As Hand-Transplant Patients Improve, Doctors Debate Risks

Matt Scott gestures as he talks. His hands open and close, moving like partners in a dance. The seamlessness is striking, because the seams are still visible: faint scars where surgeons stitched Scott’s new left hand, slightly pinker and puffier than his right, onto what was once the stump of his forearm.

It’s been 16 months since Scott, a New Jersey paramedic, became the first American--and the second person in the world--to receive a successful hand transplant, replacing the hand he lost in a fireworks accident 13 years earlier.

For years, Scott had longed for a new hand to replace his prosthetic one.

“It was never enough, because inside there’s always a yearning to be normal,” he said. “This is as close to normal as I’m ever going to get. And I feel wonderful about that.”

But Scott’s transplant and several similar ones performed around the world in the last two years remain medically and ethically controversial.

Because the grafted hands came from donors whose tissue does not match patients’ immune systems, Scott and the other recipients must take anti-rejection drugs for the rest of their lives. These drugs leave recipients vulnerable to infection, cancer and other health problems--risks that many doctors argue are too high a price to pay for a new hand. A heart, a liver, a lung--these organs are necessary for life. A hand, despite its functional and cosmetic importance, is not.

“The reason people are concerned is, we don’t think the risk-benefit ratio is in favor of the patient at the moment,” said Neil F. Jones, professor in chief of hand surgery at UCLA.

Since the first successful hand transplant, in 1998 in Lyon, France, Scott and five other injury victims--in France, China and Austria--have received a total of eight transplanted hands. In recent years, other victims of trauma have received knees, thigh bones and even a larynx, along with sections of attached blood vessels and other adjoining tissues.

Australian Clint Hallam, the first patient to receive a successful hand transplant, will mark the second anniversary of his surgery in September.

“It’s a remarkable first step,” said Warren C. Breidenbach, the plastic surgeon who led the team that performed Scott’s surgery at Jewish Hospital here. Breidenbach spoke during a conference here last month that attracted many of the surgeons who have pioneered such mixed-tissue transplants around the world.

Yet, Breidenbach added, any of the transplanted hands could still be rejected any time--or a patient could develop an infection or cancer so serious that doctors would be forced to stop the anti-rejection medicine, sacrificing the hand to try to save the patient’s life.

Hallam’s surgeon, Jean-Michel Dubernard of Lyon, said Hallam has not consistently taken the drugs prescribed to suppress his immune system and has been treated three times for symptoms of rejection. The transplant’s status is uncertain.

“It is an experiment in progress,” Breidenbach said. “It may be that two or three years from now, if these all fail, we may decide that we started too early and we need to wait.”

UCLA’s Jones said that he is encouraged that a couple of the cases “look pretty good” a year or more after surgery. But “I don’t think the final result is in on any of them,” he said. “All of them still run a very high risk of developing cancer.”

Scott, 39, maintains that the long-term risks are worth the gamble.

“I have heard my success described as ‘moderate,’ ” he told surgeons at the meeting. “But I am far better off than I’ve ever been with the prosthesis. I could not carry both my sons. I could not hug my wife with both hands.”

Scott’s transplanted left hand remains much weaker, clumsier and less sensitive than his right, but with time and physical therapy, its function has steadily improved. He has sensation on the palm and out to the fingertips, although he said his fingers are sometimes “confused” about which one is being touched.

Films and photographs shown at the conference by Dubernard and by Chinese orthopedic surgeon Guoxian Pei demonstrated similar results. The two Chinese patients, who each received a new hand in September at Nanfang Hospital in Guangzhou, were shown grasping small objects and pouring water from pitchers.

Doctors said the gradual improvement after such surgery reflects nerve growth into the new hand as well as reassignment of portions of the patient’s brain to control the graft.

“If you have an amputation, you lose that area that was receiving sensory input from the hand that was amputated,” said Jon W. Jones Jr., a transplant surgeon on the Louisville team. “That area (of the brain) is taken over by other functions.” But after a transplant, “that area in your brain can reestablish its original function and the sensory input goes back where it should.”

It will take as long as five years for doctors to assess the final function of a transplanted hand, said Susan E. Mackinnon, chief of plastic surgery at Washington University School of Medicine in St. Louis.

“If you get back neurological function, it will come from [the patient’s] own nerves” making connections with the skin and muscles of the grafted hand, she said.

Surgeon Gunther Hofmann of Murnau, Germany, described mixed results with knee and thigh bone transplants. The thigh bone transplants appear to have succeeded, but two of five transplanted knees have failed because of chronic rejection.

Transplant surgeons don’t know how to recognize and treat early signs of rejection in such cases, Hofmann said.

“It is necessary for all of us to return to the laboratory.”

With six recipients still in the recovery stage, surgeons are debating whether further hand transplants should proceed. Mackinnon and UCLA’s Jones said they favor a moratorium.

“There are several patients now done, and I think my own feeling would be to wait and see,” Jones said. “If they continue to have no rejection . . . then obviously we, as the critics, have been wrong.

“But if, in fact, they start showing rejection at the two-year period, or they start developing tumors,” he said, “we have to find other ways of modulating the immune response before we embark on this.”

But Breidenbach said he and his team at Jewish Hospital plan to proceed.

“We need to progress cautiously and systematically,” Breidenbach said, but “we’re going to go on.”