World's first transplant of both arms
13 August 2008
The Klinikum rechts der Isar of the Technical University of Munich
has successfully completed the world's first transplant of complete
arms. The 15-hour operation was performed by a team of 40 people headed
by PD Dr Christoph Höhnke and Prof Edgar Biemer.
The patient is a 54 year old farmer who lost both his arms at upper
arm level during an accident six years ago. He had to heavily rely on
help and had had two unsuccessful attempts at using artificial limbs.
He therefore approached the Clinic for Plastic Surgery and Surgery at
the “Klinikum rechts der Isar” for help. He thus came into contact with
a team of physicians with the ideal prerequisites for the operation:
apart from a decade-long tradition in microsurgery and replantation
surgery, the employees of the Clinic also have long-standing experience
in interdisciplinary surgical preparation and planning — indispensable
for such complex surgery.
The physicians of the Clinic for Plastic Surgery now had to initially
clarify whether the future patient was physically and psychologically
suitable for the difficult surgical procedure. The man was given a
complete medical exam, for in order to be prepared for the suppression
of the immune defence system required after transplantation, he had to
be perfectly healthy. The patient also has to have a stable personality
and a stable social environment.
The last phase of operative preparation was an explorative operation
on the upper arm stump, during which the physicians tested to see where
and how they would be able to seal off nerves and vessels during
transplant. During this procedure they ascertained that the main artery
in the left shoulder was occluded; this would thus require several
Then it was solely a matter of waiting for a suitable donor, matching
the host in sex, age, skin colour, size and blood group and having no
injuries to the upper extremities.
The operation was started on the evening of the 25th July, around 10
pm: five teams started simultaneously in two operating theatres — one
group each on the left and right side of the donor and host and an
additional team removing a leg artery from the donor. First they had to
expose each of the muscle ends, nerves and the vessels and prepare them
Before the donor's bones were severed, the blood vessels in the arms
were filled with cooled preservation solution (perfusion). Both arms
were then removed in such a way, that they accurately corresponded to
the patient's arm length. Then both surgical teams connected the new
body parts to the body of the host on both sides in a step-by-step
First they joined the bones together with an 8-hole plate. They then
connected the arteries and veins in order to recreate circulation of the
transplanted arms as quickly as possible. The left side had already been
prepared with three venous bypasses.
Before completion of the anastomoses, the arms were rinsed with a
special liquid to remove the preservation solution. Then the blood was
released at intervals of 20 minutes; because from an anaesthetic point
of view it must be ensured that the patient does not suffer acute damage
from the blood flowing back from the transplants.
Figure 1. Diagram showing the arteries (red), veins (blue), nerves
(yellow) muscles and the bone plate used to join the arms.
The arms quickly took on their rosy colour and there was no
significant swelling — proof for a well-functioning circulation and a
short ischemia period (lack of tissue circulation).
The surgeons then
sewed the muscle and tendon strands back together and finally
reconnected all the nerves (nervus musculocutaneus, nervus radialis,
nervus ulnaris and nervus medianus).
Next the skin could be sewn back together. Finally, a cross-joint
fixateur externe was attached with pins to the lower and upper arm. This
allows the arms to be suspended to avoid pressure marks. The operation
was successfully concluded after 15 hours.
Current situation and further care
Not only the operation itself but also the first days afterwards
continued optimally for the patient. His condition was very good under
the circumstances. Now it is a matter of avoiding future wound healing
disorders, infections, strong side effects caused by the drugs and, in
particular, any rejective reaction (see below). Quite a number of
measures were taken to this effect: close monitoring, antibiotic
prophylaxis, drug monitoring and immuno-monitoring. To avoid
degeneration of the muscles, these are regularly stimulated with
physiotherapy, among others. The patient is also given psychological
Worldwide, not many hands and lower arms have been transplanted to
date. The transplantation, performed in Munich, represents an even
greater challenge: it also encompassed the elbow joint as well as the
upper arm, signifying significantly larger regeneration areas and a more
difficult immunological situation.
Allogenic upper arm transplant: an immunological challenge
In contrast to the transplant of solid organs (liver, kidney,
pancreas, etc.), an extremity histologically represents heterogeneous
tissue, consisting of various components with varying immunogeneity.
From an immunological point of view, the focus is on
- the skin, containing cells with high immunogeneity; and
- bone marrow, which is also transferred within the scope of an
upper arm transplant.
The highly immogeneous cells of the skin lead to a strong immuno-reaction
in the host. During an upper arm transplant, approximately 20% of the
body's entire skin surface is transplanted. At least initially, this
requires a strong immunosuppressive therapy with all the possible side
effects, eg infections.
Furthermore, the skin lacks a simple lab-chemical parameter (such as
creatinine during a kidney transplant) to enable the recognition of an
immunological reaction in the host. The diagnosis of an immunological
defence reaction is thus based on the clinical assessment of the skin,
regular skin biopsies and different immunological tests. This type of
monitoring is far more complex than after transplantation of solid
The hollow bones in the upper arm contain large volumes of bone
marrow (in contrast to a hand transplant, during which hardly any bone
marrow is transplanted). Bone marrow consists of immuno-competent cells,
which could trigger a so-called graft-versus-host-reaction (GvHD).
This means that these cells are able to attack the host. Such an
attack denotes a life-threatening situation for the host. The extent of
the risk after an upper arm transplant is difficult to assess, as it has
been shown that preclinical data cannot be directly transferred to the
human situation. This also requires different immunological examinations
in order to recognise and treat the occurrence of such a reaction at an
In principle, upper arm transplantation combines the immunological
problems of bone marrow transplantation with those of solid organ
transplantation. In the long run, this is joined by possible side effect
caused by immuno-depressors.
From a transplantation surgeon's point of view, upper arm
transplantation thus represents an interesting challenge, which also
offers the opportunity of making a contribution to understanding
immunological processes after transplantation.