There’s a video on Luka Krizanac’s phone that captures him making coffee at home on an espresso machine. It’s the type of video anyone might take to show off a new gadget to friends or recommend a favorite bag of beans. But the normalcy is exactly what makes it extraordinary for Krizanac – because just a few months ago, he didn’t have hands.
Krizanac lost parts of his arms and legs at age 12 after a mismanaged infection led to sepsis and severe complications that required amputation. Last fall, nearly 17 years later, he received a double hand transplant at Penn Medicine.
Hand transplants are rare: Only 148 had been performed worldwide as of mid-2023, according to one study, and not all were double transplants.
More than 20 people were involved in Krizanac’s surgery, which lasted about 12 hours and followed years of practice.
As the anesthesia was wearing off, Krizanac turned to one of the nurses at his bedside and said, “Look how beautiful my hands are.”
He doesn’t remember that moment – it was later recounted to him by the nurse – but the profound sentiment remains.
“I don’t mean that just in an aesthetic way, but just a deep feeling of being whole again as a human,” he said.
A desire for independence
For Krizanac, living without hands was more challenging than living without legs. Hands are required for thousands of essential everyday things, and the prosthetics he had simply couldn’t fill the need as well as the prosthetics he had for his legs, he said.
“I don’t think the question is even, ‘What can’t you do?’ It’s ‘How can you live?’ ” he said. “With your legs, you walk. With your hands, you do thousands of things, from eating, taking care of yourself, to cooking, to expressing yourself. So trying to compensate for lack of arms with a plastic robotic hand is just impossible.”
The childhood he knew before ceased to exist, and he was confronted with a loss of independence, relying heavily on the strong support of loving family and friends.
“As you grow up, you want more independence. Naturally, as humans, we should be independent once we grow up,” Krizanac said. “I was not able to achieve that due to lack of working hands. So that need increased, definitely, over time.”
Making connections
Krizanac was adamant about not letting his disability define him and maintained a positive outlook by trying to live in the present, but he and his family continued to search for ways to help improve his quality of life.
They pursued hand transplantation for years, but numerous obstacles – including insurance coverage and a lack of access to skilled providers – stalled progress.
“I knew that the solution existed for my problem, and the question was how to reach that solution,” Krizanac said.
In 2018, about a decade after he lost his hands, a series of fortuitous connections brought Krizanac from his home in Switzerland to Dr. L. Scott Levin’s office in Philadelphia.
Levin, chair emeritus of the Department of Orthopaedic Surgery and professor of plastic surgery at Penn Medicine, was immediately impressed by Krizanac’s poise, and he quickly endeared himself to the full team.
“For a variety of reasons, he was a superb candidate for hand transplant,” Levin said. “He fulfilled every characteristic: intelligent, informed, incredible family support.”
But another set of challenges – including a global pandemic and wounds that had developed on Krizanac’s legs – delayed the process even further.
“During the pandemic, we had to put things on hold,” Levin said. “And for the reason that he had open wounds and skin breakdown [on his legs], he would have never been allowed to have his hand transplant, because the open wounds and the risk of infection … would have prevented us from proceeding.”
But Levin and a colleague flew out to Switzerland to treat his legs, diving into preparations for the hand transplant once back in Philadelphia while Krizanac healed.
Preparing for a double hand transplant generally takes about two years, barring other complications. But by late 2024, Levin and his team were ready. They had completed more than dozen rehearsal sessions, mapping out the intricate steps needed to blend nerves, muscles, blood vessels and bones.
Krizanac moved to Philadelphia and did his best to enjoy his stay while anxiously awaiting an update.
The call came on a rainy Sunday afternoon about two months later: There was a match. The Gift of Life, an organ donation program, had found donor hands from a person who had the right skin tone, size and gender – a unique set of considerations hat can make the match process more complex than some others.
In a matter of minutes, Krizanac was packing up and heading over to the hospital, and he was in his room within an hour.
“When you decided something is right for you over the years and you are determined to work towards this goal, once you get the green light, there is no thinking,” Krizanac said. “I did not have any reservations about the procedure. I was fully confident that after 17 years, I knew what was right for me.”
A well-orchestrated team – including plastic surgery, orthopedic surgery, transplant specialists, anesthesia and nursing – worked concurrently on Krizanac and the donor.
After blood vessels were sutured together, circulation was monitored with various devices. Nerves take time to regenerate, so it was impossible to know in the operating room whether that part of the operation had been successful.
“We count on the nerves to regenerate, but that’s not assured. All we can do is technically do the best coaptation, the best nerve repair we can do day of injury with incredible precision using the operating microscope,” Levin said. “With a little luck, if you will, and careful planning and execution of the operation, the nerves from the donor will grow into the muscles.”
Quality of life is essential
Today, Krizanac is healing exceptionally well, Levin said. Nerves will continue to grow into his arms, and his recovery will continue to evolve over the next few years.
“The sensation, the ability to feel, improves. His strength gets more. He starts to get back the fine muscles in the hand,” Levin said. “He’s well on his way. Of all the transplant patients we’ve seen, his neural recovery has been the most accelerated.”
In addition to three or four physical therapy sessions each week, Krizanac is taking a few medications to help keep his body from rejecting the hands – a regimen similar to that of someone who had a kidney transplant. One of the medications, a calcineurin inhibitor called tacrolimus, has also been found to help with nerve regeneration.
Krizanac feels that he’s on a path toward regaining independence, too. About a month after his surgery, he was using his phone with his new hands. And while washing his hands a few months later, he was surprised when the feeling of cold water made him jump back.
“I reflexively pulled back from the cold water. And this was really an a-ha moment where I thought, ‘Oh, my God, I feel the temperature of the water,’” he said.
Hand transplantation is considered an elective “quality of life” procedure, but Levin says there’s an obligation for the medical field to provide the same level of care and consideration for patients like Krizanac as there would be for someone who needed a liver transplant – as long as they are properly prepared and informed.
“This is a field of transplantation that must continue to be supported. Our research, our clinical care, our education,” he said. “For this field to be thwarted by the inability for insurance to pay for this or other agencies to accept it – for specific patients – that would be really a crime.”
Krizanac has ambitious goals for himself that are starting to feel more real, like hopefully getting a driver’s license. Really, he just wants to be a regular adult guy.
“Even though everything is recovering, even though this process is highly complex in terms of surgery and rehabilitation, these are two healthy hands, and it’s just a question of time and commitment until that is regained,” he said.
For now, smaller things bring him great joy. He recorded the video of himself making espresso because he’s honing his skills as an amateur barista – a hobby that he wouldn’t have been able to pursue without his hand transplant.
“I’m more of a cappuccino guy, but he can make me espresso anytime he wants,” Levin said.