22 | Paraplegie, März 2012 Paraplegie, März 2012 | 23

Praxis

a loved one to touch. A child to put to sleep. Or someone to welcome warmly.

«The hands belong to an individual’s person-ality. They show emotions, can carress, but also beat», says Jan Fridén, specialist in Tetra Hand Surgery. Eight fingers and two thumbs – together they assist us in communicating and are indispensable helpers in so many performances in everyday life. By a spinal cord injury, can hands, arms and shoulders be weak, stiff and numb. The higher up the spinal cord is damaged, the more serious are the limitations. For those concerned, this means losing some of their independence. Simple things – opening a bottle, reaching for a book or putting on a sock – the spinal cord injured persons have to cope with daily tasks that are difficult or even impossible to perform. «With an operation we can now en-sure that certain functions of paralyzed hands can be restored», says Jan Fridén. To-gether with physician colleague Simeon Grossmann in the Swiss Paraplegic Centre (SPC) in Nottwil, he can restore the hand function of the injured person and thereby help to get a bit of freedom back.210 consultations have been done by the two doctors in the past year, and more than 30 surgical procedures have been performed. This year the team expects an increase in treatment because of the highly specialized area is still under build-up in the SPC. Tetra-hand expert Jan Fridén has been working regularly here since January 2011. Otherwise,

he is the professor of hand surgery and leader of the Swedish Center for tetraplegia hand surgery at University Hospital in Goth-enburg. «It is a stroke of luck that we can work together with him», says Grossmann.

Strength and flexibility

Consultation in Nottwil. The two surgeons, occupational and physical therapists and physicians from the Department of Ortho-pedic Surgery and Spinal Cord Injury par-ticipate in the consultations. Today’s sched-uled patients represent different phases of the Tetrahand service: those who will soon be operated on, others who have already passed the biggest efforts and come for the follow-ups. Also newly injured patients come to learn about possibilities of further improvement.A young man comes rolling in, he drives the wheels awkwardly with the heel of the hand. The doctors want to see whether the patient can move his joints better since the previous test. «When intervention would be useful, those concerned should strengthen the ex-isting muscles and train the mobility of the joints», says Jan Fridén. «If someone is not willing to make this effort, there will be no operation.» Using simple exercises like stretch your arm, bend your thumb tests the patients’ mobility and strength is tested. The experts register exactly what is possible, how powerful the muscles work and what does not work at all.

Suddenly 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.

Text: Christine Zwygart | Photos: Astrid Zimmermann-Boog, Walter Eggenberger

A handful of freedom

The doctors in Jan Fridén, Bijan Cheikh-Sarraf and Simeon Grossman (left) inspect the hand of a patient with tetraplegia.

Hopeless cases? No, that does not exist for the two doctors. «We can almost always offer an improvement», says Simeon Grossmann. Before leaving the SPC after about nine months of rehabilitation, the patients meet again with the Tetrahand team to share in-formation. However, before an intervention is planned, patients need to gain experience

in everyday life. Therefore, operations are usually performed at the earliest six months after hospital discharge. Professor Jan Fridén says: «We ask the patients to present the five most important abilities to regain after surgery to make sure that the outcome of the procedure will meet the needs of the patient.»

Tendons and muscles

The surgical procedure is delicate: The sur-geons use intact, upper – or forearm muscles and their tendons to connect with certain tendons of the hand. This effectively makes the muscle to perform new tasks e.g. so fin-gers, previously paralyzed, can move and flex and stretch again. We restore both closing

« Hands are some of the most fascinating phenomenon that exists»

24 | Paraplegie, März 2012

Praxis

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and opening of the hand in a single inter-vention – which is «quite unique in the world», says Jan Fridén. To adjust the length and tension of tendons, the surgeon secures the future position of the thumb and fingers precisely. To form an optimal gripping hand that opens and closes, custom solutions are required. Sometimes the thumb must be stabilized, because it sticks out too little out of hand. «It’s a fascinating and responsible task to balance the function and position of the fingers and thumb again because the new hand function will serve the patient un-til the end of the patient’s life.» Fridén has invested much time to perfect the process. Thus, the specialist has developed his own technique, as he sews together two tendons: an overlap length of about five centimeters on both sides with cross-stitches, and sev-eral times all around. «So they can later withstand a load up to 25 kilograms.»In addition to surgery of the hand, the sur-geons also restore the triceps and thus en-sure that a tetraplegic person can lift his arm again. «This expands its action space. He can reach for something that is further away», says Jan Fridén. He speaks about strong emotional moments, when a patient after months and years for the first time himself or herself can stretch out the arm again. «It still touches me deeply every time and I’m reminded of how important our job is.»This feeling of happiness is confirmed by the young man who now visits the clinic. His arm is wrapped in thick splints and bandages, the procedure was a month ago – and his face shines. «Sensational! Before, I had no control over my hand. And now it just works. Chop, chop.» From his doctors he wants to know when he again could change from electric to manual wheelchair. «Please, as soon as possible.»

Independence and mobility

After surgery, patients must remain for re-habilitation up to three months in the SPC. «Mobility and independence are restricted in the first weeks after surgery», says Simeon Grossmann. Therefore, those in-volved must instruct and guide the patient carefully when the new features of the hands and arms are first trained. This time is for many people a big setback, to be way from home, back in the hospital, and tem-porarily more dependent than before. «That’s the main reason why about 20 per-cent of our patients do not want the sur-

The Tetrahand surgery is a medical field that has only about 80 doctors specialized worldwide. Therefore, the exchange of knowledge among them is of immense importance. «The procedures are delicate and have absolutely no margin for er-ror», says specialist Jan Fridén. Every three years, the experts meet at an internatio-nal conference to share their experiences. In addition, an international Tetrahand course is arranged annually and will take place this year in Nottwil from 9 to 12 April 2012 in the Swiss Paraplegic Centre (SPC).The SPC is one of the few clinics in Europe that offers a comprehensive Tetrahand surgery service. Therefore, patients come from abroad here to seek advice and treatment. «We also open the center for so-called ‹Visiting Fellowships’, where we show our interested guest doctors our work. We want to expand this in the futu-re», says Fridén. The Swede is actually one of the world’s only two professors in the field of Tetrahand surgery. Together with physician colleague Simeon Grossmann, he is building now a center of excellence at the SPC and would like to establish a European Society based in Nottwil. The aim of the European Society is to coordi-nate the training and research and to create a network of doctors and therapists, «because it makes no sense to start all over again from scratch».

international Network

gery», says Jan Fridén. Totally understand-able but also sad when you see the potential. After the first difficult weeks, the functions and abilities will improve.Accident insurance usually pays for the sur-gery. The cost of the long rehabilitation and follow-ups, however, always lead to discus-sions, because no one feels responsible for this important part of the treatment. «We will have to develop a new model, so that the patient’s rehabilitation after a shorter hospital stay is guaranteed at home with the help of assistance and trained thera-pists», says Fridén. This applies particularly

with regard to patients from abroad (see box). Either way, the expert is convinced that the state can save money in the long term: «In effect, patients will receive much more independency and require less assis-tance.»Dressing, cooking, writing, driving a wheel-chair forward, shake hands when greeting someone – that’s usually possible for tetra-plegics after surgery. Or how Fridén puts it: «Hand control is one of the most sophisti-cated and fascinating things that exists.»

For more information, please visit: www.tetrahand.comFunction before and after surgery can be viewed at www.paraplegie.ch/magazin

Operation.1 Grossmann, Fridén and Cheikh-Sarraf (from left)

identify the right tendon to link to a new function.

2 Prior to surgery, the patient can only hold the pen using both hands.

3 After surgery: The fingers have power again and the writing works better.

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