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A functioning hand

An injured Marine is just the sixth person in the U.S. to get a hand transplant. Rejection risk and ethical concerns still make it a touchy issue.

Joshua Maloney, 24, of Bethel Park, Pa., who received a hand transplant in March at the University of Pittsburgh Medical Center, relaxed with girlfriend Erin Maxa after a news conference last week. Maloney lost his right hand two years ago in a training accident at the Quantico, Va., Marine Corps base.
Joshua Maloney, 24, of Bethel Park, Pa., who received a hand transplant in March at the University of Pittsburgh Medical Center, relaxed with girlfriend Erin Maxa after a news conference last week. Maloney lost his right hand two years ago in a training accident at the Quantico, Va., Marine Corps base.Read more

Joshua Maloney says he served two tours of duty in Iraq as a Marine combat engineer and "never even caught a cold."

Then, while setting up a training exercise at the Marine Corps base in Quantico, Va., on Jan. 31, 2007, the Bethel Park, Pa., native was holding a quarter-stick of TNT in his right hand when it accidentally exploded.

That led him last month to become the first patient ever to receive a hand transplant at the University of Pittsburgh Medical Center (UPMC), and only the sixth to get one in the United States.

At a news conference in Pittsburgh last week, Maloney's doctors said he had shown no signs of rejection since his surgery about three weeks ago and was making good early progress.

Still, the experimental procedure cost more than $250,000, paid by research funds. The surgery also raises ethical questions about whether Maloney and similar patients would be better off using a prosthetic than enduring the lifetime of care that transplant recipients may need.

The transplanted hand came from an 18-year-old West Virginia man who died of head trauma, said Susan Stuart, chief executive officer of the Center for Organ Recovery & Education, an organ procurement group. The man's family also donated his liver, kidneys, and some tissue.

With his right arm in a sling and his new hand in a flexible splint, Maloney said he had thought a lot about his donor.

"Honestly, I'm going to be 25 years old this month, and it's terrible that somebody 18 years old is dead. But he was a good enough person to be willing to donate and help other people. I feel for his mother. I say my prayers and I thank God for him and ask God to watch over his mother. What else can you do?"

Maloney can wiggle his new fingers slightly, but has no sensation in the hand, and won't for months to come, said his chief transplant surgeon, W.P. Andrew Lee.

Even though the bones, tendons, blood vessels, and major nerves of the new hand have been connected to Maloney's arm, the internal nerves that will control movement still have to extend into the new tissue, and they grow at a rate of about one inch per month, Lee said.

There have been about 40 hand transplants around the world. In the United States, the other five were done over the last decade at the University of Louisville. These included Matthew Scott of South Jersey, in 1999 the nation's first hand transplant patient, who this winter marked his 10th anniversary. Scott has been supportive of his surgery over the years. He could not be reached for comment late last week.

The lead transplant surgeon in Louisville, Warren Breidenbach, said last week that his team had shown it was possible to transplant functional hands to people who had lost theirs in traumatic accidents, and to keep their bodies from rejecting the new tissue.

Breidenbach and Lee said the real challenge today in hand transplants is not the surgical techniques needed to attach the limbs, but minimizing the amount of anti-rejection medication patients must take. Anti-rejection drugs suppress the immune system, which can make a transplant patient vulnerable to infections or cancer.

UPMC's new "Pittsburgh protocol" starts by giving transplant patients a dose of a drug called Campath, which suppresses the patient's immune system, and then, within the first two weeks, infusing some of the donor's bone marrow into the recipient.

The hope is that when the patient's immune system rebounds from the Campath, it will recognize the new bone marrow cells as its own and won't attack the tissue of the transplanted hand.

"I think there's clearly a chance of weaning Joshua off immunosuppressants altogether in the future," Lee said.

Some bioethicists have questioned the risks of surgery and immunosuppression for transplants that are not life-saving.

Lee noted that it was "the concern about the risk-benefit balance that held us back for many years, because this is a quality-of-life transplant, and it is only now, when we are optimistic we can reduce the amount of medication the patient must take, that we decided to start this program."

UPMC has three more candidates waiting for hand transplants, two of whom would be double hand transplant recipients.

The key to the timing of any future transplants, he said, is finding donors who have the right tissue type, skin tone, gender, and size to match the recipient.

As he waits for sensation and fine muscle control to develop in his new hand, Maloney is undergoing occupational therapy.

In the two years since his accident, he had begun using his left hand much more, said therapist Kim Zeske-Maguire, so now his brain has to be retrained to shift control back to the right hand.

Maloney wanted the operation because his experience with two types of prosthetics - a mechanical hook prosthetic and a more lifelike one controlled by nerve impulses from his arm - was frustrating. Or, as he put it, "I never used them because I found them to be a pain in the butt."

Lee said that was not atypical. Nearly 40 percent of all hand and arm amputees never use prosthetics, particularly men in their 20s and 30s.

"The prostheses become more of a burden than not," added hand surgeon Joseph Imbriglia, "and the reason is that they have no sensation."

Still, John Lantos, a bioethicist at the University of Chicago, questions whether hand transplants are better than modern prosthetics, given the risks of surgery and lifelong medications.

What is needed, he said, is a controlled study comparing hand transplant recipients and prosthetics users on various tasks and quality-of-life measurements.

"You could look at such things as, can they pick up a penny, can they hold a pencil, can they eat with a spoon or play a piano - you can imagine hundreds of things you could measure with the two groups where you could say in these domains transplant patients are doing as well, or worse or better. And then you'd have the possibility for truly informed procedures."

No other option appealed to Maloney.

Getting a hand transplant, he said, means "I get my life back. It's going to take some work, but I thought I would be limited after I got hurt, and now I won't be."

To see video

of the surgery and interviews with patient and doctor,

go to: http:// go.philly.com/

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