Hand transplant

from Wikipedia, the free encyclopedia

A hand transplant is an operation to transfer one or both hands from a dead person to a living person. Specifically, it is a composite tissue allograft - the transfer of a foreign part, which is composed of different tissues . The difference to arm transplantation is that with arm transplantation the stump of the recipient arm lies above the elbow and therefore more tissue is transplanted. Usually, however, such a strict distinction is not made.

A special feature of the hand transplant compared to other types of transplantation, such as a kidney transplant , is that it is not a life-saving measure. Their primary purpose is to restore lost functionality to the patient. On the one hand, it can therefore offer a real perspective for those affected with a traumatic amputation of the hands or forearms. On the other hand, however, it is under criticism: it makes lifelong use of immunosuppressants (drugs that suppress the immune system and thereby have a large number of side effects) necessary, although the measure is not of vital necessity. This is why hand transplants are only used in a few patients who are selected according to strict criteria.

History of hand transplants

As early as 1900, the French surgeon Alexis Carrel achieved the first transplantation of limbs on dogs. However, he encountered massive problems with the rejection of the foreign tissue and all animals died. Aided by the development of immunosuppressants, the first human hand transplant using azathioprine and steroids was performed in Ecuador in 1964 . After just two weeks, however, it was rejected and it had to be removed again. In the 1980s and 1990s, more effective immunosuppressants such as ciclosporin were developed, but these did not allow hand transplants either. In 1997 reports appeared about a successfully prevented rejection reaction in a composite tissue allograft through a combined therapy consisting of the drugs tacrolimus , mycophenolate mofetil (MMF) and prednisone .

This finally paved the way for the first, briefly successful hand transplant: A new right hand was transplanted to Clint Hallam from New Zealand on September 23, 1998 in Lyon, France . Hallam, however, suffered physically and mentally from his new limb. He struggled with the side effects of the drugs and found the graft to be a foreign body. He also neglected his physical therapy program and eventually refused to take any medication. This led to rejection reactions of the hand, which was finally removed again on February 2, 2001 at his request.

The first hand transplant with sustained success despite limited finger mobility was performed on January 24, 1999 by doctors from the University of Louisville in cooperation with the "Kleinert, Kutz and Associates Hand Care Center" and the "Jewish Hospital & St. Mary's HealthCare" in Louisville ( Kentucky) . The patient had lost his hand in a fireworks accident at the age of 24. The University of Louisville medical professionals also performed a successful hand transplant on Jerry Fisher two years later.

Two further hand transplants had already been carried out in Guangzhou ( China ) in 1999 : A transplant of two hands on a man with a bilateral amputation in January 2000, followed by a further bilateral hand transplant in Innsbruck under the direction of Raimund Margreiter and Hildegunde Piza-Katzer in March of the same year . The recipient, Theo Kelz, was an Austrian police officer who had lost both hands in a pipe bomb .

The world's first bilateral arm transplant was performed on July 26, 2008 at the Klinikum rechts der Isar in Munich . The recipient, then 54-year-old Karl Merk, had lost both arms in an agricultural accident five years earlier. Under the direction of Christoph Höhnke and Edgar Biemer , two new arms were transplanted into him in a 15-hour operation. According to reports, the patient is still coping well with his transplants (as of 2014).

By 2014, a total of about 85 hand transplants had been performed. The International Registry on Hand and Composite Tissue Transplantation (IRHCTT) , founded in May 2002, has current data and figures on hand transplants.

Patient selection and examinations

The angiography performed here shows a normal structure of the brachial arteries , the radial arteries and the ulnar arteries , which do not suggest any problems.
Sonography is used to determine the condition of the blood vessels.

As with any surgery, hand transplantation must weigh the potential benefits against the potential risks. In addition to complications during the operation, these are mainly a rejection reaction and the side effects of immunosuppression. In order to keep all risks of a transplant as low as possible, potential candidates have to submit to a strict selection process.

First of all, the doctors consider whether the patient cannot be helped by conservative methods such as a prosthesis and thus spared the risks of an operation. Modern prostheses today allow very good functional results and can therefore compete with hand transplantation, as a study revealed at the annual meeting of the American Association for Handsurgery. was presented. The results in various tests in the group with a transplanted hand differ only by a few points from the group with a hand prosthesis. However, the study was carried out with only 13 participants. On the other hand, a hand transplant is supported by the fact that a prosthesis has no sense of touch - any sensation is impossible, which makes many manipulations only possible under visual control. Some scientists have succeeded in partially solving this problem and producing a certain degree of tactile sense, but these developments have so far only been experimental. The lower cost of the prosthesis speaks for itself. Most of the most important hand movements can be carried out with just one hand. Because of these points, the prosthesis would be preferable to transplantation if “only” one hand is lost. If you lose both hands, on the other hand, you have to think about a hand transplant earlier.

In order for a possible candidate to be accepted at all, he or she must meet a number of general criteria, which may vary depending on the clinic in which a hand transplant is offered. In general, however, a candidate must have health insurance, be no younger than 18 and no older than 60 or 65 years old, he must be motivated and healthy, and the loss of the hand must be traumatic or surgical. The period between amputation and transplantation can also be an exclusion criterion. If this is longer than 15 years, for example, the candidate can be excluded.

If these general criteria are met, the psychological suitability is examined. The hand is a visible organ that can decisively influence a person's self-perception. The recipient must be able to live with his new hand and accept it as part of himself. He therefore takes part in an intensive psychological screening and talks with a psychiatrist beforehand.

For a good functional result, a long, retarded arm stump with muscles and tendons in good condition and in any case intact nerves up to the stump is crucial.

To examine this and other things, such as the veins and / or arteries in the recipient's arm, a variety of examinations, such as x-rays , angiography , Doppler sonography , venography , or CT, can be performed. The results of these examinations make the subsequent operation much easier to plan and can lead to potential problems being recognized early. Such a problem can be, for example, an inadequate superficial venous network, so that a solution must be found in the course of vascular surgery.

So that a suitable donor can be identified at all, various laboratory tests have to be carried out, including determining the blood group .

surgery

The hand is a complex organ with many different structures in a very small space. For this reason alone, a hand transplant is not an easy procedure that can take 8 to 12 hours (for comparison: a typical heart transplant usually takes 6 to 8 hours). In addition, the simultaneous work of two teams is required. One separates the hand from the dead donor, another prepares the recipient's arm at the same time.

The surgical procedure described here relates only to the transplantation of the hand - not that of the arm.

Separation of the donor hand

The procedure for severing the hand is initially the same as for a normal hand operation, i.e. the hand is disinfected and the blood supply is interrupted by a cuff. An incision is also made in the region of the elbow in order to identify the arm artery and the most important veins and then to ligate (constrict) them. The radial nerve , the median nerve and the ulnar nerve are also identified . The muscles are then dissected and severed with a unipolar electrocautery , and the ulna and radius with a surgical saw.

After the hand has been severed, the donor's stump can be treated further and, if necessary, bandaged so that a cosmetic prosthesis can be attached to the corpse and thus greater blood loss can be avoided. Overall, this procedure takes about 15 to 20 minutes.

The following happens with the severed hand: A cannula is pushed into the arm artery so that a special, four-degree cold solution can then be introduced into the hand, which displaces the remaining blood and preserves the hand for a while. Finally, the hand is packed in two sterile towels and three sterile bags before it is brought to the recipient in a special transport box for organ transport. In some cases, however, the separation also takes place in the same operating room as the later connection between the donor's hand and the recipient.

Operational preparation of the recipient

The preparation of the recipient's hand serves to create ideal conditions for the later attachment of the donor's hand to the recipient. This preparation usually takes place during the transplant, but it may be necessary to perform a surgical procedure for this purpose before the actual transplant:

Surgical preparation before the transplant

Surgical, preparatory intervention before the transplantation can be indicated, for example, in the event of an infection: Because of the immunosuppressive drugs, an infection is a serious threat to the success of the transplantation and must therefore also be combined with the corresponding surgical options, such as bone resection (removal of a part of the bone) or osteoplasty ( plastic surgery on the bone), must be fought in advance.

Surgical preparation during the transplant

A recipient's arm stump just before the skin incision is made.

The recipient's stump is being prepared at the time of transplantation while the other team is separating the donor's hand from the donor. To begin with, the soft tissues of the arm are prepared by initially making the skin incision, then preparing the veins, arteries, nerves and tendons first on the front and then on the back of the arm; Finally, the ulna and radius follow. If the operation requires additional autologous (endogenous) tissue, this is usually taken from the legs, which then also have to be operated on. Then a third team is needed to take on this task.

The following points (except for the skin incision) are not in chronological order, but arranged according to the individual tissues:

  • The skin incision is made as far distal as possible (i.e. as far as possible at the end of the arm). The rear side (dorsal side) is incised along the connecting arch from the outer (lateral) side of the radius to the inner (medial) side of the ulna . The cut on the front (ventral) side of the arm is made in the form of a "V", with the tip being proximal (towards the origin of the arm) and the angle between the two legs of the "V" being about 90 degrees. The cut is made so far around the arm that the two legs of the “V” finally converge on the back of the arm with the cut there. The resulting teardrop-shaped skin flap initially remains in place. Then, starting from the tip of the “V”, another cut is made, which is made linearly in the proximal direction, so that the “V shape” becomes a “Y shape”. The roughly triangular space that is obtained on the anterior-medial (front and center) side of the forearm is used to receive the donor tissue later.
  • Three to four veins with a diameter greater than three millimeters are freely dissected, isolated and then closed with a clip during the mobilization of the skin flap. If there are not enough such veins in the forearm, they must be looked for further up (in the area of ​​the upper arm, above the elbow). These are then connected in the course of the operation with long veins that were taken from the donor and which are then brought further down to the hand.
  • As far as the arteries are concerned, the surgeons prepare the radial arteries and ulnar arteries freely, taking into account the accompanying veins, and cut them where they still correspond to their normal, healthy structure.
  • The tendons must also be identified and marked so that they can be easily found again later in the operation. For this purpose, sterile, labeled plastic pieces can be used, for example. If the tendon ends have to be sewn together later, it may be necessary to shorten the tendons accordingly until the tendon end has a quality that is sufficient for the later procedure. It is advantageous if the tendons lying next to one another are shortened so that the tendon ends are not at the same “height”. The reason for this is that tendon ends that are at different “heights” can slide next to each other better, which enables the patient to be mobilized earlier.
  • Bones: The optimal starting point for a hand transplant is where the best results can be expected for both sides (the donor hand and part of the recipient arm) and a prosthesis can be attached at the same time if the transplant fails. This and the fact that three screws each have to be inserted into the ulna and radius of the donor hand determine how much the recipient's bones are shortened. Those deductions and preparation of the bone worn periosteum must be stored carefully, as they can be reused later.

Connection of the donor hand with the recipient

The sequence of steps involved in connecting the donor hand to the recipient may vary from center to center. Usually, however, the bones are connected first and then the blood vessels. More rarely, however, it can also happen that the blood vessels are first connected before the other surgical steps are carried out. Milomir Ninkovic describes the following procedure in the book Hand Transplantation :

  • Osteosynthesis (connection of bones)
  • first anastomosis (connection of blood vessels)
  • Connection or transfer of muscles and tendons
  • final connection of blood vessels
  • Connection of the nerves (nerve sheaths)
  • Closing the wound

Osteosynthesis

The osteosynthesis in this transplant was carried out with two plates and six screws each.

The bones must be securely connected, but at the same time the surgeons must be careful not to restrict the movement of the joints. As with any osteosynthesis, one must pay attention to the length of the extremity (here: the hand), the alignment, the rotation and the angulation. 3.5 mm LCPs (locking compression plates) are usually used to connect the bones if the transplant is located in the middle or upper area of ​​the forearm. If, on the other hand, the operation is more at the lower (distal) end, these LCPs cannot be used; instead, you can use other special plates. After the actual osteosynthesis, the previously removed periosteum is reattached, which leads to a significant improvement in the healing of the bone.

First vascular anastomosis

A first anastomosis follows immediately after the connection of the bones in order to restart the blood flow as early as possible. The anastomosis in this step is made at either the radial artery or the ulnar artery along with one or two veins. For this purpose, the ends of the respective vessels of the donor and recipient are prepared under the microscope and then sewn together. There are different approaches to this: Some surgeons prefer to suture the veins together first because it is easier to work in an anemic area. The others connect an artery first so that fresh blood can get into the hand as quickly as possible and because the important veins can be located more easily when they are supplied with blood. The second artery and its accompanying veins are not yet connected. After this initial anastomosis has been performed, the ice that was around the donor hand is removed. After the blood vessels have been connected, the flow is checked and it is waited until a rosy color appears again, which indicates good blood flow.

Connection / transfer of muscles and tendons

After connecting the bones and important blood vessels, the tendons are joined together. This further stabilizes the hand. Different suturing techniques are used depending on the height at which the transplantation takes place. In general, the tendons should be treated as carefully as possible and sewn at different "heights" so that they can slide past each other better. To do this, they may have to be shortened if this has not already been done. Tendon transfer may also be indicated in accidents involving torn limbs.

After the tendon treatment is complete, the balance and tension between the flexor tendons (muscles that bend a limb) and those of the extensors (muscles that straighten a limb) must also be checked. To do this, the respective finger can simply be moved passively while the tendon is felt with the hand. It should be easy to bend your finger to the palm of your hand. It should also be possible to stretch the finger, but not to overextend it.

Final connection of the blood vessels

Then the surgeons can take care of the remaining blood vessels. Two points must be observed at the same time: On the one hand, the blood vessels must have the correct tension. They must not kink, nor should they be under too much tension. Therefore, they - including the blood vessels connected during the first anastomosis - must be shortened to the appropriate length. On the other hand, however, the blood supply must not be interrupted, which would inevitably happen while the arteries were shortened. This problem is circumvented as follows: First, connect the second large artery ( arteria radialis or arteria ulnaris ) and at least one other of the larger veins (second anastomosis). Thereafter, the blood flow in the first connected (first anastomosis) vessels can be interrupted (e.g. using a clamp) and the shortening performed. The vessels are then reconnected (re-anastomosis) and blood flow is restored. Once that has also been done, do the same with the blood vessels of the second anastomosis. Finally, all the other veins are connected. The following applies: The more veins that are repaired, the higher the chance of a successful transplant - at least four to six veins, some of which are in the deeper layers, must be connected.

Connection of nerves

All three major nerves of the forearm ( median nerve , ulnar nerve and radial nerve , or its branches ramus superficialis and ramus profundus ) are identified and dissected. They are then connected with the greatest care under the microscope. To do this, the nerve endings are sewn together or connected with a special connector, depending on the technique. The nerves must not be under tension.

Closing the wound

Before the surgical wound can be closed, hemostasis must have occurred. If this is the case, the skin flaps can be cut to size and loosely sutured over the drains . In the end, this results in four interlocking lobes that zigzag the wound. Often, however, there is not enough skin on the forearm for a loose, tension-free closure, so that additional skin from the donor has to be transplanted to solve this problem. In addition, hemostatic inserts and a plaster splint are inserted and a special, implantable ultrasound head for Doppler sonography is inserted in order to precisely monitor the blood flow in the hand.

Complications

Since the operation is complex, some complications can arise: on the one hand, the operation may take longer than originally planned, but on the other hand, it may lead to the formation of blood clots that disrupt the blood circulation in the hand Infection, wound healing problems, pain, excessive bleeding, or other complications.

Postoperative approach

A rosy color of the fingers and the whole hand indicates good blood circulation

The patient remains in the intensive care unit for a few days after the operation and is then transferred to a normal ward, where he remains for about one to two weeks. This period of time is subject to strong fluctuations, depending on how well and quickly the patient recovers and whether and which complications occur. During his time in the intensive care unit, in addition to the usual biological parameters such as pulse and breathing, above all the blood flow into the new hand and its temperature must be checked at regular intervals. In the further course of the hospital stay, an intensive physiotherapeutic program, electrical stimulation of the muscles and nerves of the new hand, psychological care, checks on a possible rejection reaction and the exact dosage of the immunosuppressive drugs take place. Even after they are discharged, patients must do physiotherapy exercises and regularly come to the hospital to be checked for rejection reactions. These examinations usually decrease over time - provided that there are no problems.

Immunosuppression

In principle, the same immunosuppressive drugs are used for a hand transplant as for conventional organ transplants. Contrary to original expectations, this does not even require a higher dose. The type and amount of individual medication can vary from clinic to clinic performing the procedure. However, a calcineurin inhibitor such as tacrolimus , an antimetabolite such as mycophenolate mofetil (MMF), a monoclonal antibody such as alemtuzumab and a glucocorticoid such as methyl prednisone are common .

In the first year after the transplant, around 85% of patients experience a rejection reaction, which can normally be treated well with a simple increase in the dose of immunosuppressants or the additional use of glucocorticoids. The advantage over a “normal” organ transplant is that rejection in a hand transplant can easily be recognized by discoloration of the skin, swelling of the hand and skin biopsies .

Result - advantages and criticism

Studies in patients have suggested that hand transplantation can produce very good results with properly selected patients, correct surgery and targeted immunosuppression. It has been shown that in patients in Europe and the USA the survival rate of the transplant is 94% and that in practically all of them the pain perception and in 90% the sense of touch could be established in the new hand, which is a clear advantage over prostheses. The degree of sensitivity in the new hand with a hand transplant is comparable or even better than with an autologous transplant (the body's own tissue is transplanted). 88% of patients are able to distinguish between surface structures through the sense of touch in the transplanted hand, which goes beyond just perceiving the object they touch. For example, a patient who was operated on in the USA in 1999 reported that his ability to differentiate between two points of contact with 5 to 9 mm, as well as the result of 69 out of a maximum of 99 points in the Correll score, was almost normal. In addition, it can differentiate between hot and cold as well as rough and soft surfaces. Martin Kumnig, together with other authors in the journal Wiener Klinisches Magazin , states that the functionality of a transplanted hand corresponds to around 75% of that of a normal hand.

However, this feeling cannot be achieved directly after the operation. When the donor hand is separated from the donor, the nerves are severed so that the axons in the transplanted hand die. As a result, the nerves of the recipient remaining in the stump of the arm must first grow back into the new hand. This happens at a rate of about one millimeter per day, so depending on the size of the transplant it can take several months before a feeling returns. After about a year (with a hand transplant below the elbow), the sensation of temperature, sensitivity to pressure, sensation of pain and the ability to differentiate between two points set in. This sensitivity continues to improve in the following years until no further improvement occurs about five years after the transplantation. This long period of slow improvement, even after the nerves have completely grown into the hand, suggests that the brain also has to get used to the new body part again: the nerve cells that were once responsible for the hand take over after the Amputation new tasks. Therefore, the hand must first be reintegrated after the transplant. When examining the recipient's brain using MRI, it has been shown that the motor cerebral cortex is able to integrate the new hand into the existing system and to reorganize itself. This cortical reintegration can - as a side effect, so to speak - also lead to the phantom pain , which sometimes occurs in amputated hands, being improved or even disappearing completely.

Muscle regeneration begins with regeneration of the forearm muscles, which allows some patients to perform grasping movements very soon after surgery, and continues with thenar and hypothenar regeneration between approximately the ninth and fifteenth months after surgery. Regeneration can be improved through targeted electrical stimulation. Overall, the regenerative results are so good that the patient is able to cope with most everyday tasks. This includes things like eating, writing, brushing your teeth, shaving, combing, and washing yourself. More complex fine motor movements, such as buttoning up shirts, sometimes cause difficulties for the patient, but are sometimes also well managed. Overall, however, the objective comparability or measurability of the functionality is limited - more subjective criteria such as patient satisfaction often play a greater role.

Because of the good results, most patients perceive the new hand as their own and a significant improvement in their quality of life. Many can also go back to work.

Nevertheless, there is also criticism of hand transplants: the main point of criticism is lifelong immunosuppression, which drastically increases the risk of infections and has other side effects such as diabetes and high blood pressure , although a hand transplant is not a life-saving measure and there are more gentle alternatives with prostheses. Due to this immunosuppression and the operation with possible complications, the hand transplant is potentially fatal: two of the recipients have died worldwide so far.

In addition, a hand transplant is a great psychological burden for the recipient. He sees the hand of a dead stranger donor on his own body every day and can easily develop an identity disorder. Therefore, the mental stability of a potential candidate must also be greater than that of a candidate for a heart transplant, for example.

In addition, ethical questions arise about whether the hand of the dead is acceptable for a living person who does not necessarily need it.

Hand transplant costs

The cost of the operation itself is estimated at around € 250,000.

However, if you add the estimated cost of lifelong immunosuppression, physiotherapy, possible complications, etc., a hand transplant costs a total of around $ 530,000, according to an American research group - for both a single and a bilateral hand transplant. Another study found about $ 760,000. Both studies assume that the recipient will live 40 years with his new hand ( quality-corrected year of life ). In terms of their cost-benefit analysis, however , hand transplants lag far behind conventional prostheses in both studies. This becomes particularly clear when calculating the so-called "incremental cost-utility ratio (ICUR)" (German for example: additional cost-benefit analysis ) for bilateral hand transplants in comparison to the prosthesis. The ICUR here would be around $ 320,000 to $ 380,000, depending on the study, per quality-adjusted year of life. The result is thus far above the traditionally recognized limit of approx. $ 50,000 per QALY and also above the limit of $ 100,000 per QALY established by recent studies.

Implementation of hand transplantation in different countries

Germany

In Germany only one operation of this kind has been carried out so far: It was the transplant of two arms on July 26, 2008 in the Klinikum Rechts der Isar. Actually, this transplantation would even have been forbidden, because a hand transplant involves tissue and, according to current regulations, this must first be examined before it can be transplanted. However, this would take far too long for a later transplant.

Austria

In Austria, the Innsbruck hospital has emerged as a “center” for hand transplants. So far, five patients have had new hands transplanted there; the success rate is 100%. The costs for an operation, which are estimated at around € 250,000, are covered by the health insurance in Austria after a case-by-case examination.

United States of America

There are several clinics in the United States that offer hand transplants. On the one hand there is the merger of the Kentucky One Health Jewish Hospital , the Christine M. Kleinert Institute for Hand and Microsurgery , the Kleinert Kutz Hand Care Center and the University of Louisville , which also carried out the world's second hand transplant with Matthew Scott as the recipient.

On the other hand, the Johns Hopkins Hospital offers hand and face transplants . Noteworthy is the study by the hospital, which aims to reduce the number of immunosuppressants to a single drug.

Southern Illinois University School of Medicine, along with Memorial Medical Center, also offers hand transplants.

Great Britain

In the UK , the National Health Service Teaching Hospital in Leeds offers hand transplants.

Others

In his book The Fourth Hand , author John Irving tells the fictional story of a hand transplant recipient.

literature

Web links

  • Hatem Amer, Brian T. Carlsen, Jennifer L. Dusso, Brooks S. Edwards, Steven L. Moran: Hand Transplantation . Minessotamedicine.com, May 2011 (English)

Individual evidence

  1. ^ Brian Gander, Charles S. Brown, Dalibor Vasilic, Allen Furr, Joseph C. Banis Jr, Michael Cunningham, Osborne Wiggins, Claudio Maldonado, Iain Whitaker, Gustavo Perez-Abadia, Johannes M. Frank, John H. Barker: Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery , August 18, 2006, In: Transplant International. November 2006. doi: 10.1111 / j.1432-2277.2006.00371.x
  2. ↑ Esther Vögelin: Hand Transplantation - Fiction or Reality? (PDF) In: Therapeutische Umschau , Verlag Hans Huber, Bern 2011, doi: 10.1024 / 0040-5930 / a000237
  3. ^ U. Schulte: Nobel Prize in Medicine 1912: Alexis Carrel . In: Universal Lexicon. 2012.
  4. ↑ Stefan Schneeberger, Luis Landin, Jerzy Jableki, Peter Butler, Christoph Hoehnke, Gerald Brandacher, Emmanuel Morelon and for the ESOT CTA Working Group: Achiements and challenges in composite tissue allotransplantation. In: Transplant International. Volume 24, No. 8, August 2011. doi: 10.1111 / j.1432-2277.2011.01261.x
  5. ↑ John H. Barker, Cedric G. Francois, Johannes M. Frank and Claudio Maldonado: Composite Tissue Allotransplantation . In: Transplant Forum . tape 73 , no. 5 , March 15, 2002, p. 832-835 .
  6. ↑ Transplanted Hand Amputated . In: The New York Times. February 4, 2001, accessed July 27, 2015.
  7. ^ Lawrence K. Altman: THE DOCTOR'S WORLD; A Short, Speckled History of a Transplanted Hand . In: The New York Times. February 27, 2001, accessed July 27, 2015.
  8. ↑ Volker Stollorz in an interview with Matthew Scott: Now it belongs to me . In: Frankfurter Allgemeine Zeitung. August 3, 2008, accessed July 27, 2015.
  9. ↑ Hand Transplant History . handtransplant.com; accessed on July 27, 2015.
  10. ↑ Matthew Scott . handtransplant.com; accessed on July 27, 2015.
  11. ↑ Helping Hands 2014: Theo Kelz's new hands . In: WorldPress.com. accessed on July 27, 2015.
  12. ^ A b Alfred Berger, Robert Hierner (ed.): Plastic surgery: Volume IV: Extremities . Springer Verlag, Berlin Heidelberg 2009, ISBN 978-3-540-68814-3 , p. 476 .
  13. ↑ 20 years after the pipe bomb: Theo Kelz is satisfied . In: Kleine Zeitung , August 20, 2014; accessed on July 27, 2015.
  14. ↑ a b Nicola Siegmund-Schultze: Transplantation Medicine: For the first time complete arms transplanted . In: Deutsches Ärzteblatt. 105, No. 33, 2008, accessed July 27, 2015.
  15. ↑ Karl Merk: With new arms firmly in the saddle again . Technical University of Munich, July 24, 2013; accessed on July 27, 2015.
  16. ↑ Ingo Jensen: Accident with the maize chopper: The man with strange arms . In: Augsburger Allgemeine. July 24, 2013; accessed on July 27, 2015.
  17. ↑ German farmer got new arms . In: Salzburger Nachrichten. September 7, 2014; accessed on July 27, 2015.
  18. ↑ a b c Emily Underwood: People with hand transplants can gain near-normal sense of touch . In: Science. American Association for the Advancement of Science, November 19, 2014, accessed July 27, 2015.
  19. ↑ International Registry on Hand and Composite Tissue Transplantation, accessed July 27, 2015.
  20. ↑ M. Kumnig, G. Rumpold, A. Weissenbacher, J. Pratschke, G. Brandacher, St. Schneeberger, Th. Hautz: Composite Tissue Allotransplantation . ( Memento of the original of July 13, 2015 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. In: Wiener Klinisches Magazin. March 2011, Springer Verlag, SpringerMedizin.at @1@ 2Template: Webachiv / IABot / www.springermedizin.at
  21. ↑ Stefan Salminger, Agnes Sturma, Aidan Roche, Marina Ninkovic, Gerhard Pierer, Adam Chelmonski, Jerzy Jablecki, Oskar C. Aszmann: Functional Comparison of Hand Transplantation and Prosthetic Fitting in Below-Elbow Amputees . In: handsurgery.org. American Association for Hand Surgery, accessed July 27, 2015 (presented at the annual meeting of the American Association for Handsurgery. In cooperation with the British Society for Surgery of the Hand. January 21 to 24, 2015.)
  22. ↑ Stanisa Raspopovic, Marco Capogrosso, Francesco Maria Petrini, Marco Bonizzato, Jacopo Rigosa, Giovanni Di Pino, Jacopo Carpaneto, Marco Controzzi, Tim Boretius, Eduardo Fernandez, Giuseppe Granata, Calogero Maria Oddo, Luca Citi, Anna Lisa Ciancio, Christian Cipriani, Maria Chiara Carrozza, Winnie Jensen, Eugenio Guglielmelli, Thomas Stieglitz, Paolo Maria Rossini, Silvestro Micera: Restoring Natural Sensory Feedback in Real-Time Bidirectional Hand Prostheses . In: Science Translational Medicine . tape 5 , no. 222 . American Association for the Advancement of Science (AAAS), February 5, 2014, doi : 10.1126 / scitranslmed.3006820 (English, abstract ).
  23. ↑ Lena Stallmach: Prostheses with a sense of touch . ( Memento of the original from June 11, 2015 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) In: Neue Zürcher Zeitung , October 15, 2014, part 1, p. 51; accessed on July 27, 2015. @1@ 2Template: Webachiv / IABot / www.balgristtec.ch
  24. ↑ a b Kevin C. Chung, Takashi Oda, Daniel Saddawi-Konefka and Melissa J. Shauver: An economic analysis of hand transplantation in the United States . In: Plastic and Reconstructive Surgery . tape 125 , no. 2 . Lippincott Williams & Wilkins, February 2010, doi : 10.1097 / PRS.0b013e3181c82eb6 , PMC 4387885 (free full text) - (English).
  25. ↑ Information for Potential Hand Transplant Patients handtransplant.com; accessed on July 27, 2015.
  26. ↑ Eligibillity ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The @1@ 2Template: Webachiv / IABot / brighamandwomens.org archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Brigham and Women's Hospital, March 17, 2014, accessed July 27, 2015.
  27. ↑ Hand Transplantation and Psychiatric Issues . handtransplant.com; accessed on July 27, 2015.
  28. ↑ Martin M. Klapheke, Carrie Marcell, Greg Taliaferro, Beth Creamer: Psychiatric Assessment of cadidats for hand transplantation. In: Microsurgery. 20, No. 8, 2000, pp. 453-457. doi : 10.1002 / 1098-2752 (2000) 20: 8 <453 :: AID-MICR18> 3.0.CO; 2-Y
  29. ↑ Requirements for hand transplantation ( Memento of the original dated May 26, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Innsbruck University Hospital, accessed on July 27, 2015.  @1@ 2Template: Webachiv / IABot / www.chirurgie-innsbruck.at
  30. ↑ Elizabeth George, Dimitrios Mitsouras, Kanako K. Kumamaru, Nehal Shah, Stacy E. Smith, Kurt Schultz, Pamela M. Deaver, Katherine M. Mullen, Michael L. Steigner, Edwin C. Gravereaux, Shadpour Demehri, Ericka M. Bueno , Simon G. Talbot, Bohdan Pomahac and Frank J. Rybicki: Upper extremity composite tissue allotransplantation imaging. In: Eplasty. Volume 13, No. e38, 2013. PMID 23943677 , PMC 3716341 (free full text).
  31. ^ A b Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 192 .
  32. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S. Gorantla, N. Ruben Gonzalez, Ashley C. Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Preoperative Details . Medscape.de March 5, 2014.
  33. ↑ Volker Schumpelick, Niels Bleese, Ulrich Mommsen and others. a .: Short textbook surgery . 8th edition. Georg Thieme Verlag, Stuttgart New York 2010, ISBN 978-3-13-127128-0 , pp. 797 .
  34. ^ The Hand Transplantation Procedure . In: UCLA Health. accessed on July 27, 2015.
  35. ↑ a b c Our Hand and Arm Transplant Services ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The @1@ 2Template: Webachiv / IABot / brighamandwomens.org archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Brigham and Women's Hospital, February 14, 2013, accessed July 27, 2015.
  36. ^ A b c Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 188 .
  37. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S Gorantla, N. Ruben Gonzalez, Ashley C Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Interoperative Details . Medscape.com, March 5, 2014, accessed July 27, 2015.
  38. ^ Osteoplasty . Roche Lexicon of Medicine, Urban & Fischer, 5th edition
  39. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 191 .
  40. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 193 .
  41. ^ A b c Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 194 .
  42. ^ A b Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 195 .
  43. ^ A b c Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 199 .
  44. ↑ Composite Tissue Allograft: Hand Transplant Fact Sheet . handtransplant.com; accessed on July 27, 2015.
  45. ↑ Composite Tissue Allograft: Hand Transplant Surgical Procedure Animation . handtraspnlant.com; accessed on July 27, 2015.
  46. ↑ a b c d Kodi K. Azari, Joseph E. Imbriglia, Robert J. Goitz, Jaimie T. Shores, Marshall L. Balk, Gerald Brandacher, Stephan Schneeberger, Vijay Gorantla, and WP Andrew Lee: Technical Aspects of Recipient Operation in Hand transplant . In: Journal of Reconstructive Microsurgery . tape 28 , no. 1 . Georg Thieme Verlag, 2012, p. 27-34 , doi : 10.1055 / s-0031-1285820 .
  47. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 200 .
  48. ↑ Composite Tissue Allograft: 3D Images of Hand Transplant . handtransplant.com; accessed on July 27, 2015.
  49. ^ A b Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 201 .
  50. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 201 and 202 .
  51. ↑ Jesse Selber, Richard Andrassy, ​​John Holcomb: Composite Tissue Allotransplantation , MD Anderson Cancer Center, The University of Texas, 2015, accessed July 27, 2015.
  52. ^ Reconstructive Hand Transplant Surgery . In: Johns Hopkins Medicine , The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System, accessed July 27, 2015.
  53. ↑ a b Barida Amiriak, Craig R. Lehrman, Vijay S. Gorantla, N. Ruben Gonzalez, Ashley C. Campbell and Gordon R. Tobin: Hand Transplant Treatment & Management . Medscape.com March 5, 2014, accessed July 27, 2015.
  54. ↑ Before, During and After a Facial Transplant ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Brigham and Womens Hospital, March 17, 2014, accessed July 27, 2015. @1@ 2Template: Webachiv / IABot / www.brighamandwomens.org
  55. ↑ Our Hand and Arm Transplant Services ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , Brigham and Womens Hospital, February 14, 2013, accessed July 27, 2015. @1@ 2Template: Webachiv / IABot / brighamandwomens.org
  56. ↑ Our Services. ( Memento of the original from May 25, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Brigham and Womens Hospital, March 17, 2014, accessed July 27, 2015. @1@ 2Template: Webachiv / IABot / brighamandwomens.org
  57. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S. Gorantla, N. Ruben Gonzalez, Ashley C. Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Postoperative Details . Medscape.com, March 5, 2014; accessed on July 27, 2015.
  58. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S. Gorantla, N. Ruben Gonzalez, Ashley C. Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Follow-up . Medscape.com March 5, 2014, accessed July 27, 2015.
  59. ↑ H. Madania, S. Hettiaratchyb, A. Clarke and PEM Butler: Immunosuppression in an emerging field of plastic reconstructive surgery: composite tissue allotransplantation . In: Journal of Plastic, Reconstructive and Aesthetic Surgery . tape 61 , no. 3 , March 2008, p. 245-249 (English).
  60. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S Gorantla, N. Ruben Gonzalez, Ashley C. Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Medical Therapy . Medscape.de, March 5, 2014.
  61. ↑ Palmina Petruzzo, Marco Lanzetta, Jean-Michel Dubernard, Jean-Michel, Luis Landin, Pedro Cavadas, Raimund Margreiter, Stephan Schneeberger, Warren Breidenbach, Christina Kaufman, Jerzy Jablecki, Frédéric Schuind and Christian Dumontier: The International Registry on Hand and Composite Tissue transplant . In: transplant . tape 90 , no. 12 , December 27, 2010, p. 1590–1594 , doi : 10.1097 / TP.0b013e3181ff1472 (English).
  62. ↑ Raimund Margreiter, G. Brandacher, M. Ninkovic, W. Steurer, A. Kreczy and S. Schneeberger: A double-hand transplant can be worth the effort! In: transplant . tape 74 , no. 1 , July 15, 2002, p. 85-90 (English).
  63. ^ Warren C. Breidenbach, Gordon R. Tobin, Vijay S. Gorantla, Ruben N. Gonzalez and Darla K. Granger: A position statement in support of hand transplantation . In: The Journal of Hand Surgery . tape 27 , no. 5 , September 2002, p. 760-770 (English).
  64. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 355 .
  65. ↑ a b c Gerald Brandacher and Andrew Lee: Hand Transplantation . In: The Clinics: Orthopedics . tape 27 , no. 3 . Elsevier Health Sciences, 2011, ISBN 978-1-4557-0930-4 .
  66. ↑ Martin Kumnig, Gerhard Rumpold, Annemarie Weissenbacher, Johann Pratschke, Gerald Brandacher, Stefan Schneeberger, Theresa Hautz: Composite Tissue Allotransplantation . In: Wiener Klinisches Magazin. June 2011, doi: 10.1007 / s00740-011-0361-4
  67. ^ Robert F. Schmidt, Gerhard Thews and Florian Lang (eds.): Physiologie des Menschen . 28th edition. Springer Verlag, Heidelberg, New York 2000, ISBN 978-3-662-09346-7 , pp. 219 .
  68. ^ Marco Lanzetta, Jean-Michel Dubernard: Hand transplantation . Springer Verlag, 2007, ISBN 978-88-470-0374-3 , pp. 292 .
  69. ↑ C. Neugroschl, V. Denolin, F. Schuind, C. Van Holder, P. David, D. and T. Baleriaux Metens: Functional MRI activation of somatosensory and motor cortices in a hand-grafted patient with early clinical sensorimotor recovery . In: European Radiology . tape 15 , no. 9 . Springer Verlag, September 2005, p. 1806–1814 , doi : 10.1007 / s00330-005-2763-4 (English).
  70. ^ Göran Lundborg: The Hand and the Brain - From Lucy's Thumb to the Thought-Controlled Robotic Hand . Springer Verlag, 2013, ISBN 978-1-4471-5334-4 , pp. 166 . ( Page under Google Books )
  71. ^ NS Chu: Phantom finger phenomena and the effects of toe-to-finger transplantation . In: Neurorehabilitation and neuronal repair . tape 14 , no. 4 , 2000, pp. 277-285 , PMID 11402878 .
  72. ↑ Hatem Amer, Brian T. Carlsen, Jennifer L. Dusso, Brooks S. Edwards, Steven L. Moran: Hand Transplantation . May 2011, Minessotamedicine.com, accessed July 27, 2015.
  73. ↑ Gerald Brandacher, Vijay S. Gorantla and WP Andrew Lee: Hand Allotransplantation . In: Seminars of Plastic Surgery . tape 24 , no. 1 , February 2010, p. 11–17 , doi : 10.1055 / s-0030-1253243 , PMC 2886996 (free full text).
  74. ↑ Kurt Martin-Mayer: From the beginning it was my hands , August 2, 2008, Focus online , accessed on July 27, 2015.
  75. ↑ Results ( Memento of the original of July 22, 2015 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. , Innsbruck University Hospital, accessed on July 27, 2015.  @1@ 2Template: Webachiv / IABot / www.chirurgie-innsbruck.at
  76. ↑ Barida Amiriak, Craig R. Lehrmann, Vijay S. Gorantla, N. Ruben Gonzalez, Ashley C. Campbell, Gordon R. Tobin: Hand Transplantation Treatment & Management: Outcome and Prognosis . Medscape.com March 5, 2014, accessed July 27, 2015.
  77. ^ Fabian Stucker, Daniel Ackermann: Immunosuppressants - Effects, Side Effects and Interactions . In: Therapeutic review . tape 68 , no. 12 . Hogrefe, December 2011, p. 673-677 , doi : 10.1024 / 0040-5930 / a000230 .
  78. ↑ Which side effects can occur with immunosuppression? ( Memento of the original from May 18, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Transplant Center Campus Benjamin Franklin, Charité 2015; accessed on July 27, 2015.  @1@ 2Template: Webachiv / IABot / transplantation-cbf.charite.de
  79. ↑ Esther Vögelin: Hand Transplantation - Fiction or Reality . In: Therapeutic review . tape 68 , no. 12 . Hogrefe, December 2011, p. 730-734 , doi : 10.1024 / 0040-5930 / a000237 .
  80. ^ Neil F. Jones: Concerns about human hand transplantation in the 21st century . In: The Journal of Hand Surgery . tape 27 , no. 5 . Elesevier, September 2002, p. 771-787 , doi : 10.1053 / jhsu.2002.34373 (English).
  81. ↑ a b Marieke Degen : The second hand . Deutschlandfunk, July 18, 2012; accessed on July 27, 2015.
  82. ^ Alfred Berger, Robert Hierner (ed.): Plastic surgery: Volume IV: Extremities . 1st edition. Springer Verlag, Berlin Heidelberg 2008, ISBN 978-3-540-00144-7 , p. 477 .
  83. ↑ M. Siegler: Ethical issues in innovative surgery: should we attempt a cadaveric hand transplantation in a human subject? In: Transplantation Proceedings . tape 30 , no. 6 . Elsevier, September 1998, pp. 2779-2782 (English).
  84. ↑ a b c Feeling and grasping with the hands of a dead person . RP-Online, September 9, 2014, accessed July 27, 2015.
  85. ^ Peter Pollack: Hand transplant not cost-effective . In: American Academy of Orthopedian Surgeons . tape 9 , no. January 6 , 2010 (English).
  86. ↑ Composite tissue allograft: Welcome. handtransplant.com; accessed on July 27, 2015.
  87. ^ Nation's First and Second Successful Hand Transplants . (Video) handtransplant.com; accessed on July 27, 2015.
  88. ↑ Human Upper Extremity Allograft: A Hand and Arm Transplant Research Study . Johns Hopkins Medicine , The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System, accessed July 27, 2015.
  89. ↑ Immunomodulatory / Minimization Protocol . Johns Hopkins Medicine , The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System, accessed July 27, 2015.
  90. ↑ Hand transplant . www.siumed.edu, accessed July 27, 2015.
  91. ^ Welcome - Restoring Hands that look and function as normal . handtransplantuk.com, accessed July 27, 2015.
  92. ↑ The Fourth Hand , john-irving.com, accessed July 27, 2015 (web design by Adrian Kinloch.)