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International Tetrahand Surgery Course in Switzerland

April 12, 2012, 11:39 am
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The 5th International Course on Tendon Transfers in Reconstructive Tetraplegia Hand Surgery was recently held in Nottwil, Switzerland. The purpose of this course was to provide hand surgeons state-of-the-art knowledge in tetraplegia hand surgery. Briefly, this course covered clinical examination, anatomy, biomechanics, surgical techniques, rehabilitation and outcome measurements in the field of surgical reconstruction of upper limb functions in persons with tetraplegia.Emphasis of this course was to equip surgeons with a science-based and reliable toolbox of procedures to reconstruct hand function in tetraplegia.One full day was dedicated to practical training of the most important tendon transfer procedures and techniques for tendon-to-tendon attachments. The course, that was arranged under the patronage of the Federation of European Societies for Surgery of the Hand (FESSH), attracted hand surgeons from eight countries in three continents.
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A Handful of Freedom

April 18, 2012, 2:06 pm
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In the latest issue of Paraplegie (No 141, 2012), journalist Christine Zwygart reports her impressions after spending two full days with the Tetrahand Surgery team. Her introduction lines "Suddenly being able to raise your arm and grab something with force – the wish for many tetraplegics - Thanks to surgery, it is now possible to awaken paralyzed hands to new life" pinpoint the goal of this service. Mrs Zwygart translates very powerfully how crucial hand function is in real life and the necessity of giving the paralyzed spinal cord injured patients access to expert assessments and opportunities to undergo surgical reconstruction of hand function when feasible. In a separate paragraph "Freedom and mobility", mrs Zwygart details some of the vitals aspects of the post-operative training to achieve functions useful in daily life. She finally states that "Dressing, cooking, writing, driving a wheelchair forward, shake hands when greeting someone – that’s usually possible for tetraplegics after surgery". Figure above shows hand writing technique is patient before (left) and after (right) reconstruction of hand function. For more info, see full article below.


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Tetrahand Surgery Topic at Bad Neustadt Workshop and International Symposium

May 18, 2012, 10:00 pm
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Uppper Limb Tetraplegia Surgery was one of the topics at the 20-year anniversary of the famous Hand Surgery Clinic in Bad Neustadt, Germany. Professor Jan Fridén was invited to report the state-of-the-art of this rapidly developing field. The presentation and ensuing discussions highlighted the importance of immediate active training and relearning after surgical reconstruction of hand function. Multiple new surgical techniques were detailed and patient perceived outcome of surgery and rehabilitation was reported. It was made clear the a new era of surgeries and rehabilitation methods has made the results better from the functional and patient perspectives. Outcome measurements must be an integrated part of this type of treatment.





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Nerve Transfer to Reconstruct Wrist Extension in High-Level Spinal Cord Injuries

June 16, 2012, 9:07 pm
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Active wrist motion enabling passive grip is the key function in high-level tetraplegic patients. It is, however, absent and cannot be restored by traditional tendon transfer in patients have no functioning muscle below the elbow. Drs. Jan Fridén (Göteborg, Sweden) and Andreas Gohritz (Hannover, Germany) presented recently a 36-year old male patient with high-level tetraplegia due to diving, regained active wrist extension (picture) after transfer of the motor nerve of one of the nerves to an elbow flexor onto the nerve of an wrist extensor. Four months after the operation, the first active extension of the wrist was observed and gradual training and electrical stimulation further improved the power of the wrist extensor. No functional deficit of elbow flexion occurred. This procedure may become a valuable method for patients without transferable muscle regain useful wrist-driven hand function.
Reference:Fridén J, Gohritz A. Brachialis-to-Extensor Carpi Radialis Longus Selective Transfer (BEST) to Restore Wrist Extension in High-Level Tetraplegia by Nerve Transfer – Case Report. J Hand Surg (Am), epub ahead of print June 2012.
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Tetrahand Reconstruction Acknowledged in Swiss Popular Press

June 25, 2012, 10:24 pm
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An article acknowledging the Tetrahand service at Swiss Paraplegic Centre in Nottwil was published in the newspaper"20 Minuten". The article highlights some of the benefits that can be obtained by surgical reanimation of hand function in patients with tetraplegia. The article (in German) includes both the basic ideas of the surgery and some of practical effects e.g. writing a text message on the mobile phone.

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American, Swedish and Swiss Tetrahand scientists meet in San Diego

July 3, 2012, 9:59 am
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The purpose of the meeting is to launch a research project addressing surgical options to improve balance and control of hand in tetraplegia. Specifically, the researchers aim to model and simulate how the loss of fine tune hand control in tetraplegia affect the mobility and force of finger joints upon surgical reconstruction. The loss of intrinsic balance of the fingers has always been a great challenge in surgical reconstruction since the loss is much more pronounced than after peripheral nerve injury. Although much knowledge exist about the intrinsic finger balance in the normal hand, the presentation of the functional loss in tetraplegia differs in several aspects e.g. the complicated interactions of long muscle-tendons units with intrinsic hand muscles. This fact affects choice of methods to passively position fingers i.e., so called tenodesis. The research that is scheduled to last from July through December 2012, include Drs. Jan Fridén, Richard L. Lieber, David Muzykewicz, Ursina Arnet and Tim Tirrell (picture).
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"Reconstructive Surgery of Paralyzed Patients using Muscles as the Motors" topic at Scripps Institute, San Diego, USA.

July 16, 2012, 6:52 pm
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The San Diego Skeletal Muscle Research Center had Professor Jan Fridén from University of Gothenburg, Sweden as national seminar speaker at the Sanford Burnham Medical Research Institute on July 9th, 2012. Dr. Fridén presented and challenged, step by step, multiple dogmas in tendon transfer surgery. For example, immobilization vs. immediate postoperatieve training, tensioning of the tendon transfer complex during transfer, surgeons' decision-making strategies, age aspects and the future of nerve transfer in tetrahand surgery were thoroughly illustrated and discussed during this one-hour presentation.  The audience actively participated and the discussions included several topics ranging from very technical aspects of surgical reconstruction to measures to increase awareness as well as the need for international network, communication and training courses for hand surgeons, basic scientists and therapists.  Examples of successful developments were given from Sweden and Switzerland.  Professor Fridén repeatedly emphasized the need to strengthen the axis "Surgeons-Therapists-Rehabilitation Medicine Specialists-Basic Scientists.
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Rehab Station Stockholm celebrates 25th Anniversary

September 22, 2012, 12:38 pm
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On the 22nd of September, Rehab Station Stockholm celebrated its 25 years existence.  This comprehensive unit with its dedicated personnel, spectacular location right at the shores of Brunnsviken, tight, efficient and welcoming premises, has been instrumental in the development of a modern clinic to enhance state-of-the-art rehabilitation in spinal cord injuries.  The anniversary attracted more than 200 guests including several Swedish medalists from the recent London Paralympics. From a tetrahand surgical point of view, Rehab Station plays a key role in Sweden because no other unit has as many hand and upper limb assessments as well as patients referred to reconstructions of hand function.  Happy Anniversary Rehab Station!  Picture aove from Celebration Day with paralympic medalists interviewed.
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Nordic Tetrahand (NORTH) network meeting in Göteborg, Sweden

October 5, 2012, 1:14 pm
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Participants at NORTH network
Swedish National Center for Reconstructive Surgery in Tetraplegia arranged the first Nordic network meeting in Göteborg, Sweden on the 4th to 5th of October 2012. The idea of this get-together was to establish an expert group for the Nordic countries in the field of tetrahand surgery and rehabilitation.This first network meeting setting was informal as the primary goals were to get to know each other and to summarize the current knowledge in this field. The organizers wanted to facilitate interactions among surgeons and therapists and to provide a strong knowledge basis for future development. 26 hand surgeons and therapists joined the meeting. The format of the meeting also included group sessions where surgeons and therapists separately listed their prioritized items to be covered in future. Next NORTH network get-together is planned to be held in Bergen, Norway in September 2013.
Tetrahand Rehab specialists in group meeting

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Tetrahand Surgery in South Africa

October 24, 2012, 1:52 pm
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Prof. Hans Myburgh, Dr. Erich Mennen and prof. Jan Fridén meet at Swiss Paraplegic Centre in Nottwil to discuss the concept of surgical reconstruction in tetraplegia. The meeting includes patient consultations, surgeries and site visits at the ergo- and physiotherapy units. Tetrahand surgery service in South Africa is under development and many aspects of the treatment protocols need to be adapted to the local circumstances. It is agreed that skilled therapists are crucial for providing a comprehensive service. Joint ventures with surgeons and therapists communicating about goals and means are important for establishing reliable and sustainable tetrahand service.


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Swedish Tetrahand Service Awarded

November 7, 2012, 8:33 am
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Jan Fridén and Johanna Wangdell
The Swedish National Centre for Reconstructive Tetraplegia Hand Surgery was awarded the Quality Prize for Good Care at a ceremony hosted at the Sahlgrenska University Hospital on November 1st. Jury citation reads as follow: "This workdescribes the resultsof surgicalrestorationof arm andhand function in tetraplegia.Central to thedesignof the treatmenthas been thepatient's ownprioritized goals with surgery.Thisscientific workundertakenhas shown thatpatientexpectationsare metat the highest internationallevel.The workinspiresgood internal controland hasbeen pursuedwith great dedication and endurance which nowresults in a10-years follow-up".  Prize was 20000 SEK (2300 €).
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PhD Thesis on Patients´ Perceived Outcomes of Tetraplegia Hand Surgery by Johanna Wangdell

February 21, 2013, 4:14 am
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Cover drawing by Anna-Maria Edgren
Aim: To investigate patients perceived benefits after upper limb surgery in persons with tetraplegia - with a special focus on the participants’ perspective and their experiences from regaining lost functions. 
Methods: A combined Quantitative and Qualitative design was used. The outcome measures in study I and III was the Canadian Occupational Performance Measure (COPM). It captured patients perceived performance and satisfaction with their prioritized activities. Study II was a correlation study between activity gains and physical factors. Study IV and V used a grounded theory approach to capture patients experiences regarding a) changes in their daily life and b) the transformation process of regained function into daily use. Patients were recruited from National center of Reconstructive hand surgery in tetraplegia, Sahlgrenska University Hospital, Sweden. Patients came from diverse parts of the Nordic countries. 
Results:Patients set up goals relevant to the specific surgery, they experience improvements and were satisfied with the performance of their prioritized goals. All types of goals improved after grip reconstruction, especially eating and goals generally regarded as more complex ea domestic life and leisure activities. The satisfaction was similar to the performance improvements. When the patients expressed their experienced after surgery the core theme was “enhanced independence” including both practical and psychological aspects and an increased self-efficacy in their hand control. No correlation between a single physical factor and perceived improvement in activity was found, suggesting there are also other factors relevant for the transformation process to use regained function in daily life.  “Determination for higher independence” was the core concept to transform the function into daily use, described by the participants. Time, training in home environment and social support was other important factors. In the process “belief in ability” and later “confident in ability” were important stages to proceed further into daily use. 
Discussion: Reconstructive hand surgery and rehabilitation are shown to have impact in many dimensions in life and it gives reflexions in all domains of the International Classification of Functioning, Disability and Health (ICF) model; body structures and function, activity, participation, personal factors and environmental factors. A carefully informed and highly motivated patient is important to receive a good result, not only in grip strength but also in all the other domains of ICF. No single physical factor known before surgery, e.g. sensibility or age could alone explain improvements in prioritized activities. Traditional limitations with high age and lack of sensibility could not be proven to be a limitation to activity improvement in present study. Therefore, all patients with tetraplegia should have the opportunity to choose to have hand surgery. Neither could grip strength alone demonstrate a correlation with activity improvements. Physical factors have of course an important impact on the capability in activity performance but in agreement with the ICF model, personal and environmental factors also plays an important role in activity and participation improvements after reconstructive hand surgery in tetraplegia. Accordingly, body functions, activity and participation all should receive attention in the rehabilitation after surgery and also the need for evaluations in the diverse dimensions to capture multiple perspectives of changes after surgery. 
Conclusion: Reconstructive hand surgery is a useful and valuable intervention for people with tetraplegia. The participants experienced an increased hand control that had impact not only on physical aspects but also in participation, practical and psychological aspects. Together with the physical improvement, high motivation and development of self-efficacy in hand control seems, from the results of these studies, to be important factors to secure activity and participation improvements after surgery. 
Keywords: Outcome, tendon transfer, tetraplegia, patient perspective, hand function
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Tetrahand Talks at Indian Spinal Injuries Centre

March 6, 2013, 5:04 am
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Swedish and Swiss Tetrahand Surgeons visited the Indian Spinal Injuries Centre in New Delhi to discuss the concepts of surgical reconstruction in Tetraplegia.  Dr Mishra, director of the service (to right in picture) presented the hospital´s overall philosophy and the possibility of developing the  reconstructive upper limb surgery in conjuction with specialists from overseas.  Drs Gohritz, Fridén and Reinholdt (to left in picture) presented the concepts of surgical rehabilitation in Switzerland and Sweden.
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Tetrahand PhD Thesis about Grasp Control by Carina Reinholdt

March 14, 2013, 1:46 pm
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Dr. Carina Reinholdt presents her PhD thesis about surgical reconstruction of grasp control in tetraplegia. The thesis is based on five separate papers (I-V).
Aim: The overall aim of this thesis was to improve the grasp and release function of patients with tetraplegia undergoing reconstructive hand surgery. In order to reach this objective, new and more cost-efficient surgical concepts with maintained patient safety were designed.
Patients and methods: 111 individuals were assessed pre- and postoperatively on their pinch and grip strength, range of motion (ROM), hand opening , as well as a satisfactory score (COPM) (retrospective comparative studies I-IV) and dynamic electro-goniometry to assess spasticity (prospective pilot study V).
Results: I: Selective release of tight interossei muscles in the hand (distal ulnar intrinsic release) increased the ROM up to 45 %. II: The alphabet procedure (a single-stage combination of procedures) reliably provided tetraplegic patients with pinch, grasp and release function after only one operation and one rehabilitation period. III: The extensor carpi ulnaris tenodesis corrected radial deviation deformity of the wrist joint and increased the grip strength by double. IV: Patients who underwent the alphabet procedure demonstrated significantly more grip strength and opening of the hand compared with patients, who had traditional grip reconstruction. Early active rehabilitation was particularly important after multiple simultaneous procedures. V: Dynamic electro-goniometry proved a feasible method to assess spasticity-reducing surgery by measuring joint angular velocity and repetitions per second. Together with COPM, these assessment points can be used to evaluate the outcome of surgery or non-operative spasticity treatments.
Conclusion: This thesis reports development and refinement of several surgical techniques that individually and combined, facilitate the reanimation of grasp control in people with tetraplegia. Rebalancing of the hand by selective release and tendon lengthening techniques enables more favorable mechanical conditions for the forearm, wrist and finger actuators in patients with tightness and spasticity. Shorter total operation room and rehabilitation times with preserved patient security enforce the recommendation of applying these techniques.
Keywords: alphabet procedure, distal intrinsic release, ECU-tenodesis, electro-goniometry, grasp and release, grip strength, intrinsic tightness, opening of the 1st web space, pinch strength, spasticity, tendon transfer, tetraplegia.
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Kappa Delta Award to US-Sweden Research on Muscle-Tendon Mechanics

March 20, 2013, 4:13 am
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JanFridén, professor of hand surgeryat the SahlgrenskaAcademy andconsultant at SahlgrenskaUniversity Hospital, has been awarded the prestigious "Kappa Delta  Elisabeth Winston Lanier Award."The prize, which is shared withthe American researchersRichardLieberand SamWardat University of California, San Diego is given for "Outstanding Orthopaedic Research."The award ceremony tookplace at theAAOSMeeting (American Academy ofOrthopaedic Surgeons) in Chicagoon March 20. The prize is worth20000U.S. dollars. Much of these scientists´work have focused on understanding the mechanics in tendon transfer surgery. Numerous new surgical procedures to reanimate lost upper limb function in tetraplegia have been developed and validated through this long-term collaboration.
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Successful Tetrahand Congress in Hong Kong

June 14, 2013, 3:27 am
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The 11th International Meeting on Surgical Rehabilitation of the Tetraplegic Upper Limb was recently held in Hong Kong. Participants from all continents participated in vivid discussions about various topics related to the reconstruction and rehabilitation of hand control in tetraplegia. The invited speakers covered a wide and informative spectrum of topics:
Tragedy and Miracle Khalid Mohammed (New Zealand), Debilitating contractures in tetraplegia, Anne Bryden (USA),  Spasticity reducing surgery in tetraplegiaCarina Reinholdt (Sweden),  Local experience in tetraplegic hand managementJosephine Wing Yuk Ip (Hong Kong), Shoulder Pain in tetraplegiaKhalid Mohammed, Nerve transfer in tetraplegiaAndreas Gohritz (Switzerland), Tetraplegic Hand Reconstruction: the High and the Low Pak-Cheong Ho (Hong Kong), The Alphabet procedureJan Fridén (Sweden), Surgical balance of the thumbJeremy Simcock / Gordon Beadel (New Zealand), Techniques for Intrinsic Balancing in the HandJames House (USA), Lessons Learned: Neuroprosthetics, 1976-2013 Michael Keith (USA), Myoelectric Control for Upper Extremity NeuroprosthesesDustin Hardwick, Functional electrical stimulation in tetraplegia hand surgery Ines Bersch-Porada (Switzerland).

Panel discussions about current trends and choice of surgical techniques allowed colleagues to challenge the experts. Multiple high-standard free papers were presented.  Some current trends could be identified. They included the use of neurotization to reanimate key motor functions, single-stage multi-procedure reconstructions, immediate active mobilization after surgery and a more clear focus on patient perceived perspective of decision-making process before surgery and considerations during the surgical rehabilitation.   

A lot of attention was paid to the "art" of intrinsic balancing i.e., the intricate restoration of normality of grasp. Jan Fridén, James house and Ursina Arnet (Photo left) provided clinical and kinematical data on how to best rebalance a paralyzed hand by use of active or passive actuators on finger joints. A consensus was reached about not only understanding the mechanics of the hand balance but also the superiority of the House procedure before other procedures to secure intrinsic balance.
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2nd NORTH (Nordic Tetrahand) Congress Held in Bergen, Norway

September 6, 2013, 2:38 pm
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Hand Surgeons and therapists from all nordic countries met for a two-days congress in Bergen, Norway, September 5-6, 2013. Topics covered included the following topics
"Epidemiological trends in traumatic spinal cord injuries during 50 years", "Principles of tendon transfer", "Surgical Reconstruction of grasp control in tetraplegia", "From finding function to daily use - Patients’ journey after grip reconstruction","Enhanced independence – patients experiences after grip reconstruction", "Complications after reconstructive tetra hand surgery", "from the Hong Kong Tetrahand congress 2013"- nerve transfer, and other news".  
 Next congress was decided to be organized in Reykjavik, Iceland in June of 2014.

 
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Loss and Recapture of Hand Control: Professor Jan Fridén at TEDxZurich

October 2, 2013, 11:10 am
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The sophisticated control of the human hand is not guaranteed for life. Numerous diseases and accidents may affect hand performance. One of the most dramatic losses of hand control is the high spinal cord injuries at the neck level causing complete paralysis of all four extremities. It can happen in traffic, when you are skiing or snowboarding or even at home or in your garden.

But this is not the end of the story. Life is not over and mobility can be restored using modern surgical techniques to transfer nerves and muscles to reanimate lost functions and get hand control back. Some examples of this fascinating surgery, the brain plasticity to relearn and regain hand functions are demonstrated in this talk. Most importantly, the individuals’ perception and course of motor relearning to achieve the new functions are illustrated. Increased mobility and freedom by integration of the new functions into daily activities is the ultimate treatment success.

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2014 Reconstructive Tetraplegia Hand Surgery Course in Nottwil/Basel - Now Open also for Therapists

February 19, 2014, 1:41 pm
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Reconstructive Tetraplegia Hand Surgery and Rehabilitation, 23-26 April, 2014, Nottwil and Basel, Switzerland
This 3-days course under guidance of Prof. Jan Fridén will provide state-of-the-art knowledge on surgical reconstruction of upper extremity functions in persons with spinal cord injuries and tetraplegia.  Our aim is to provide a science-based and reliable toolbox of operative procedures for hand surgeons. For the first time we are also inviting therapists to attend and learn fundamentals and guidelines in assessments, training protocols, splinting and, most importantly, share experiences and ideas with each other.
Emphasis is on practical training. Therefore, for surgeons, one day in the anatomy laboratory is dedicated to hands-on-training of the most important tendon and nerve transfer procedures. For therapists, the same day will be focused on practice of splinting and motor relearning.
For details and registration, click here.
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6th Reconstructive Tetraplegia Hand Surgery and Rehabilitation Course completed

May 6, 2014, 3:14 am
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Intensive discussions
We have just completed the 6th Tetrahand Surgery course.  This time it was arranged as a collaboration between the Swiss Paraplegic Centre in Nottwil and University of Basel, Switzerland.  The course attracted 50 participants with equally many surgeons and therapists a
nd representing 18 nationalities.  
Organizing team and faculty
Surgical instructions
The lectures included a wide range of topics e.g. Introduction and Overview (Concepts and Procedures), The Role of Rehabilitation Medicine in Tetrahand Surgery, Assessments and Preparation, Surgical techniques for Triceps and Grip Reconstructions, Nerve Transfers, Spasticity-reducing Surgery, Patient-Focused Outcome Measurements and Clinical Cases. A  particularly interesting and entertaining contribution was Dr Turcsanyi´s lecture about "How to Start a new Tetraplegia Hand Service". 
Participants and Faculty

Therapist Practical Training
In addition to lectures and discussions, the course also offered practical training for both surgeons and therapists i.e., Cad-Lab training of suture techniques as well as nerve and tendon transfer surgical training for surgeons and assessments, splinting methods, electrical muscle stimulation and specific rehabilitation protocols for triceps and grip reconstructions for therapists. The practical day was finished by demonstrations of the Surgical Procedures to all participants.
The course was wrapped up with open discussions covering many aspects of Tetrahand Surgery.




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