Follow-Up Clinics

Functional Outcomes after Bilateral Hand

Transplantation: A 3.5-Year Comprehensive
Follow-Up
Mansher Singh, M.D.
Background: Since the first successful hand transplantation in 1998, 72 patients
Geoffroy Sisk, M.D.
have been operated on for unilateral/bilateral hand transplantation across 13
Matthew Carty, M.D.
countries. There have been multiple studies evaluating the outcomes of hand
Christian Sampson, M.D. transplantation; however, there is considerable variability among the outcome
Philip Blazar, M.D. measures evaluated in these studies.
George Dyer, M.D. Methods: This article reports functional outcomes in a patient with bilateral
Brandon Earp, M.D. hand transplants at a mid-forearm level with serial follow-ups over 3.5 years.
Julian Pribaz, M.D. Different parameters used to study the functional outcomes include the Dis-
Bohdan Pomahac, M.D. abilities of the Arm, Shoulder, and Hand score, the Carroll test, the Hand
Simon G. Talbot, M.D. Transplant Score System, the Short Form-36 Health Survey, and routine occu-
Boston, Mass. pational therapy measures. Various task-oriented outcomes were also assigned
to provide milestones to the recovery.
Results: The patient had a Disabilities of the Arm, Shoulder, and Hand score
of 40, a Carroll test score of 48 (right) and 49 (left), and a Hand Transplant
Score System score of 58 (right) and 57.5 (left) at 3.5-year follow-up. Interest-
ingly, his objective scores did not change significantly during the follow-up,
but he continued to function quite independently and is subjectively pleased
with his outcomes.
Conclusions: Multiple functional outcome measures provide an objective way
to follow patients who have undergone hand transplantation. The authors pro-
pose a series of measures to elucidate subtleties in functional gains. However,
use of this series in isolation may belie subjectively good results. They also
propose a series of milestones in the recovery to give a better real-world ex-
planation of progress.  (Plast. Reconstr. Surg. 137: 185, 2016.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

S
ince the first successful hand transplantation
in 1998, 72 patients have been operated on
for unilateral/bilateral hand transplantation
across 13 countries.1–3 With the initial “success” of
this procedure, the focus has now shifted from fea-
sibility to quality of life and functional outcomes
after transplantation. There have been multiple
studies evaluating the outcomes of hand trans-
plantion.4–10 However, there has been variability
among the outcome measures evaluated in these
studies. We present our comprehensive series of
functional outcomes over 3.5 years in a bilateral
mid-forearm transplant patient. Our goals with
this set of outcome measures are (1) to evaluate
whether hand transplantation has improved func-
tion in this patient; (2) to determine the most
informative outcome measures to help better
define a minimum set of scales to be used; (3) to
begin to elucidate various milestones indicative
of stages of recovery/improvement; and (4) to
determine whether objective functional measures
correlate with subjective measures.

From the Division of Plastic Surgery and the Department of

Orthopedic Surgery, Brigham and Women’s Hospital.
Received for publication June 22, 2015; accepted July 23,
2015.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001872
Disclosure: The authors declare no potential con-
flicts of interest with respect to research, authorship,
and/or publication of this article. They received no
financial support for this research work.

www.PRSJournal.com 185
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 Plastic and Reconstructive Surgery • January 2016

Table 1.  Combined Scores at Serial Follow-Up in a Bilateral Hand Transplant Patient Using the Disabilities of
the Arm, Shoulder, and Hand Score, the Carroll Test, and the Hand Transplant Score System
Preoperative 6 Weeks 3 Months 6 Months 9 Months 1 Year 2 Year 2.5 Years 3 Years 3.5 Years
DASH 25 75 50 25 54 56 56.6 35 31 40
Carroll test – – – 30 (R), 44 (R), 52 (R), 56 (R), 58 (R), 51 (R), 48 (R),
27 (L) 41 (L) 54 (L) 57 (L) 63 (L) 52 (L) 49 (L)
HTSS NA – – 58.5 (R), 63 (R), 65 (R), 61.5 (R), 56.5 (R), 66 (R), 58 (R),
58.5 (L) 64 (L) 65 (L) 63.5 (L) 58 (L) 66.5 (L) 57.5 (L)
DASH, Disabilities of the Arm, Shoulder, and Hand; HTSS, Hand Transplant Score System; NA, not applicable; R, right; L, left.

PATIENTS AND METHODS
We have performed three bilateral hand
transplantations at our institution. Our index
patient, a 68-year-old man, had lost all four limbs
in 2002 because of sepsis and disseminated intra-
vascular coagulation related to a renal stone. He
underwent bilateral hand transplantation at mid-
forearm level on October 5, 2011. We describe a
complete list of functional outcomes with serial
follow-ups over 3.5 years. Validated functional out-
come scales used included: Disabilities of the Arm,
Shoulder, and Hand score11; the Carroll test12; the
Hand Transplant Score System13; and the Short
Form-36 Health Survey.14 The objective physical
measures used included total active motion, grip
strength, and Semmes Weinstein sensation across
different time points.
The Disabilities of the Arm, Shoulder, and
Hand questionnaire is an upper–extremity-spe-
cific outcome measure that contains a 30-item
disability/symptom scale concerning the patient’s
health during the preceding week. The scores
for all items are used to calculate a score rang-
ing from zero (no disability) to 100 (most severe
disability).11 The Carroll test integrates mobility,
motor function, and sensation to assess global
hand function. It quantifies the functional ability
of the upper extremity on a scale of zero to 99,
with a score of less than 50 being considered poor
and a score greater than 85 being considered
excellent.12 The Hand Transplant Score System
is based on a total value of 100 points that evalu-
ates six aspects: appearance (15); sensibility (20);
movement (20); psychological/social acceptance
(15); daily activities and work status (15); and
patient satisfaction and general well-being (15).
Scores between 61 and 80 are graded excellent,
61 to 80 are graded good, 31 to 60 are graded fair,
and 0 through 30 are graded poor.13 The Short
Form-36 Health Survey is self-reported by patients.
It consists of eight sections of scaled scores rang-
ing between zero (maximum disability) and 100
(no disability).14 The health concepts assessed by
the Short Form-36 Health Survey include vitality,
physical functioning, bodily pain, general health
perceptions, physical role functioning, emotional
role functioning, social role functioning, and
mental health.
RESULTS
Our patient’s preoperative Disabilities of the
Arm, Shoulder, and Hand score was 25, indicating
that he was highly functional with his prostheses.
Although his score generally improved gradu-
ally over serial follow-ups, he had not achieved
his preoperative state after 3.5 years of follow-up

Table 2.  Analysis of Different Aspects of the Hand Transplant Score System in a Bilateral Hand Transplant
Patient at Serial Follow-Ups (Not Measured)
Feature (Max) 2 Years 2.5 Years 3 Years 3.5 Years
Appearance (15) 15 (R) 15 (R) 13.5 (R) 15 (R)
15 (L) 15 (L) 13.5 (L) 15 (L)
Sensibility (20) 9 (R) 2 (R) 10 (R) 6.5 (R)
9 (L) 4 (L) 10 (L) 6.5 (L)
Movement (20) 3.5 (R) 2.5 (R) 7.5 (R) 2.5 (R)
5.5 (L) 2 (L) 8 (L) 2 (L)
Psychological and social acceptance (15) 12 (R) 14 (R) 14 (R) 14 (R)
12 (L) 14 (L) 14 (L) 14 (L)
Daily activities and work status (15) 8 (R) 8 (R) 8 (R) 9 (R)
8 (L) 8 (L) 8 (L) 9 (L)
Patient satisfaction and general well-being (15) 14 (R) 15 (R) 13 (R) 11 (R)
14 (L) 15 (L) 13 (L) 11 (L)
Total (100) 61.5 (R) 56.5 (R) 66 (R) 58 (R)
63.5 (L) 58 (L) 66.5 (L) 57.5 (L)
Max, maximum; R, right; L, left.

186
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 Volume 137, Number 1 • Bilateral Hand Transplantation Outcomes

(Table 1). The Carroll test scores and Hand Trans-

plamar hands
plant Score System, which are more specific to

dorsal and
MF 4.31 b/l,
3.5 Years
110 (R) hand functions, stabilized around the 1-year
60 (R)

25 (R)

105 (R)

11.7 (R)
90 (L)

65 (L)

65 (L)

115 (L)

8.3 (L)
follow-up and have been stable since that time
(Table 1). When his scores are broken into com-
Table 3.  Total Active Motion, Grip Strength, and Semmes Weinstein Sensation in a Bilateral Hand Transplant Patient at Different Follow-Up

ponent parts, our patient consistently scored well

in appearance, psychological and social accep-

except thumbs
plamar hands
tance, and patient satisfaction and general well-

dorsal and
MF 4.31 b/l,
110 (R)

80 (R)

0 (R)

100 (R)

10 (R)
65 (L)

30 (L)

30 (L)

68 (L)

10 (L)

(3.61 b/l)
3 Years

being (Table 2). However, he continues to make

progress with sensibility and movement of his
hands (Tables 2 and 3). Most of the aspects of the
patient’s Short Form-36 Health Survey scores did
not change significantly during the entire dura-
MF 4.31 b/l, MF 4.56 R, dorsal

line dorsally and palmar hand hand. MF 4.31,

tion of the follow-up (Table  4). It is noteworthy

palmar hand
L dorsal and
2.5 Years
110 (R)

60 (R)

0 (R)

122 (R)

15 (R)

and palmar
105 (L)

50 (L)

50 (L)

95 (L)

10 (L)

that the patient was undergoing significant emo-

tional stress, not related to his transplant, during
the 3-year and 3.5-year follow-ups, which could
have affected his scores. Based on the milestones,
the patient was able to achieve a fair degree of
independence with daily activities by as early as 6
dorsal and
110 (R)

80 (R)

70 (R)

110 (R)

15 (R)
100 (L)

60 (L)

60 (L)

85 (L)

10 (L)
2 Years

months and continued to improve for the entire

follow-up (Table  5). At 3.5 years, he was able to
drive, swim, play frisbee, play chords on the piano,
use a computer, and perform most activities of
scar line on volar
aspect. MF 4.93
inch below scar inch below scar

aspect. MF 6.10 b/l, dorsal and

3 inches below

daily living.
b/l, dorsal and palmar hand
MF 5.07 b/l, 1
110 (R)

80 (R)

30 (R)

120 (R)

10 (R)
115 (L)

55 (L)

55 (L)

90 (L)

10 (L)
1 Year

DISCUSSION
We present the comprehensive functional
outcome of a bilateral hand transplant recipient
with serial follow-up over 3.5 years. The goal of
palmar hand
tal to scar and 3 inches

line on volar
MF 5.07 b/l, 1

line dorsally

hand transplantation is to help amputees achieve

9 Months
135 (R)

95 (R)

30 (R)

120 (R)

10 (R)
140 (L)

65 (L)

65 (L)

90 (L)

10 (L)

below scar

independence in their daily activities. There

have been several studies that describe func-
tional outcomes after hand transplantation.3–10
Ravindra et al.8 used the Carroll test, whereas
recorded

recorded

other studies9,10 have used the Hand Transplant

6 Months

inch dis-
100 (R)

90 (R)

5 (R)
100 (L)

90 (L)

10 (L)

b/l, 0.5
Vague sensation MF 4.93

Score System and Disabilities of the Arm, Shoul-

line

TAM, total active motion; MF, monofilament; b/l, bilateral.

der, and Hand scores as indicators for functional

Not

Not

outcomes. The 3-year scores from these studies

below scar line

are similar to those of our patient, and both

3 Months

the Carroll and Hand Transplant Score System

Not recorded

Not recorded

Not recorded

b/l, 0.5 cm
110 (R)

40 (R)
120 (L)

20 (L)

scores continued to improve in these studies

with longer follow-up.9,10
Based on our experience, although bilat-
eral hand transplantation recipients are able to
achieve moderate independence, our current
Other digits TAM, degrees

scoring systems tend to underestimate changes.

Wrist extension/flexion
Pronation/supination

Thumb TAM, degrees

Several mechanisms may underlie this relatively

Semmes Weinstein

static scoring: patients may be very well adapted

Grip strength, lbs
range, degrees

range, degrees

to amputations preoperatively, which makes their

Feature (Max)
Time Points

initial scores high; our scoring systems may not

sensation

accurately reflect key aspects of independence;

and/or hand transplantation may not have as
clear an objective improvement as we believe it

187
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 Plastic and Reconstructive Surgery • January 2016

Table 4.  Short Form-36 Health Survey Scores at Different Follow-Up Time Points in a Patient with Bilateral
Hand Transplant
6 Weeks 3 Months 9 Months 1 Year 2 Year 2.5 Years 3 Years 3.5 Years
Physical functioning 83 80 45 50 45 45 75 55
Role limitation due to
physical health 0 100 50 25 25 100 25 0
Role limitation due to
emotional health 100 100 100 100 100 100 25 0
Energy/fatigue 40 55 60 75 55 70 70 35
Emotional well-being 92 84 84 84 92 76 80 68
Social functioning 100 100 100 100 100 87.5 75 85
Pain 70 57.7 47.5 60 35 80 57.5 35
General health 100 80 90 100 70 75 80 75

does. Our experience would suggest that the first
of these two explanations is most likely.
Overall, we believe that despite fairly static
scores, our patient and surgeons agree that his
outcome has been generally positive. Further-
more, his function in activities such as recreation
may supersede the limited information gained
from the multiple scales. We believe that the
combination of these multiple scales is useful to
inform the gross aspects of recovery; however, in
Table 5.  Milestones at Different Follow-Up Time
Points in a Patient with Bilateral Hand Transplant
(Adapted from Occupational Therapist Notes)
3 Months Improved ability to feed himself with the
(right) hand using a wrist splint and built-up
utensils, able to don his shirt on and off
using environmental assist. Able to sweep
the floor but unable to use the dustpan.
6 Months Able to do all self-care independently and
most ADLs without devices and with mini-
mal to moderate assistance, able to unlock
his (right) lower extremity prosthesis with
his fingers, able to open a bottle of pain
medication.
9 Months Back to driving, doing some yard work, swim-
ming, and playing catch with his grandchil-
dren. Able to work at computer making
cards and managing e-mails. Also able to
sign his name (somewhat legibly) with the
(right) hand without a device. Completed
nine-hole PEG test with left hand.
1 Year Continued to be independent with his own
care except for showers because of safety
issues as a bilateral below-knee amputee.
Also tried bowling.
2 Years Able to write his name with both hands with-
out a device in an adapted fashion. First doc-
umented pinch test (2 lbs) with left hand.
Reports being happy with the transplant and
able to most of his ADLs.
2.5 Years Improved dexterity with speed and accuracy
of movements. Improved sensation with left
hand. Continues to be independent with his
daily activities.
3 Years Continues to be independent with no signifi-
cant changes.
3.5 Years Able to drive, swim, play Frisbee, play chords
on the piano, use computer, do most ADLs.
ADLs, activities of daily living.
time, we anticipate that a more comprehensive
scoring system will be produced. Our develop-
ment of various milestones has been a useful way
to objectify the recovery, and we expect that this
may help future patients. We concurrently col-
lected psychosocial data and present this correla-
tion separately.
CONCLUSIONS
Multiple functional outcome measures pro-
vide an objective way to follow the patients who
undergo hand transplantation. However, our
experience suggests that patients may be quite
functional and relatively independent even
without significant changes in their scores. This
should be kept in mind when interpreting these
metrics.
Simon G. Talbot, M.D.
Department of Plastic Surgery
Brigham and Women’s Hospital
Harvard Medical School
75 Francis Street
Boston, Mass. 02115
sgtalbot@partners.org
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 Volume 137, Number 1 • Bilateral Hand Transplantation Outcomes
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