Current long-term graft survival among patients in Europe and the United States is better than 94 % [22]. Immune-mediated rejection has been the primary cause of graft loss [23]. The first case of graft loss occurred in 1998 in Lyon, France, with the first unilateral hand transplant patient; pathologic specimens of the rejected hand showed evidence of lichenoid-like lesions, which can also be seen in cases of graft versus host disease [22, 23]. Rejection occurred after the patient stopped taking his immunosuppression medications. The only case of graft loss in a US patient was the result of ischemia caused by fibro-intimal hyperplasia. Fibro-intimal hyperplasia is thought to be a form of chronic rejection similar to that which has been described in heart transplant recipients [24].

Functional outcomes have been very encouraging, with all patients recovering protective sensibility, 90 % recovering tactile sensibility, and 82.3 % recovering discriminative sensibility [22]. Muscle recovery begins with the extrinsic flexor and extensor groups, allowing some patients to perform grasp-and-pinch activities shortly after transplantation. The recovery of intrinsic muscles can take up to 15 months. Recovery of intrinsic muscle function has been confirmed by electromyographic studies in several hands [12, 25]. Extrinsic and intrinsic muscle function has allowed patients to perform most daily activities, including eating, driving, grasping objects, riding a bicycle or motorbike, shaving, using the telephone, and writing [3]. In addition, functional MRI has demonstrated that after transplantation, hand representation is regained within the sensory and motor cortex of the brain [26, 27].

A unique phenomenon occurs after upper extremity transplantation in which portions of the recipient’s brain are reassigned to control the limb. This plasticity of cortical organization has been demonstrated to occur after amputation as well as after limb transplantation [26]. After a hand is amputated, the area of the brain that was receiving signals from the hand is gradually lost and is taken over by other functions. However, after an upper extremity transplant, that area of the brain can reestablish its original function, and the signals from the new hand go back to the area of the brain that was used to control the original hand [28].

The progressive increase in worldwide hand transplantation will lead to common rehabilitation protocols and data collection. That being said, it is important to remember that every patient will require his or her own unique treatment plan. Therapy guidelines should consider the level of transplantation, bilateral versus unilateral, and any lower extremity issues. Ultimately a successful hand transplant is dependent on the involvement of an occupational therapist, during candidate selection and postoperatively.