It was a simple game of catch.

Except that there was nothing simple about it, thanks to the two men who were involved.

On one end was Joshua Maloney, the 25-year-old Marine veteran from Bethel Park who became the first recipient of a hand transplant at UPMC last March. On the other was Jeff Kepner, a 57-year-old Air Force veteran, who became the nation's first double hand transplant recipient at UPMC in May.

They were sitting a couple feet from each other in an occupational therapy room earlier this month, tossing a miniature basketball back and forth with their new hands.

To be accurate about it, Mr. Maloney was tossing the ball with his transplanted hand, and Mr. Kepner was batting it back with the back of one of his hands, because he doesn't yet have full control over his fingers and thumbs.

When it comes to hand transplants, nerve regrowth is everything. The recipient gets every other type of tissue from a donor -- muscles, tendons, blood vessels, skin -- but the donor nerves are gone, and the patient's own nerves must grow from his arms into the new hands.

The nerves grow about one inch per month, so a patient's comeback is inextricably linked to where his amputation is situated.

Mr. Maloney's amputation -- his right hand was blown off in a military training accident in 2007 -- was much closer to his wrist than Mr. Kepner's amputations, and that, combined with his youth, has made the Bethel Park resident's recovery quicker.

Six months after his surgery, he has progressed even faster than his doctors expected, and he has regained some sensitivity and motion in all his transplanted fingers and thumb.

"Here, try me," he said in the therapy room. Closing his eyes, he held out his transplanted hand and then identified each digit as it was randomly touched.

Mr. Kepner lost both arms and legs to a severe bacterial infection 10 years ago, and had lived since then with prosthetic hooks on his arms and titanium rod prosthetics on his lower legs. His arm amputations were a few inches below the elbow, so his nerves have a longer route to travel to activate his new hands.

At this point, he can slightly clench his fingers and thumb, but doesn't have a lot of individual control over the digits. He has feeling down to about mid-forearm, he said, and while the exterior of his hands is numb, he can sometimes feel tingling inside when his hands are touched or stroked.

Despite the lack of sensation, he has felt from the beginning that the donor's hands and forearms are his own.

"I'm not the kind of person to say, 'Ooh, those aren't mine.' From the beginning, I thought, 'These look pretty darn good.' He was hairier than I was, but I felt like they've always been on my arms. I'm tickled with the results of that."

He also understands he has a long road ahead of him. In some ways, he said, it was easier to adjust to his original amputations than to the double transplant.

With the amputations, "they were just taking off and sewing up. I did have to learn how to roll over and sit up and do all that stuff again, but with this, the amount of time it's going to take to get just the slightest movement ... I'm waiting for that finger and thumb pinch, and it's going to take a year to get that back."

Complicating matters is the fact that he had to learn how to walk again.

When he began physical therapy about six weeks after his May 4 operation, Mr. Kepner was so "deconditioned" that he would get lightheaded just sitting up in bed, said Michael Munin, medical director of UPMC Montefiore's Institute for Rehabilitation and Research.

In addition, the nerves in his right leg were injured when a catheter was inserted in his thigh during his transplant operation, he said, and that had made the right leg much slower to recover.

Today, he is able to get into a standing position on his prosthetic legs pretty easily, and spends about 15 minutes walking, three times a week, in physical therapy, using a specially adapted walker with armrests.

That is now part of a regimen that includes five hours of occupational therapy on his hands each day, led by Kim Zeske-Maguire, a certified hand therapist at UPMC Montefiore.

On one day this month, she led him through a series of exercises designed to train his brain and hands to grasp, release, rotate and position.

He stacked and unstacked small plastic cones. He picked up soft foam shapes and put them in a container. He bounced the mini-basketball and caught it. He stacked Legos. He tossed Ms. Zeske-Maguire a small football as she apologized that it wasn't in Steelers colors.

And always, there was banter between the cheerfully determined Ms. Zeske-Maguire and her droll, low-key patient.

Mr. Kepner, who was a fast-pitch softball star in the Air Force, said his athletic ability probably helped in bouncing and catching the ball, even though he didn't have much feeling in his hands.

"I think it does help with my eye-hand coordination," he said in mid-bounce, " 'cause if Kim were to try this, she probably couldn't do this at all."

"Oh you are so ... Will you please quote me that I am verbally abused every day," she said with mock exasperation.

His progress is slow and steady -- sometimes so slow he can hardly notice it, even though his visitors often are amazed at how far he has come.

"I liken it to when your children are growing up and someone says, 'Look how much they've grown' but you don't see it because you're with them every day."

He also has become used to the bulging rings of flesh around his incision sites -- "I call it my ham hock." Most of that is fluid that eventually will be absorbed by other parts of his body, but some of it will remain, said his chief surgeon, Dr. W.P. Andrew Lee.

With hand transplants, surgeons have the luxury of using as much of the donor's appendages as they want. To make the attachments more secure, Dr. Lee's team overlapped the tendons and muscles of the donor's hands and arms with Mr. Kepner's.

Neither Mr. Kepner nor Mr. Maloney has suffered any serious rejection incidents, in which their bodies react against the foreign tissue, Dr. Lee said.

Mr. Maloney had a minor rejection episode about six weeks after his operation that showed up as a skin rash and was treated with a topical immunosuppressive cream.

That has been reassuring to Dr. Lee, who helped develop a medication regimen called the Pittsburgh Protocol that is designed to minimize the amount of anti-rejection drugs patients must take.

"While it's still too early to call the protocol a success, we're very encouraged so far."

The two men also share one other basic sign of success -- the fingernails on their transplanted hands are growing steadily, and one of their doctors is actually assigned to give them occasional manicures, to avoid clipping any cuticles and causing an infection.

Now that he is walking, Mr. Kepner said his main goal is to get himself ready to go home to Augusta, Ga., by the end of this month.

Will there be a big party?

"I'm sure they'd like that," he said, but because his medications dampen his immune system, "I'm not allowed to be around large groups of people."

Among other things, that means he won't be able to attend church services at Burns Memorial United Methodist Church in his hometown for three or four months, even though "I'm anxious to get back to church because we've had so much support from the people there."

When he leaves, his wife Valarie, who has been by his side since the day he arrived, will go with him, and he will finally get to see his daughter, Jordan, an eighth-grader, each day.

Mrs. Kepner is the real reason he has his hands, he said.

"She wanted me to have my independence more than I think I did. It took a lot of convincing for me to actually decide to do this, but she was right."

He will be able to shower on his own, to cook again, to change a light bulb. He will be able, simply, to make contact.

"Obviously, it's going to be great. I'll be able to reach out and touch and hug. I'm anxious to touch my daughter's face and interact in that way. That'll be a big deal."

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