New Tendons Restore Hands -- In-Depth Doctor's Interview
Scott W. Wolfe, M.D., from the Hospital for Special Surgery, discusses how he was able to give one of his patients function in her hand when before she nearly had none.
Can you tell us about the condition that Nikki had that prevented her from using her hand?
Dr. Scott Wolfe: Sure. I am not a neurologist, but Nikki had a condition called transverse myelitis; I think that the closest analogy is probably polio, where the nerves that affect the muscles in any or all of the extremities are knocked out, and where the sensory nerves that give a sensation were not. That effect on Nikki resulted in the near complete loss of function in her elbow to hand on one arm.
What kind of prognosis does a patient with this normally have?
Dr. Scott Wolfe: I think that when you are dealt with a hand like that at age five, you learn to adapt and live with it, and ultimately go out and try to do everything. As Nikki got older and watched kids do things that she couldn’t do and certainly gained aspirations to do more, she started being less satisfied. Without surgery, Nikki’s prognosis for her arm was quite bleak – no spontaneous recovery was possible.
How long was the planning process for this?
Dr. Scott Wolfe: She first presented as a child with open growth plates, and so I wanted to be careful when doing something this intensive for someone that young. Furthermore, I think that you need to understand the person – their intellect, level of enthusiasm and aspirations – and that involves two or three meetings at a minimum. Its important to really see how she functions on different occasions. The opportunity to see her function on different occasions, and the consistency therein led me to believe that there was really something that we could do. The planning started two years before the final operation. It was several nights thinking about it, discussions with Nikki and her mom in terms of what we could do and the different opportunities; getting feedback from them was definitely important in the process as well.
Was she basically not using that arm at all?
Dr. Scott Wolfe: That’s correct. She could use her shoulder and her elbow, but from her elbow down it was more or less trick motions; she had a way of flipping her hand this or that way. She could do a minimum of things with only a couple of muscles in due course working in her hand – one that lifted her thumb up and one that lifted her index finger up. She had a little control of her wrist, however, it was minimal. She was limited to types of trick motions of the hand, initiated by the working muscles in her elbow and shoulder.
In a normal hand, how many working muscles are there?
Dr. Scott Wolfe: There are nearly twenty different muscles in the forearm alone; add to that another fifteen muscles in the hand. It is a very intricate balance of what we call extensors, which straighten the fingers, and flexors, which bend, as well as those that perform the wrist motions and forearm rotations.
Can you talk to us about the first procedure?
Dr. Scott Wolfe: As Nikki could only really raise her thumb and her index finger and couldn’t actively bend them, we needed to come up with a way to help her extend the other digits and flex them as well, and moreover use them in normal daily activities. Nikki had expressed a goal to me, which was in fact a very simple goal; one that I thought was very realistic, and that was to use both hands to eat from a cup of ice cream. At the time, that is how disabled she was. So, with that in mind, the idea of obtaining a pinch between her thumb and her index finger, and the idea of getting her fingers out of her palms so that they weren’t going to be in her way really was our goal. When someone has nothing, even a little is a lot. To gain her confidence for surgery, it was necessary to help her understand that we could give her some of the mundane aspects of life that the rest of us take for granted, but which for her were huge hurdles. The first procedure was to harness the ability that she had to straighten her index finger; by using that particular muscle, we could tie that into her other fingers so as she moved her index finger the rest could come along for the ride as it were. That portion of the procedure wasn’t actually much different from the normal situation – we often extend or open all of our fingers simultaneously. The other part of the procedure was to stabilize her thumb. Although she was able to lift her thumb up, it was what we call flail. She really didn’t have enough muscles to give it stability, and in order to give it stability we had to actually fuse one of the key joints in her thumb. So, the idea was to stabilize her thumb by fusing one of the joints at its base, to give it a stable platform for future transfers, and to enable her open her fingers together. That was the plan for the first stage.
How long was it between each surgery?
Dr. Scott Wolfe: The time frame was variable, and we were able to adjust that as she went along, but I needed to have the fusion portion heal –that generally requires about six weeks – and then I wanted to give her six to twelve weeks so that she could use the hand, and accomodate to the changes before moving to the next stage.
What did the fusion allow her to do?
Dr. Scott Wolfe: At the end of the first stage, she perform do a rudimentary pinch, and she could just learn to straighten her fingers. That was about it. It didn’t add that much value -- in fact she was a little bit skeptical following the first surgery. “Was this all worth it? I don’t really see anything?” I understood that. She is a young person, and obviously as do most of us, she was a little impatient. But she was also very realistic, and understood that she was in it for the long run. She couldn’t actually grasp afterwards; she could release but couldn’t grasp. For most of us, the grasping part is the key part in situations.
Can you discuss the second procedure and the difficulties that you encountered?
Dr. Scott Wolfe: The second procedure was a little bit tricky, because even with preoperative testing and MRIs and electrical studies to try and determine which muscles were working, I could never be absolutely sure. You can say that it was a leap of faith to say that she actually had three muscles in her forearm to control her wrist, because that is really what we needed to do in the next step. For the next stage, we had to borrow two of the three muscles, and then transfer those to the palm aspect of the hand – one to close her fingers and one to close her thumb. As she used those transfer muscles, or as she would use those transfer muscles together, she would actually be able to pinch and to ultimately grasp. If my calculations were wrong, the surgery would fail, and potentially leave her worse off.
Typically, where are those three muscles that you used two of?
Dr. Scott Wolfe: Most of the muscles that work our hand are actually positioned in the forearm, and they are connected to long tendons that connect to the fingers. That gives us the opportunity to take working muscles from one position in the forearm, and actually move them and reconnect them in a different place so that those same muscles do a different task.
How long after that second procedure was she able to see these results?
Dr. Scott Wolfe: Transverse myelitis injures the nerves, and when the nerves are injured the muscle atrophies. She was spared three or four muscles in her forearm out of those original thirty plus muscles. Our task was to find out how to mix and match those working muscles to give her back the functions that she needed, and in fact we took that leap of faith and moved forward. I was confident that we had enough evidence to say that she has two of those three working muscles. That duplicity of function gives her some redundancy without stealing anything from her; we can move two of those muscles and give her more function without taking any away. Your question about how she can learn to do things . . . that was a great one because not everyone can do that. Young people in particular are very skilled at learning new functions, and we believe that this is all due to brain plasticity – the ability of the brain to remap what the muscles are doing so that it becomes second nature to us. We no longer have to think to do one thing when we are in fact doing something else. Just to give you an example, one of the muscles that straightens the wrist (wrist extensor) will now be the one that bends the fingers. Within six weeks (in Nikki’s case) she was able to remap and able to bend her fingers just by thinking bend fingers rather than straighten wrist. Those of us who aren’t fifteen years old probably would take longer to do that. When developing tendon transfers, we use a concept known as synergism. When you reach out to grab something, you will generally extend your wrist as you grasp your fingers. So, the brain is already partially mapped to that effect. The results are best when we use synergistic muscles, and that is in fact what we did with Nikki.
So because of her age and brain plasticity, it became second nature to her pretty quickly?
Dr. Scott Wolfe: Very quickly. Actually, far quicker than I could have ever predicted.
Can you discuss what you have seen so far post surgery?
Dr. Scott Wolfe: We have to protect someone after we have done these transfers, and the reason for that is even in your sleep your muscles will contract; that generates tension, and what we don’t want to happen is have the tendon repairs stretch or disrupt. So, we protect someone in a cast for about four weeks. We then take the cast off and have them work with a certified hand therapist. Certified hand therapists have undergone years of specialty training, and understand what we have done surgically so that they can translate our work into clinical function. So, the therapist worked closely with Nikki and helped her to learn these new tasks. That process requires two to three months . . . Nikki learned it in about three to four weeks. It was pretty exciting to watch.
What was it like for you to see her gain these functions back?
Dr. Scott Wolfe: It was exciting. It was very gratifying to see that we can intervene in a situation like this and make things happen, but it is more exciting to see the smile on her face and see her able to eat that cup of ice cream. I also understand that she is getting ready to take her driver’s test as well.
I know that this case is unique, but could these principals be used to help other people who may suffer from a condition similar to that of Nikki’s?
Dr. Scott Wolfe: Certainly. None of these are new procedures. What I am doing is borrowing from tried and true techniques that have worked in the past, and actually and interestingly enough these techniques began in the days of leprosy and polio; when muscles were knocked out, and surgeons had to use new and creative ways to use existing muscles and recreate the functions lost. These techniques have been used for decades, but in the incidence of an isolated nerve injury from trauma for instance, or multiple nerves from a Brachial Plexus injury, a combination of nerve and tendon surgery is sometimes applicable. The Brachial Plexus is the nerve center of the arm and lies between the neck and the shoulder. In a severe motorcycle injury, for instance, these nerves can be stretched or ruptured, impairing many or all of the normal functions of the arm. We are adapting some of those techniques in cerebral palsy, brachial plexus conditions and polio-like conditions such as Nikki’s. We are adapting these techniques to again match what the patient has and what the patient is missing, and try to come up with a creative solution to the problem.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Scott Wolfe, M.D.
Hospital for Special Surgery
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