A double-hand transplant can be worth the effort!

Composite-tissue transplantation offers a new therapeutic option for patients with loss of a hand. Little is known, however, about the long-term outcome after such a transplant with regard to graft function and immunosuppression and its side effects. We here report on our experience with a double-hand transplant performed more than 18 months ago.

Both distal forearms and hands of an age-, gender-, and size-matched cadaveric donor were transplanted to a 47-year-old policeman 6 years after loss of both hands. He received antithymocyte globulin as induction therapy and tacrolimus, mycophenolate mofetil, and prednisone as maintenance immunosuppression. Ganciclovir and co-trimoxazole were given prophylactically for cytomegalovirus and Pneumocystis carinii infection. A special rehabilitation program based mainly on cognitive therapy was designed and continued for 1 year.

Apart from a small area of skin that became necrotic early and some arteriovenous fistulas in the left forearm, which required ligation 6 months after transplantation, there were no surgical complications. One acute rejection episode occurred on day 55 and resolved completely after high-dose steroids and topical tacrolimus. Despite ganciclovir prophylaxis, virus replication was observed. The patient became negative for cytomegalovirus only after additional treatment with foscarnet (Foscavir) and cidofovir. At the end of 18 months, graft function with regard to motility is overall 60% of normal and enables the patient to pursue activities he could not with his myoelectric prostheses.

Excellent long-term results can be achieved with double-hand transplantation. Prerequisites are an appropriate surgical technique, careful immunosuppression, and an extensive rehabilitation program.