EDITORIAL CHRONIC REJECTION, HAND TRANSPLANTATION, AND THE MONKEY'S PAW
This year, at a combined session of the American Asso- ciation of Hand Surgery, the American Society of Reconstructive Microsurgery, and the American Society of Peripheral Nerve, a panel reviewed composite-tissue transplantation in general, and clinical hand transplantation in specific detail. 1 The panel presented data on the ongoing problems with immunosuppression in patients with hand transplants. Further discussion reviewed the phenomenon of chronic rejection in transplanted hands. One panelist noted that acute rejection episodes in organ transplants predictably herald the eventual onset of chronic rejection and transplant failure. In transplanted hands, chronic rejection may become most evident in the skin, leading to dermal fibrosis and dyskeratosis. 2 As reported by this panel, all known clinical hand transplants have had multiple episodes of acute rejection, and chronic rejection can be anticipated. While the course of chronic rejection on bones, joints, nerves, and vessels may have yet undescribed implications, the progressive skin destruction can be expected to result in chronic wounds, contractures, and digit infarctions. This first group of hand transplants may eventually be remembered as a model of scleroderma. 3 Several commentators raised concerns about chronic rejection early on in the debate about the current practice of hand transplantation. 4,5 More concretely, earlier primate models of hand transplantation repeatedly demonstrated progressive skin damage with chronic rejection. [6][7][8][9][10] The prophetic position of those primate transplants reminded me of an old short story, ''The Monkey's Paw,'' by W.W. Jacobs. 11 The story takes place in a cottage inhabited by an elderly husband and wife and their grown son, who