Gabl Markus, Blauth M, Lutz M, Zimmermann R, Angermann P, Arora R, Piza-Katzer H, Hussl H, Ninkovic M, Ninkovic M, Schneeberger S, Margreiter R
Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Unfallchirurgie und Sporttraumatologie, Innsbruck, Osterreich.
Handchir Mikrochir Plast Chir. 2009 Aug;41(4):224-9. doi: 10.1055/s-0029-1234049. Epub 2009 Aug 17.
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.
对一名双侧前臂移植患者的上肢运动功能改善情况进行了研究。
2003年，一名41岁男性患者因电击伤导致双侧前臂近端截肢后接受了双侧同种异体移植。缺失和功能不足的肌肉用供体肌肉单位进行了替代。为防止移植失败时使用肌假体，在受体处保留了肱桡肌（BR）、桡侧腕长伸肌（ECRL）、桡侧腕短伸肌（ECRB）和尺侧腕伸肌（ECU）的残端。采用3.5毫米动力加压钢板（DCP）固定前臂骨骼，未进行骨移植。供体的旋前圆肌（PT）、桡侧腕屈肌（FCR）、指浅屈肌（FDS）、掌长肌（PL）固定于肱骨内上髁，尺侧腕伸肌（ECU）和指伸肌（EDC）固定于尺骨骨膜。供体的尺侧腕屈肌（FCU）、肱桡肌（BR）、桡侧腕长伸肌（ECRL）、桡侧腕短伸肌（ECRB）缝合至受体肌肉的相应筋膜。对于运动功能，将正中神经的神经肌接口（NIA）、神经植入点（NIP）以及支配旋前圆肌（PT）、桡侧腕屈肌（FCR）、指浅屈肌（FDS）、掌长肌（PL）的运动支进行了吻合。尺神经在支配尺侧腕屈肌（FCU）的运动支远端进行了吻合。诱导治疗后，目前的免疫抑制方案（IS）包括他克莫司（谷浓度8纳克/毫升）、依维莫司（谷浓度6纳克/毫升）和泼尼松（5毫克/天）。
在6年1个月的随访时，两个移植肢体均存活。在最初3年中，发生了移植排斥反应、机会性感染和短暂性代谢紊乱，通过全身和局部用药以及调整免疫抑制方案均成功治愈。骨愈合情况正常。上肢的总主动活动度（TRM）从术前的32.7%提高到正常水平的74.6%，腕关节活动度/前臂旋转增加了8.7%，手指活动度增加了33%和2%。深层屈肌、伸肌和固有肌的肌力为中度（M4/5），这被认为是由于神经再支配距离长、术前存在神经电损伤以及反复发生排斥反应所致。
上肢的活动范围主要通过外在肌功能得到改善。肌肉力量和握力为中度。患者称以下方面最为有益：活动范围改善、无需视觉控制即可完成任务、每天24小时都能活动以及产生了新的身体完整感。
