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challenging. Multiple authors cite inconsistencies in the metrics used, variations in the anatomic level at
which transplantation is performed, and the proposed theory that a recipient will only attain maximum
function after years of post-transplant therapy and rehabilitation [48,49,55] . Furthermore, the standards that
define an acceptable functional outcome inevitably differ between unilateral and bilateral transplant
recipients. The concept of bilateral hand transplantation is fairly widely accepted as an indication, given the
disabling nature of bilateral hand/arm loss. However, the morbidity of immunosuppression, substantial
economic burden associated with VCA, and ever-improving prosthetic technology raise questions about the
[56]
practice of unilateral hand transplants . Nonetheless, the evidence suggests that following unilateral or
bilateral hand transplantation, most patients attain a reasonable degree of sensation and strength, have
DASH (Disabilities of the Arm, Shoulder and Hand) scores indicating an ability to perform most activities
of daily living, and demonstrate continued improvement with increasing time since transplant [49,57] .

CONCLUSION
Despite the ever-evolving sophistication of the methods used for hand and upper extremity reconstruction,
the devastating sequelae of mutilating injuries and amputations continue to pose substantial challenges. The
past few decades have seen remarkable refinements in the ways surgeons are able to restore form and
function using techniques such as FFMT and VCA. At the same time, advances in prosthetic technology
paired with the leveraging of peripheral nerves through TMR offer the promise of meaningful functional
outcomes for those in whom limb salvage or transplantation is not a viable option. In summary, these
techniques represent the pillars of the new era of upper extremity reconstructive surgery.

DECLARATIONS
Authors’ contributions
Manuscript writing and editing: Bekisz J, Hacquebord JH

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Both authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2022.

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