Claes Hultling's message

"Dear folks!

I’m addressing this on Professor Jan Fridén’s web site because I feel the urge to do it since a large number of tetraplegics are still lacking proper hand surgery service. I’m a 57 year-old Visiting Professor at Stanford University in Palo Alto, California. I’m a M.D., Ph.D., and I was a trained anesthesiologist in 1984 when I had my C6-C7 spinal cord fracture. I had a fairly good right hand but on my left hand and arm I was lacking the majority of the muscles that normally operate my hand. I had two muscles left: musculus extensor carpi radialis longus and musculus extensor carpi radialis brevis. I did know that something could be done with either of these muscles to achieve a flexion grip in my left hand. I was fortunate to get in contact with the late Eric Moberg who is one of the fathers of modern hand surgery. Together with his collaborators at the Sahlgrenska Hospital in Gothenburg on the west side of Sweden surgery was performed the 15th of April, 1985, which was 10 and half months after my spinal cord injury. This is one of the best medical moves I made since I broke my neck.
Why is that? One important element was the timing. One should wait long enough in order to make sure that you don’t regain function and are embarking on hand surgery too early. The other thing is to do it early enough in order to avoid starting to develop secondary techniques that will be perceived as an obstacle or hurdle later on. It is so common that people wait too long and then feel awkward regarding embarking onto major surgery that will hospitalize them even further for a period of a couple of months, during the time it takes for the tendon transfers to heal. One of the most important things with modern reconstructive hand surgery is to be sure that you have time and guidance to exercise your hand after the surgery. There is no point, it is useless to do this if you go back to your home in a remote town and just “hang around” and think that time will help you. You have to be dedicated and in the right mood in order to get the best results. In other words, if you don’t have full hand function after spinal cord injury, never, ever, question whether you should embark on reconstructive hand surgery. It is a huge waste not to do this. Good luck! "

Rochus’ story

Rochus Gelsinger is a role model. The 62-year-old retired craftsman sustained a severe paralysis that particularly affected his right upper extremity during a car accident in 1972. It left his right hand almost useless. “Nothing can be done about this”, he was told, however, he worked full-time until his retirement using his right hand as a counterbalance, but else only could hold a paper as his grip was extremely weak with flail fingers and a floppy thumb. In September 2009, almost 40 years after his accident, he was operated by Prof. Fridén and Andreas Gohritz at the Clinic of Plastic, Hand and Reconstructive Surgery (chaired by Prof. Peter Vogt), Hannover Germany. Mr Gelsinger underwent an operation called ABCDEFG (Advanced Balanced Combined Digital Extension Flexion Grip) reconstruction to restore key pinch between thumb and index finger, thumb stability, opening and closure of the fingers and wrist alignment. In order to increase the awareness of treatment options for this type of functional deficits, surgery was real-time broadcasted as part of an International Instructiomal course at the German Society of Plastic, Reconstructive and Aesthetic Surgeons. After the operation, Rochus trained very diligently under supervision of his therapist, but also on his own at home and excercised his new hand functions. Over the following months, he has regained a strong and stable thumb-to-index pinch with strength of more than 2 kg, a firm global finger grip (grasp) to hold larger objects and a controllable hand opening. Rochus’ example shows that tendon transfer offers the chance to restore hand function lost by paralysis even decades after the original injury. This is possible as tendon transfer relies on remaining function of intact muscles whose tendons are simply reattached to a different point of insertion to restore essential abilities like wrist extension, pinch or grasp. Therefore, no arbitrary limit of delay or patient age exists for tendon transfer - opposed to nerve reconstruction for example, which is only reasonable within about 2 years as the denervated muscle becomes fibrotic and unable to contract by nerve stimulation. Rochus is very happy with his new skills, such as eating, drinking, cooking, writing, grooming, holding large objects and a firm manly hand-shake with other people - using his formerly almost inoperable and hidden right hand. He is still exercising everyday to take literally more new things into his own hand. “I want to become even better …” Rochus is a true role model – it is never too late to improve.

Physiotherapist Ann-Sofi Lamberg reports about positive effects of early active training of reconstructed triceps function

In a recent study we investigated the effect of early postoperative activation on elbow extension strength and elbow joint range of motion after reconstruction of Posterior Deltoid muscle to triceps transfer compared to a control group. Fourteen individuals underwent early activation after surgery. They were compared to a control group matched for age at injury and remaining functions. Both groups adhered to same standard protocols after reconstruction elbow extension except for early activation in one of the groups. Those who had early isometric activation started with training of elbow extension in the cast on the first day after surgery. The purpose was to activate the new triceps to straighten the elbow. They trained four times per day with 3 sets of 5 repetitions. Those who underwent early activation demonstrated a significant increase in elbow extension range of motion both passively and actively after surgery. Of those who trained actively, 8 individuals had the same range of motion in elbow extension and 6 increased in elbow extension post-operatively compared to the control group where 9 individuals had no change, 3 decreased in elbow extension and 2 increased in elbow extension. Individuals in the early activation group generated more power in elbow extension compared to the control group. It is concluded that early activation after reconstruction of Posterior Deltoid to Triceps is safe and reduces the risk of elbow extension deficits.

Preparation for upper limb reconstruction by occupational therapist Johanna Wangdell

The final decision to undergo surgical reconstruction of upper extremity function is made after thorough considerations of pros and cons. Persons living with tetraplegia hesitate to become more dependent even though it is temporary. Therefore it is essential to reduce the extent of postoperative dependency as much as possible. Restrictions no doubt exist after surgery to protect the newly reconstructed functions but nevertheless much can be done to prevent tissue swelling by using muscle pump and to retain a generally good physical shape. Most patients have struggled quite a lot to reach a “normal” level of physical and psychological status and maintaining this accomplishment as far as possible is critical also during the surgical rehabilitation. Preparations prior to surgery must include detailed information and discussion about restrictions and what consequences these limitations will have for the individual in daily life. The ability to transfer both to the wheelchair and in the wheelchair, intimate self-care and the ability to work are common matters brought up before surgery. Specific transfer training and different parts of ADL training with new techniques and aids are necessary in order to maintain independence. Ability to maintain pressure relief might be limited and needs to be addressed. Analysis and, if necessary, modification of sitting position in the wheelchair is another important aspect of preparation to prevent pressure sore.