Prosthetic replacements for a lost hand are more sophisticated than ever. But they don't feel like the real thing or transmit those familiar sensations. An increasingly viable alternative is to have a limb transplanted.
Abdul Rahim picks up a thick blue permanent marker and begins writing Bismillah in his native Pashto language on a white pad.
He finishes, and pours and drinks a cup of tea. Then he lays out and straightens his prayer mat.
None of this would be remarkable were it not for the fact that Mr Rahim is performing the tasks with his new transplanted hands.
The former Afghanistan military captain lost his hands while defusing mines in Kandahar three years ago.
On April 10, he underwent a 15-hour operation in Kochi, India, where more than 20 doctors transplanted the hands of a traffic accident victim. He is finally ready to show off the results.
The healed transplant scars reach up close to his elbows, with the skin of his new hands a few shades darker than his own fair skin.
It was the second time surgeons in India had performed a double hand transplant.
Dr Subramania Iyer, head of plastic and reconstructive surgery at Amrita Institute of Medical Sciences, said he and his team reconnected two bones, two arteries, four veins and 14 tendons in each hand.
Despite its apparent success, hand transplants are a new and experimental surgery. Fewer than 200 are thought to have been carried out worldwide.
Michael Errico is a co-author of the 2012 academic paper "History and Ethics of Hand Transplants", published in the Journal of the Royal Society of Medicine. He says the procedure is a "controversial concept with ethical, financial and psychological implications".
Medically, it is a much more complex procedure than most other organ transplants because of the complexity of the hand – skin, bone, muscles, nerves, arteries, veins, soft tissues and tendons. All of these need to be transplanted on to, and accepted by, the recipient if the procedure is to be a success.
Rejection of the transplanted tissues by the body’s immune system is the biggest challenge facing patients and doctors. Recipients have to take drugs for the rest of their lives to prevent the transplanted hand from being attacked by the immune system.
There is also the psychological effect of having someone else’s hand.
However, a successful transplant has obvious advantages over even today’s highly sophisticated prosthetic hands. Dr Maria Siemionow, the head of plastic surgery at the Cleveland Clinic, in the American state of Ohio, led the team of surgeons in the first face transplant in the US in 2008. She says the major issue with a prosthesis is the lack of sensory feedback and feeling of human flesh when one touches it.
“At this point, prostheses do not provide sensory feedback such as feeling when you touch something hot or cold, or shaking a hand with another person, or touching a baby,” says Dr Siemionow.
The first human hand transplant was performed in September 1998 on New Zealander Clint Hallam. Doctors in Lyon, France, spent 13 hours attaching the right forearm of a brain-dead donor on to Mr Hallam, then 48. The success was short-lived. Three years later the hand was removed by doctors in the UK, reportedly at Mr Hallam’s request, because he had not been able to adapt psychologically.
Mr Errico, of Hull York Medical University in the UK, says Mr Hallam’s reaction to the unfamiliar hand caused him to stop taking his immuno-suppressive medicine, leading to acute tissue rejection.
Johns Hopkins Medicine's transplant centre warns its hand and arm transplant patients to be prepared for an "intensive rehabilitation" process, some of which will be needed for the rest of the patient's life. It recommends its patients start moving their new hand within 48 hours to reduce swelling and stiffness, and calls caring for and rehabilitating the transplanted hand "a full time job for the first one to two years after the transplant".
Patients need to attend hand therapy for at least six hours a day, five days a week for up to six months after the transplant.
Not everyone who is missing a hand or arm is eligible for a transplant, the hospital says, and some would much prefer to have prosthetics or nothing at all. “However, some people find prosthetics difficult to use and the lack of sensory ‘feedback’ from their prosthetics can significantly limit their function,” its website says.
Prof Wei-Ping Andrew Lee, head of the Johns Hopkins University School of Medicine’s department of plastic and reconstructive surgery, says hand transplant patients can function at a level that “far exceeds” what prosthetics can accomplish.
“Many of our hand transplant recipients have been able to resume activities of daily living such as bathing, dressing and driving,” Prof Lee says. “Most have returned to work or school, and regained personal autonomy that was lost after hand amputation due to the need for near constant personal assistance.”
The International Registry on Hand and Composite Tissue Transplantation has reported long-term graft survival rates of more than 90 per cent when patients fully complied with the immuno-suppressive medicine regime. A paper by the organisation, which was set up by Prof Jean-Michael Dubernard, the lead surgeon in Mr Hallam's procedure, also reported that nine out of 10 patients developed tactile sensation.
The operation can be more difficult than a kidney or liver transplant, Dr Siemionow says, and requires additional skills such as training in microsurgery to reattach veins and nerves.
Despite the successes, Mr Errico argues that hand transplant surgery is “non-essential” and the ethical considerations of it should not be overlooked. The benefits, he says, should not be “unintentionally exaggerated by an overzealous physician, motivated by the thrill or medical advancement”.
The small number of case studies means the full financial cost of a single or double transplant is hard to estimate.
One 2010 study solely on the costs of the procedure in the US put the lifetime cost for a single hand transplant at US$529,315, or more than Dh1.9 million. The total cost of a single and double prosthesis is $20,653 and $41,305, the study said.
Prof Lee disagrees with this, saying that a hand transplant often allows the recipient to return to gainful employment, and to take only one anti-rejection drug at low doses, significantly reducing the cost of the medicine.
“Furthermore, the cost for maintenance and replacement of prosthetics are not insubstantial,” he says. “In properly selected patients, therefore, hand transplantation is a superior option over prosthetics.”
Dr Siemionow also argues that because prostheses need to be changed over time as the patient gets older, and each new generation of prosthetic is more expensive, there are circumstances where the cost of a hand transplant is worth paying.
Some of the earliest recorded prosthetics date back to as early as the 16th century.
The German knight Gottfried von Berlichingen lost his right arm when he was hit by a cannonball during the siege of Landshut in 1504. He was later given two iron hand replacements so he could return to battle. He controlled the fingers, which could grip his horse’s reins and a feather quill pen, using gears triggered by pressure inside the arm.
Mass production of prosthetic limbs began after the Second World War, when the number of amputations rose suddenly.
In 1948, a Bowden cable-controlled prosthetic was released. It no longer required a healthy hand to control it, like many previous models, instead using cables around the upper body.
A decade later, the first myoelectric prosthesis was unveiled, using muscles in what was left of the arm to control the functions.
"The use of transistors reduced bulk and allowed portability of the device, with the batteries and electronics worn on a belt and connected to the prosthesis by wires," reported Kevin Zuo and Jaret Olson in the 2014 paper "The Evolution of Functional Hand Replacement", in Plastic Surgery. The authors noted that although it was a step forward, the hands were still heavy, slow to react and move, and the wire connections were susceptible to damage and electrical interference.
The principles of myoelectricity are still the most common used in making prostheses. In 2012, Johns Hopkins University completed a $30m project to develop a mechanical arm that mimicked the properties of the real thing. The university's Applied Physics Laboratory team developed the modular prosthetic limb, which "has nearly the same numbers of degrees of freedom as the human arm".
The device can be controlled by transferring residual nerves from an amputated arm into the chest of the patient, or by picking up signals generated by the muscles beneath the skin of the residual limb.
But for Mr Rahim, the former military man who defused mines, a prosthetic was not enough. He wanted new hands. So, after hearing that the hospital in Kochi had performed another double hand transplant in January, he contacted doctors there. According to The Indian Express newspaper, he was “at the end of a search for hand transplant in many other countries”.
Dr Iyer says he will need physiotherapy for 10 months. It is not known where he will receive his medication or rehabilitation after that.
munderwood@thenational.ae