Introduction: Although arm transplantation was proposed as a therapeutic option in arm amputees, only 14 cases were reported.

Objectives: A double arm transplantation including reconstruction of the left shoulder was performed on January 13, 2021 in Lyon (France). We report the results one year after the transplantation.

Materials and Methods: The recipient was a 48-years old patient with bilateral amputation at proximal arm level after electric shock in January 1998, who underwent liver transplantation in 2002. He received the grafts from a deceased 35-year old male donor. In the recipient on the right side donor humerus was fixed on the remaining 9 cm-long proximal stump, which was reinforced with the donor fibula in an intra-medullary fashion. On the left side the whole donor humerus including the humeral head was transplanted, with reconstruction of the gleno-humeral joint capsule by performing a suspension ligamentoplasty.  On the right side the anastomoses were performed between donor and recipient axillary arteries and veins; on the left side the arterial anastomoses were performed between donor and recipient subclavian arteries and the venous anastomosis between donor subclavian vein and recipient jugular vein; Nervous repair was at the proximal nerve level on the right side and at level of the brachial plexus trunks on the left side. Both deltoid muscles were transplanted: on the right side it was used to assure skin vascularization; on the left side the recipient deltoid muscle was reinserted and the donor one was reported posteriorly with its innervation. Cold ischemia time was 101 minutes on the right side and 133 minutes on the left side. Continuous hemodialysis was performed during the surgical procedure to reduce reperfusion-induced ischemic disorders after revascularization. The immunosuppressive protocol included antithymocyte globulins and tacrolimus, steroids and mycophenolate mofetil. An intensive rehabilitation program was initiated since the first post-operative day.

Results: In the first post-operative period partial thrombosis of the venous bypass occurred and an anticoagulant treatment was started with consequent hematoma in the left pectoralis, which was successfully treated with percutaneous drainage.
A specific antibiotic therapy was given against Propionibacterium acnes, evidenced in the biopsies performed on the recipient’s bones during the transplantation.
Twenty days after transplantation the patient developed a Banff grade 2 acute rejection episode on both arms, which disappeared after IV steroids and clobetasol and tacrolimus creams. The patient suffered neuropathic pain at level of the grafted upper extremities.
Twelve months after the procedure, the patient is well and very satisfied. His ability in daily life activities is already equivalent to that with the prostheses.

Conclusions: This case seems to confirm that bilateral arm transplantation represents a treatment option in bilateral amputees.