Background: Upper limb loss has severe consequences with regard to functional status and mental health. Prostheses, though sophisticated, lack sensory feedback and appear unnatural. Upper limb transplantation is now a clinical reality, and represents an opportunity to better restore form and function, with resultant improvements in quality of life (QoL) anticipated. In October, 2011, we performed a successful bilateral hand transplant in a 65-year-old male who lost four extremities to sepsis nine years prior. We report on outcomes after one year.

Methods: Bilateral hands and forearms were procured and transplanted at the mid-forearm. Daily therapy focusing on strength, range of motion (ROM), and motor skills began immediately. Evaluations of sensory (Semmes-Weinstein monofilament [SWm]) and motor function (Carroll), QoL (SF-36), and disability (QuickDASH) were routinely performed.

Results: Motor function shows gradual improvement but limited Carroll testing has not been reflective of improvements in activities of daily living. Recovery was hampered by adhesions requiring tenolysis in month 7, with marked subsequent improvements of wrist and digit ROM. Vibration and temperature sense show early recovery at one year and SWm shows return of pressure sense to forearm and palmar and dorsal hand. QoL and disability metrics improve in the initial recovery, after which pain caused by improved sensation and motion restrictions caused by adhesion result in decreased QoL. After tenolysis, function and satisfaction has improved.

Conclusions: Occupational therapy is a key component of functional recovery after hand transplantation. Functional recovery is graded and may be hindered by the inflammatory process and slow nerve regeneration. As expected, QoL and disability metrics initially worsen after surgery, but generally trend upward thereafter. Our experience has demonstrated poor correlation between subjective function and objective metrics. Development of instruments specifically suited for hand transplant recipients should be a focus of further research.

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