[Musculosceletal reconstruction in bilateral forearm transplantation]

Improvement of motor function of the upper extremity was investigated in a patient following bilateral forearm transplantation.

Following an electric shock injury with amputation of both forearms at the proximal level a bilateral allotransplantation was performed 2003 in a 41-year-old male patient. Missing and insufficient muscles were replaced by donor units. For use of myoprothesis in case of transplant failure remnants of BR, ECRL, ECRB and ECU remained at the recipient. 3.5 mm DCP plating was used without bone grafting to stabilize the forearm bones. PT, FCR, FDS, PL of the donor was fixed to the medial epicondyle of the humerus, ECU and EDC to the periosteum of the ulna. FCU, BR, ECRL; ECRB of the donor were sutured to the corresponding fascia of the recipient muscles. For motor function NIA; NIP and the motor branches of the median nerve for PT, FCR, FDS, PL were coapted. The ulnar nerve was coapted distally to the motor branch for the FCU. Following induction therapy today IS consist of tacrolimus (trough level 8 ng/ml), everolimus (trough level 6 ng/ml) und Prednisone (5 mg/day).

Both grafts are vital at FU of 6 years and 1 month. During the first 3 years episodes of graft rejection, opportunistic infection and transient metabolic disorder occurred which could be treated successfully by systemic, topical agents and change of IS. Bone healing appeared normal. TRM of the upper extremity improved from 32.7% before surgery to 74.6% of normal, with gain of wrist motion/forearm rotation of 8.7% and finger motion of 33, and 2%. The moderate muscle power (M4/5) of the deep flexors, the extensors and the intrinsic muscles is considered to be due to the long distance of reinnervation, a pre-existing electric damage to the nerv and repeated rejection episodes.

Range of motion of the upper extremity improved primarily by extrinsic muscle function. Muscle strength and grip are moderate. The patient described the following to be most beneficial: the better range of motion, the possibility to perform tasks without visual control, the availability of his range of motion 24 h a day and a new sense of body integrity.