Toronto surgeons expect to perform the country’s first hand transplant, marking the start of a new age in tissue reconstruction and giving hope to Canadians who suffer from debilitating and disfiguring injuries.

Reconstructive surgeons at Toronto Western Hospital are looking for possible candidates for a hand transplant, and say the first patient to undergo the pioneering procedure will likely be someone who needs two new hands.

Children who have lost a hand in an accident or been born without arms or hands will also be candidates for a transplant, overseen by surgeons at The Hospital for Sick Children.

Dr. Steven McCabe, director of the University of Toronto Hand and Upper Extremity Program, says the first hand transplant — expected within six months — opens the door to Toronto offering other innovative tissue surgeries, including partial and full face transplants.

“As we gain experience, this is going to be a whole new era of plastic and reconstructive surgery,” says McCabe, who was a member of the surgical team that performed the first U.S. hand transplant in Louisville, Ky., in 1999.

About 80 patients around the world have received hands from cadaver donors. Not all have been considered a success.









On Jan. 19, 1999, Matthew Scott became the first American — and only the second person globally — to receive a hand transplant.

The New Jersey paramedic, who lost his left hand in a fireworks accident 13 years before, read a newspaper article about the groundbreaking procedure being considered by doctors in Louisville while on holiday in England.

“Then and there, I wanted to get on the plane back to the United States.”

Though Scott had adapted to a prosthesis — he returned to work as a paramedic nine months after the 1985 accident — he never felt that he fully adopted it.

“It was just something that was necessary, not something that was optimal,” he says, recalling that he had to carry extra batteries for his prosthesis, take it off before bathing, and call the company when it broke down. “It was a machine … and after a while the limitations started to become really apparent.”

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Doctors in Louisville determined Scott was an ideal candidate following screening that involved health checks as well as a psychiatric analysis to ensure he had the motivation and social supports needed to take on the surgical risks and lengthy rehabilitation.

Scott says being a medical professional helped him understand the procedure’s short term and lifelong risks. And he didn’t balk at being a pioneer.

“Somebody had to be first, and why not me,” he says during a conversation from his office in Blackwood, NJ, where he is director of the paramedic training program at Virtua Health. Nor was he daunted by the idea of a hand transplant; he says he had thought about the possibility of a new hand almost from the day of his catastrophic accident.

“Every time somebody does something new, there is always a risk. We don’t move ahead without taking some kind of risk. And I needed to move ahead for me.”

Toronto specialists have waited until 2014 to embark on hand transplants because of ethical concerns around the procedure.

A hand transplant is different from an organ transplant in one important way: A new heart or lungs will save a person’s life. A new hand, however useful, is not the difference between life and death.

But in both cases, recipients must take anti-rejection drugs for the rest of their lives. These drugs, which suppress a patient’s immune system, leave them susceptible to infections and at risk for serious health problems, including diabetes and cancer.

A person who needs a new heart to survive must accept these risks. Debate continues about whether the risks are too high a price for a new hand.

After careful consideration, the Toronto team believes hand transplantation is worth the risk — for the right patient.

The patient who is initially chosen for a transplant will likely need two new hands. The thinking is that a person who has lost two hands — perhaps in a machinery accident, a car crash or fire — will be left largely dependent on the help of others for all aspects of life. Even with prostheses, many patients who have lost both their hands say their lives are limited as a result.

But a pair of transplanted hands would enhance a patient’s life to such a degree, likely offering a return to independence, that these benefits overwhelm the surgical and drug-related risks.

“A lot of time has gone into sorting out which patients, with which types of injuries, can be best helped by this kind of surgery,” says McCabe, who was recruited to Toronto from Louisville in 2012 to lead the hand program. “We don’t want to just reattach a hand; we want to make sure it works.”

He hopes that someone reading this story will come forward to be Canada’s first hand transplant recipient — someone who has lost both of their hands through a sharp, clean injury, near the wrist.

“That would be the person we feel strongest that we can help.”

Fifteen years after his surgery, Scott is considered the world’s most successful hand transplant recipient. No one has had a donor hand longer than him.

His left hand — a faint lightning-bolt scar can still be seen around his wrist — will never be as strong or as nimble as his true right hand. But he relies on it every day, thinking of it as his own, grateful for its function as he cooks dinner, ties his shoelaces, presses his left palm on the top of a stranger’s fingers during a warm, two-handed handshake.

“It’s gotten to be second nature; I don’t think about it anymore,” Scott says of his left hand, which still has scars from his donor, a sheet metal worker, criss-crossing the flesh, a different shade of pink than his right hand.

“I carry those with me every day.”

Earlier this year, during a news conference marking the 15th anniversary of the transplant, Scott, now 53, described what the donor hand has meant to him.

“When I came to Louisville, I was a little broken,” he said, his voice quavering with emotion. “And this saved me.”

McCabe agrees that a hand transplant, though not technically a life-and-death procedure, can indeed enhance someone’s life so drastically that it can be considered life saving.

For that reason, the Toronto team has not ruled out the possibility of offering a transplant to someone who needs one hand and is clear-eyed about the risks.

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“We have to be cautious and safe,” says McCabe, who grew up in Dresden, Ont., and studied at Western University and the University of Toronto before taking the post in Louisville. “But if we have someone who has a single amputation, if that person is well-informed, asks the appropriate questions … we have to take their perspective into account.”

Despite advances in the procedure and improvements in anti-rejection drugs, there is a possibility that recipients can lose their new hand.

Famously, the world’s first person to have a successful hand transplant — an Australian man who had the procedure in France in 1998 — stopped taking his drugs and had to have his donated hand removed.

According to a 2014 review article published in the Journal of Bone and Joint Surgery, at least seven people in China have had to have a transplanted hand removed. Reports suggest these patients either did not comply with the strict drug regime, or did not have the appropriate medications or supports following surgery.

In the U.S. and Europe, several people have lost their transplanted hands. This includes an American patient who stopped taking anti-rejection drugs and lost the new hand 29 months after the transplant.

Some patients have died following the procedure, including a French patient who had a double hand transplant at the same time as a face transplant and died 65 days after surgery. In Turkey, two patients have died — one after a triple limb transplant, one after a quadruple limb transplant.

Dr. Ronald Zuker, a reconstructive surgeon at The Hospital for Sick Children who has co-led the push for Toronto to offer hand transplants, says the team has spoken with surgeons and hand recipients from around the world to determine the physical and mental characteristics required for a patient to have success.

“It’s imperative that we pick the right patient to go through this. Because if there is a problem at any step of the way, the whole concept will fail.”

From a medical standpoint, Zuker says Toronto is well positioned to succeed at hand and other tissue transplants.

Surgeons at Toronto Western Hospital, a part of the University Health Network (UHN), have long been at the forefront of delicate hand surgeries.

Toronto, too, is a leader in solid organ transplant. In the 1980s, surgeons at Toronto General Hospital performed the world’s first single and double lung transplants and the hospital, also part of UHN, performs the most organ transplants in the province.

“We have the expertise, the ability, the brain power and the man power,” says Zuker, who is a professor of surgery at the University of Toronto. “It’s important that we use it … We want to be part of this new exciting revolution.”

Staff at Trillium Gift of Life, the agency charged with overseeing organ and tissue donation in the province, have been trained on how to approach potential hand donors.

Surgeons at London’s Roth McFarlane Hand and Upper Limb Centre, a part of St. Joseph’s Healthcare, are also preparing for hand transplantation. The renowned surgical centre is ready to proceed once an appropriate patient has been identified, says Dr. Douglas Ross, a plastic surgeon at St. Joseph’s and professor at Western University.

The program, he says, has made provisions for five adult hand transplant patients within the next three to five years.

Zuker says the team is not yet sure how many Ontarians would want — or would qualify for — a donor hand. No one has kept track of single or double amputees who would be eligible for a transplant since the procedure has never been available to Canadians.

“Once we launch this program, I think we will be able to find those people and they will come to us.”

At first, Zuker estimates the Toronto team will offer hand transplant to four adults and two children a year.

To the first Canadian hand transplant recipient, Scott has this advice:

“You have to decide whether this is for you. If it’s just to make you look good — something for cosmetic reasons — that’s not good enough. . . . There has to be a real strong desire in you to want it.”

Because, he adds, the days and months after the transplant, as you recover from surgery, begin gruelling rehabilitation and adjust to anti-rejection drugs, will be among the hardest of your life.

“I don’t think that anybody who goes into this knows how tiring and taxing — physically, emotionally and mentally — it’s going to be,” says Scott. He says fear of failure — he knew that if he failed, then others wouldn’t get the chance of a new hand — got him through the toughest days.

He hopes the first Canadian to undergo a hand transplant will have the same grit, the same determination to succeed. Because, he says, the payout is so big.

“It was life saving for me. There were pieces of me that were missing. This transplant gave them back to me.”

Facts and figures

A hand transplant procedure takes between 8 and 10 hours. A double hand transplant could take twice as long. By comparison, a heart transplant takes between 6 and 8 hours.

To attach a donor hand, surgeons must first connect two bones using screws and steel plates. They then join the three main nerves and two arteries that feed into the hand, followed by hours of stitching together muscles, tendons, veins and skin.

The immunosuppressive drugs for a hand transplant are similar to those required following a kidney transplant.

Success is dependent on how well the nerves — which must grow from the recipient’s arm right through to the tips of the donor hand — regenerate.

Patients can expect to have 50-per-cent function of a normal hand. That means some sensation, the ability to gauge pressure, the ability to pick up and drink from a glass of water and, hopefully, the ability to write with a pen.

video

An animated video shows you how doctors reattach a hand. At thestar.com/life