A New Hand

Duke Surgeons Perform North Carolina's First Hand Transplant
June 22, 2016

North Carolina saw its first hand transplant on May 27

Laredo, Texas native Rene Chavez received a new left hand after a complex 12-hour surgery at Duke. The 54-year-old is recovering well so far and has already had some sensation in the new hand. 

Chavez and CendalesThis procedure makes Duke one of fewer than 20 hospitals in the United States that have performed a hand transplant surgery. Chavez, who lost his left hand in a meat grinder accident when he was four, is one of fewer than 90 people worldwide who have ever received a transplanted hand.

There are several reasons why this type of surgery is so rare. As with any transplanted organ, the new hand has to match the blood type and immune chemistry of the recipient. Hands are additionally tricky to match, however, because they need to match the recipient’s skin tone, and the donor hand has to be a perfect size match to the recipient’s arm. Finding a perfect donor can take months.

Even if a match is found, getting that hand donated can be difficult. Donor hands are taken from recently deceased organ donors, but checking the organ donor box at the DMV doesn't automatically sign someone up to donate a hand. The donor’s family has to give consent, which is an understandably trying decision for anyone to make after having just lost a loved one.

More than these though, the immense complexity of the surgery and the staggering level of recovery and rehabilitation required after the surgery limit the number of hand transplants. 

Hand transplants fall under a category of surgeries called vascularized composite allotransplantations (VCAs) or composite tissue allotransplantations (TCAs), which are technical ways of saying the transplants involve many different types of tissues.

Hand in SurgeryTo attach the donor hand, surgeons must first join bones from the donor to those from the recipient with plates and screws. Then they have to reattach the tendons and muscles that will allow the new hand to move. After that, arteries and veins must be reattached to get blood to the new hand and beyond that surgeons have to repair the nerves that bring feeling and control. Watch an animation of that process here.

To further complicate things, the surgery can be different every time depending on where the recipient’s arm is disfigured or removed. Some clinics will take patients with any damage below the shoulder, and at each point on the arm, the muscles, tendons, bones and nerves are arranged differently. Instead of one surgery, a hand transplant is several surgeries that take on a thousand different forms depending on where the old meets the new.

Dr. Linda Cendales, surgeon and director of Duke’s hand transplant program, however, was a well-prepared surgeon to take on this surgery. She directed the VCA program at Emory University and was part of the team that completed the first two hand transplants in the United States in 1999 and 2001.

She directed two teams totaling more than a dozen surgeons, technicians, nurses and anesthesiologists through Chavez’s successful 12-hour surgery. Now that the surgery is over, however, Cendales’s job is far from over.

As with all transplants, there is a possibility that the recipient’s body will reject the donor organ. The body’s immune system is designed to attack foreign invaders and if the immune system decides there is something fishy about the organ, it will attack, which is called a rejection.

Operating RoomTo date, there has not been a transplanted hand rejection, but researchers around the country are investigating ways to make sure transplant patients do not reject their new limbs. Chavez’s operation marks the first case in a clinical trial of the immunosuppressant drug belatacept, which is currently used to prevent rejection in kidney transplants, for hand transplant operations. Other medical centers are working on trials for different methods.

Chavez still has more work to do as well. Learning to use his new hand will require almost full-time physical therapy for months and some form of rehabilitation for the rest of his life. 

Still, Chavez, a construction worker and car dealer says he is excited about the opportunity to learn how to live life with his new hand for the first time in 50 years.

—Daniel Lane

Daniel Lane covers science, medicine, engineering and the environment in North Carolina.