - Courtesy of UCLA Health System
Other photos - Courtesy of Jewish Hospital; Kleinert, Kutz and Associates Hand Care Center; and University of Louisville