As human beings, we often take our hands for granted until we realize that they aren’t functioning properly or have been suddenly injured in an accident. That’s when patients turn to plastic surgeons such as Laurence T. Glickman, MD, MSc, FRCS(C), FACS, and Roger L. Simpson, MD, MBA, FACS, director of plastic surgery, Nassau University Medical Center.
Both physicians are part of Long Island Plastic Surgical Group, Garden City, NY Although Glickman and Simpson do not exclusively focus on hand reconstruction in their practices, they see numerous cases every day. In fact, Simpson notes during our interview that there are 75 cases currently at the hospital and that he sees more hand surgery cases now than he ever did during his hand reconstruction fellowship.
PSP talked to Glickman and Simpson about the state of the hand and the latest in technology, techniques, and trends.
PSP: Where are you seeing the most need right now in hand reconstructive surgery? The military? Accidents? Aesthetics in any way?
Simpson: I think there’s a tremendous need for hand surgery in the community. Our community is somewhat unique in that we run a private practice, but we also run a teaching program, as residency in plastic surgery. That residency is in a large public hospital. So, the combination of private medicine and public medicine sees a tremendous number of hand patients on a weekly basis.
Glickman: We see the full spectrum of hand surgery: congenital, traumatic, osteo and rheumatoid arthritis, as well as Dupuytren’s, carpal tunnel, and peripheral nerve problems—the full spectrum of hand surgery. However, we tend to see more trauma cases here at the hospital because it’s a level one trauma center. We see industrial accidents, chain and table saw injuries, and car accidents that can lead to devastating injuries as well.
PSP: Are aesthetics growing at all in your practice?
Glickman: We see some aesthetics in the office. Mostly, they’re asking for hand rejuvenation, which has to do with the texture of the skin, pigmentation changes, wrinkling of the skin. It’s increasing, but it’s still a small percentage of the practice.
PSP: What new hand reconstruction techniques have you seen in the last few years that’s exciting?
Simpson: Arthroscopy is probably the latest. It’s been around for a while, but the applications are increasing. Some of the plating systems have now really paid attention to fine detail, and they’re very easy to use. The ability to fix fractures now with very reliable fixations in patients who are not always that compliant is very good. The combination of the two has really brought hand surgery further these last few years.
Glickman: In terms of microsurgical reconstruction, the optics on the latest microscopes has improved. The instrumentation is about the same for microsurgery. It’s really arthroscopy that’s made a difference. It’s really something new and not everyone is doing. Actually, Dr Simpson is one of the few people on Long Island who will do arthroscopy.
PSP: How are you applying arthroscopy in your hand reconstruction surgery practices?
Simpson: Mostly, we’re using it in trauma cases. You’re dealing with ligament ruptures in the wrist and trying to align the bone structures, and so we’re using the arthroscope to be sure that the bone structures are in line.
Osteoarthritis, now at the base of the thumb, is also an area where arthroscopy is just finding its own niche. These may be procedures that take the place of some open surgeries, but not entirely; but in some cases, they will.
|Roger Simpson, MD, utilizes the latest hand arthroscopy techniques at LIPSG.|
PSP: Are there any other new techniques making hand reconstruction more easy to perform or more efficient?
Simpson: Things that are coming out now are the endoscopic approaches to cubital tunnel syndrome or ulnar never compression. Also, at the carpel tunnel I’m not sure they’re making the surgery easier, but you’re using new technology to achieve what some people feel are equivalent results—long term. You’re seeing an attempt to be less invasive. When you discuss both, as far as the advantages, you’re going to have people out of both schools telling you that one surgery is better than another surgery, but it’s uncertain which is better. I think the open approach still remains effective, and I think new techniques with endoscopy are also here at the present time.
Glickman: I think there are many schools of thought but no gold standard of open versus closed techniques for procedures that we are discussing. They both have their advantages and disadvantages. But for wrist arthroscopy, that’s a technique that’s unique in terms of the ability to evaluate the bones and ligaments and structures without having to make a big incision. You look in with a scope to evaluate before you actually have to do the operation, or sometimes you can do the operation through the scope itself without opening the hand.
PSP: Are there any other new technologies that are helping your practices?
Simpson: The types of screw fixation have improved. Years ago, we were subject to using only pins to hold things in place and hoping that everything would heal in that regard. Now, you have compression screws that will take care of fractures with a single screw. You have bone anchors that allow you to sew them right to the ligament, rather than creating tunnels and moving tendons around.
Also, the equipment that we’re using today is very sophisticated. Wrist arthroscopy will play a role in some of these applications, where you’ll place the wrist arthroscope to be sure that your alignment is as good as it looks from the outside. But the combination there is certainly a challenge.
PSP: Hand transplants were in the news a number of years ago, but we haven’t seen that news repeated often. With today’s advanced microsurgery techniques, why is hand transplantation still such a challenge?
Glickman: The issue is not the technical aspect of the transplant, which any good microsurgeon has the technical ability to do. In fact, the transplant vessels are quite big, and bones are quite big. The problem is rejection. The transplanted tissue is a composite tissue. When you do a kidney transplant, the organs lend themselves to transplant because of the uniform cellular structure. A hand has muscles, bones, tendons, arteries, veins, nerves, and skin. Those combined tissues create a tremendous challenge for transplantation because of rejection. Patients have to be put on very large doses of antirejection medicine, which poses a host of problems. In particular, there’s the problem with malignancies down the road because the patients have been immunosuppressed for such a long time. One reason that there are so few hand transplant programs is that they haven’t overcome the obstacle of rejection. It’s still an ethical dilemma.
|Most of hand surgery is done with relatively simple instrumentation.|
PSP: What do you see as the solution for hand transplantation in the long term?
Simpson: Eventually, I think medications will be developed with fewer side effects that can suppress the immune system in a way that doesn’t present with so many problems. It’s only then that transplant programs will become something that’s commonplace. Not until that time.
PSP: What technologies or techniques in hand reconstruction are going to become more mainstream in the coming years?
Simpson: If you look at some of the research that’s being done and presented in the national meetings, you’re looking at the possibility of growing new tendons in areas where we have the ability to create a housing with a plastic rod and then substitute a tendon.
Scar healing is probably one of the most difficult problems today because scar impedes motion. And the question is, how do you get beyond the scar yet guarantee that the healing process, for which scar is required, is adequate enough to hold everything where you want it? I think therein you will have the answer to hand surgery if you can figure that out. It was present years ago, it still remains present, and there are all new techniques.
If you look at Dupuytren’s contracture, there is now a product called Xiaflex or collagenase Clostridium histolyticum, which has just been FDA-approved to dissolve some of the cord structures in an attempt to treat these cases conservatively. Whether it will be as selective as they suggest—so that you can use an injection to break up scar and everything else remains the same—it’s too early to tell.
Glickman: In terms of future trends, there are now available nerve graphs that are off-the-shelf. That is, they’re autologous tissue that’s been processed, not unlike what we use for dermis or tendons. So, now you can utilize a manufactured, processed nerve graft to bridge a gap in someone’s nerve that has been injured or resected for tumor or trauma and achieve good results. It’s not quite as good as using their own nerve, which remains the gold standard, but the patient will have a sensory deficit if you harvest their own nerve.
I think anything that’s on the horizon that’s off-the-shelf, that can be tissue engineered where you can build something that will be tolerated immunologically—whether it’s skin for burn tissue or tendons or nerves for hand patients—that’s exciting to me. That’s going to happen. It’s just a matter of time.
PSP: What do you wish you had right now that you don’t? That is, if you asked a manufacturer to create or improve something for hand reconstruction, what would you ask?
Simpson: I think there are so many things out there right now that we’re using that are working well. But as far as what the manufacturers could make for us, I think joint replacement is still in a degree of flux. There was a standard joint replacement that was around for years and worked very well. And now you’re looking at complex materials and pyrocarbons, etc.
I think we’re always looking for the best joint replacement and the ability of the bone to keep it in place. But these are wound healing issues, and I’m not sure that’s going to come through manufacturers or industry.
Glickman: The reason it might not be developed quickly is because hand reconstruction is a small market and the research and development is expensive on those items.
Tor Valenza is associate editor of PSP. He can be reached at [email protected]