The Hand--October 1977
EDITORIAL Seven years' experience of upper limb surgery in tetraplegia including performing 108 hand operations and fifty-two elbow extensor reconstructions, has left me in no doubt that here lies help in some form for the right patients. The results of some additional cases operated on by other surgeons collaborating with me, according ot the same principles, have confirmed me in the view that a negative attitude in this field is not longer realistic. In my opinion at least some 65% of all tetraplegics can be given at least some help. It would be a great mistake to talk about "repair" or about results approaching the normal. But there is still truth in the words of Bunnell, "If you have nothing, a little is a lot". Moreover, the little here is a plus to what can b e ~ a i n e d by the best training or re-education, and also to what different kinds of appliance can Offer. What can be done in the right cases is the construction, (and this is different from reconstruction) of one or other kind of a single hand grip and also of an active elbow extension for the 70% where this is lost. Nothing in Medicine is 100%. Still it can be stated that this surgery can be performed almost totally without risk of further functional loss. Only reversible procedures should be used. The two papers in this number of The Hand, will show some aspects of this surgery. The contribution by Newman, is a continuation of the work started by myself at the well-known Rancho Los Amigos Hospital in the Los Angeles area, helped and stimulated by Vernon Nickel. Part of the work has been done by Arnold Smith, the follow-up, as well as some of the surgery by Newman. The other paper by Bryan is, I believe, a continuation of a tradition at the Mayo Clinic, initiated by the earlier work in this field by Lipscomb and Henderson, and their co-workers. The open-minded way in which the failures are reported in these papers will teach some important facts. It is rare that more than one hand or more than one elbow extensor procedure should be done at the same time. Re-education requires full attention to a single function. One must resist the patient's desire to have more done at one sitting. The function aimed at, but not achieved, can never be obtained or restored later. Complicated procedures usually fail. Concentrate all available effort on one useful function, which will still not be too strong. I have not adopted the threaded wire due to the risk of making the procedure irreversible. If the sharp ends of the K-wire are blunted, migration is rare and easily restored. Further studies have shown (to be reported in a new book shortly) that the brachioradialis muscle will n o t make a good transfer without an elbow extensor antagonist. Therefore, if need be, always start with a deltoid transfer. When this gives full extension and ninety degrees of elbow flexion, the hand procedure can be performed. The Hand--Vol. 9
No. 3
1977
205
The Hand--October 1977
But the reason why the advances in this field must make slow progress are many. First of all, it must always be performed by a hand surgeon who really has the time and the interest to do all the work necessary. It includes the examination in detail of the upper limb, the evaluation of indications with the closest consideration of the patient's special needs and desires, the surgery, and of course the direction of the post-operative re-education. A consultant coming in just for a few hours of surgical work, will usually mean disaster. The new approach is based on the afferent impulses, a m u s t for all gripping procedures. In tetraplegia, these afferent impulses are often limited to vision, though some tactile gnosis and proprioception may remain, and these must be mapped out in detail. A new understanding of hand physiology, the evaluation of a different neurology, a different approach to indications and a different re-education--all this is needed for success. All this is now to be found in the literature today. Confidence on the part of these brave patients is a necessity. They will teach the surgeon new facts every day. To start with good cases, and to make slow advancement is needed to keep their confidence. For me the best sign of the usefulness of this surgery, is the fact that of the forty-six Scandinavian cases so far operated upon, five have returned to have four further reconstructive procedures (two elbow extensors and two hands) nine for three further procedures, and thirteen for two more operations. All this in spite of the fact that for many of them surgical possibilities only existed, for example, for one hand or one elbow. The surgery discussed is only at its beginning. It must advance cautiously but it can be made a blessing. E R I K MOBERG.
206
The Hand--Vol. 9
No. 3
1977
EDITORIAL Seven years' experience of upper limb surgery in tetraplegia including performing 108 hand operations and fifty-two elbow extensor reconstructions, has left me in no doubt that here lies help in some form for the right patients. The results of some additional cases operated on by other surgeons collaborating with me, according ot the same principles, have confirmed me in the view that a negative attitude in this field is not longer realistic. In my opinion at least some 65% of all tetraplegics can be given at least some help. It would be a great mistake to talk about "repair" or about results approaching the normal. But there is still truth in the words of Bunnell, "If you have nothing, a little is a lot". Moreover, the little here is a plus to what can b e ~ a i n e d by the best training or re-education, and also to what different kinds of appliance can Offer. What can be done in the right cases is the construction, (and this is different from reconstruction) of one or other kind of a single hand grip and also of an active elbow extension for the 70% where this is lost. Nothing in Medicine is 100%. Still it can be stated that this surgery can be performed almost totally without risk of further functional loss. Only reversible procedures should be used. The two papers in this number of The Hand, will show some aspects of this surgery. The contribution by Newman, is a continuation of the work started by myself at the well-known Rancho Los Amigos Hospital in the Los Angeles area, helped and stimulated by Vernon Nickel. Part of the work has been done by Arnold Smith, the follow-up, as well as some of the surgery by Newman. The other paper by Bryan is, I believe, a continuation of a tradition at the Mayo Clinic, initiated by the earlier work in this field by Lipscomb and Henderson, and their co-workers. The open-minded way in which the failures are reported in these papers will teach some important facts. It is rare that more than one hand or more than one elbow extensor procedure should be done at the same time. Re-education requires full attention to a single function. One must resist the patient's desire to have more done at one sitting. The function aimed at, but not achieved, can never be obtained or restored later. Complicated procedures usually fail. Concentrate all available effort on one useful function, which will still not be too strong. I have not adopted the threaded wire due to the risk of making the procedure irreversible. If the sharp ends of the K-wire are blunted, migration is rare and easily restored. Further studies have shown (to be reported in a new book shortly) that the brachioradialis muscle will n o t make a good transfer without an elbow extensor antagonist. Therefore, if need be, always start with a deltoid transfer. When this gives full extension and ninety degrees of elbow flexion, the hand procedure can be performed. The Hand--Vol. 9
No. 3
1977
205
The Hand--October 1977
But the reason why the advances in this field must make slow progress are many. First of all, it must always be performed by a hand surgeon who really has the time and the interest to do all the work necessary. It includes the examination in detail of the upper limb, the evaluation of indications with the closest consideration of the patient's special needs and desires, the surgery, and of course the direction of the post-operative re-education. A consultant coming in just for a few hours of surgical work, will usually mean disaster. The new approach is based on the afferent impulses, a m u s t for all gripping procedures. In tetraplegia, these afferent impulses are often limited to vision, though some tactile gnosis and proprioception may remain, and these must be mapped out in detail. A new understanding of hand physiology, the evaluation of a different neurology, a different approach to indications and a different re-education--all this is needed for success. All this is now to be found in the literature today. Confidence on the part of these brave patients is a necessity. They will teach the surgeon new facts every day. To start with good cases, and to make slow advancement is needed to keep their confidence. For me the best sign of the usefulness of this surgery, is the fact that of the forty-six Scandinavian cases so far operated upon, five have returned to have four further reconstructive procedures (two elbow extensors and two hands) nine for three further procedures, and thirteen for two more operations. All this in spite of the fact that for many of them surgical possibilities only existed, for example, for one hand or one elbow. The surgery discussed is only at its beginning. It must advance cautiously but it can be made a blessing. E R I K MOBERG.
206
The Hand--Vol. 9
No. 3
1977
