HorizonHOSPITAL FORSPECIAL SURGERY:SPECIALISTS INMOBILITY

WINTER 2009

The Hand: Incredible Form, Extraordinary Function

The orthopedic surgeons onthe Hospital’s Hand Serviceare expertly skilled in howbest to repair the nerves,vessels, soft tissues, and bonesof the hand, wrist, and elbowso that they work individuallyand together for optimalfunction.

Pictured are (seated) Scott W.Wolfe, MD, Chief of the HandService, with (left to right)Michelle G. Carlson, MD,Andrew J. Weiland, MD,Robert N. Hotchkiss, MD,Aaron Daluiski, MD, EdwardA. Athanasian, MD, andLana Kang, MD.

The human hand is nothing short of incredible. It allowsus to work, to touch, to tie a tie, or to catch a ball.Our hands help us to communicate and to express ouremotions. From morning ‘til night, they are ever moving,and when something goes awry in their intricate anatomy,their importance to our lives is never more apparent.

The Hand Service at Hospital for Special Surgery offers anunparalleled depth of expertise that encompasses a broadarray of treatments for common and complex conditions.“When you consider the number of activities that require

the use of our hands, any injury or disorder that compromisestheir function can be devastating to a career or quality of life,”says Thomas P. Sculco, MD, Surgeon-in-Chief. “Our hand special-ists, through their skills in surgical interventions that includereconstruction of nerve injuries, arthroscopic repairof complex ligament tears and wrist and forearmfractures, microsurgical repair of blood vessels,and reconstruction of complex elbow injuries, arecommitted to giving patients every opportunity torecover optimal function so that they can resumethe lifestyle they had previously.”

“While our seven physicians treat conditions affecting every facet of theupper extremity,” says Scott W. Wolfe, MD, Chief of the Hand Service, eachhas further developed a subspecialty expertise in such areas as traumaticinjuries, degenerative diseases, congenital hand disorders, vascular diseases,nerve injuries, tumors of the upper limb, and reconstruction of the elbow.”

Reconstructing Nerves in the Brachial PlexusStephen Cook was harvesting a tree on his farm in the Adirondacks when adead branch fell 80 feet, hitting him, and fracturing his skull, arm, neck, andback. His brachial plexus, the web of large nerves that originate from thespinal cord in the neck and direct the movement and sensation of the entireupper limb, had been severely injured. “I rode snowmobiles, hunted, andthen, ‘hey buddy, you’ve got only one good arm!’” recalls Mr. Cook. “The localdoctors painted such a bleak picture that I was contemplating amputation.I dealt with that for a few months, and then I Googled brachial plexus.Dr. Wolfe’s name popped up. I called him and he told me time was of theessence since it was already five months past the date of the accident.”

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The Hand: IncredibleForm, ExtraordinaryFunction

Extensive surgery byDr. Scott Wolfe on thenerves of the brachialplexus saved StephenCook’s arm, enabling himto return to his work as atree farmer and rusticfurniture maker. At left,a microscopic view ofbrachial plexus nerves inthe midst of being surgi-cally repaired. (more onlineat www.hss.edu/horizon)

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“A brachial plexus injury can have a devastating impact on upper limbfunction, potentially affecting – as in Mr. Cook’s case – the muscle power ofthe entire arm,” says Dr. Wolfe. “There is a small window of time that if youdon’t get a spark going in the muscle, it’s never coming back. To allow regen-erating nerves to connect with paralyzed muscles and restore muscle functionbefore dense scarring develops, nerve reconstructive surgery is ideallyperformed within the first three to five months after an injury. Recovery frombrachial plexus surgery is measured in months and yearsrather than days or weeks. At four to eight months aftersurgery, patients will experience a flicker of muscle recovery,with a gradual return of strength and mobility.”

“When my bicep started twitching,” recalls Mr. Cook,“I noticed just a little twitter. I worked it hard. About a yearfrom that I was able to raise my arm.” That was over fouryears ago and, today, Mr. Cook continues to make his livingas a rustic furniture maker.

The Hand Service has established a brachial plexus registry,enabling the Hospital’s surgeons to pursue studies of innovative nervetransfer and repair procedures and research and evaluate patient out-comes to improve management of these complex injuries even further.Many of these procedures require a microsurgical approach in order toaddress the reconstruction of the body’s minute nerves and vessels.

Applying Microsurgical TechnologyPerformed under the magnification of a microscope, microsurgery is typicallyused to transplant tissue from one part of the body to another, or to recon-struct arteries, veins, and nerves by placing sutures in the walls of the bloodvessels and nerve coverings. Connections for blood vessels and nerves canthen be made to reestablish blood flow and nerve transmission. The field ofmicrosurgery has vastly improved since the 1970s, when Andrew J. Weiland,MD, performed some of the world’s first free tissue transfers and bone grafts.

According to Dr. Weiland, innovative techniques using microsurgical dissec-tion, such as nerve transfers, have revolutionized how surgeons can recon-struct extremities and repair nerves and vessels. “Technology has alsoadvanced nerve repairs and treatment of tendon injuries,” says Dr. Weiland.“Surgeons are starting to use nerve guidance tubes to make up gaps in nervesthat may perhaps be equivalent to performing nerve grafts. In the future I thinkbiologics will be the answer. We’ll have a better handle on growth factors andhow to get those to help us heal tissues.”

Emphasizing the Elbow JointAt the age of eight, Adriana Ricottone fell and suffered a radial head frac-ture of her right elbow with resulting tendon and ligament contracture.This type of elbow fracture is very common, usually caused by falling onan outstretched hand. “The radial head, which is a small bone in the fore-arm near the elbow, is important for bending of the elbow joint, as well asrotation of the forearm,” says Robert N. Hotchkiss, MD. “If there is only aslight loss of motion, we let the child continue to grow and follow his or her

Dr. Scott Wolfe performssurgery to repair damagednerves, tendons, and bloodvessels associated with abrachial plexus injury.

The patient’s nerves areelectrically stimulated inthe surgical field andrecordings are obtainedfrom nerves and/or musclesto assess the degree ofnerve injury. Says BrionD. Reichler, MD, whodirects the IntraoperativeNeurophysiologicalMonitoring Service, “Thishelps to differentiatefunctioning from non-functioning nerves.”

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functional capabilities closely. But Adriana’s elbow had become very stiff tothe point where she actually couldn’t move the joint at all. On September 8,2008, Dr. Hotchkiss performed surgery to release contractures and removethe bone affected by the fracture. Six weeks after her surgery, Adriana’smother, Stephanie, reported she was doing very well. Difficult orthopedicconditions around the elbow – from fractures in children to arthritis in olderadults – are a subspecialty focus of Dr. Hotchkiss. He and histeam of researchers are addressing all aspects of elbowreconstruction. “We are one of the few institutions aroundthe country that has the concentration of practice, the accu-mulated experience, and the multidisciplinary collaborationwith engineers, biologists, and implant manufacturers whocan come to the table to discuss challenges to elbowreplacement and generate progress,” says Dr. Hotchkiss.

Addressing Athletic AilmentsSports-related injuries to the hand and forearm can rangefrom a jammed finger during a basketball game to a fracture or dislocation ofthe wrist. Professional and recreational athletes, or active teens and chil-dren, are all prone to these types of injuries, and regardless of the severity,prompt attention from a hand surgeon can make an important difference inlong-term recovery and ability to continue inthat sport. No one knows this better then anelite athlete such as the Knicks’ forward JaredJeffries. Injured in a game in which he fell onhis wrist, Mr. Jeffries had fractured thescaphoid bone – a small bone that sits at thebase of the thumb. “With athletes, particularlyprofessional athletes, we need to determinewhether to let them continue to play andrepair the injury at the end of the season, orfix it now and get them back to playing assoon as possible,” says Michelle G. Carlson,MD, who consults on hand injuries for theNew York Knicks, working closely withAnsworth Allen, MD, an orthopedic surgeon with Hospital for SpecialSurgery, who serves as the Knicks team physician, and Lisa R. Callahan, MD,medical director of the Knicks. Dr. Carlson put a screw into Mr. Jeffries’scaphoid to allow for the quickest healing of the bone. “We followed up withregular CT scans to evaluate when the bone was healed, and at six weeks hewas able to return to play.”

Treating Tumors, Retaining FunctionEdward A. Athanasian, MD, focuses on bone and soft tissue sarcomas of thehand, forearm, and elbow which, although uncommon, can be life-threatening.“My goal is to accomplish both the primary objective of getting the tumorout and preventing local recurrence and metastasis, and then put thingsback together so that the hand will retain as much function as possible,”

Dr. Michelle Carlsoninspects the progress ofNew York Knicks playerJared Jeffries, who hadfractured his wrist duringa game.

Adriana Ricottone gives a“thumbs up” to Dr. RobertHotchkiss, Director ofResearch for the HandService and Director ofClinical Research for theHospital, during a post-operative examination.

Total Care ofthe Hand,Wrist,and Elbow

Orthopedic surgeon EdwardA. Athanasian (standing) andradiologist Douglas Mintz, MD,combine their expertise insoft tissue tumors of the handand upper extremity to maxi-mize outcomes for patients.Using MRI and other imagingtechnologies for diagnosis andfor monitoring treatmentresponse, Dr. Mintz providesimportant information thatDr. Athanasian will need forsurgery to remove the tumorand preserve healthy tissue.

“Throwing a dart requires aspecific wrist motion that enablesus to perform a number ofoccupational and sports-relatedactivities,” says Scott Wolfe,MD, Chief of the Hand Service,who directs federally fundedresearch in wrist kinematics.Dr. Wolfe and his research teamin the Leon Root, MD MotionAnalysis Lab are detailing thearc of a dart-thrower’s motionusing markers affixed to thehand and the forearm in orderto calculate parameters thatallow wrist motion. The data willprovide important informationfor treatment, and will also beused to develop a breakthroughwrist replacement prosthesis.

Among the many conditions that bring patients toHospital for Special Surgery’s Hand Service are:

Distal radius fracture This fracture of the largerof the two forearm bones linking the hand to theelbow occurs when the radius breaks, usuallywhen landing on outstretched hands

Basal joint arthritis Osteoarthritis of the jointat the base of the thumb

Carpal tunnel syndromeA gradual reduction in thecarpal tunnel (the space inthe wrist bound on threesides by bone) for the nerve thatruns from the neck to the fingers

Dupuytren’s contracture A conditionwhere the fingers contract towards thepalm and cannot be fully extended

Tendonitis Entrapment of a tendon commonlyseen in the wrist, fingers, and elbow causing,swelling, pain, and discomfort

The location of these conditions are identified in theaccompanying illustrations.

Bones of the Hand and Wrist

Soft Tissue Tumors

Understanding Wrist Motion

Twenty-nine bones make up thewrist and hand. The wrist itselfcontains eight small bones, calledcarpals. These join with the twobones in the forearm – radius andulna – to form the wrist joint.

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The three-dimensional model ofthe ulna based on CT scans andthe planned surgical procedurecreated by Joseph Lipman, MS,Director of Device Developmentin the Department of AppliedBiomechanics and OrthopedicSurgery, served as the templatefor reconstruction surgery on apatient with a complex fractureat the tip of the ulna. Thepost-operative radiology imagedisplays the pins, wires, andscrews that were used to securethe ulna, radius, and humerusbones in the proper position.

Dr. Andrew Weiland has severaldecades of experience withmicrosurgery, which is per-formed under the magnificationof a microscope and used torepair or reconstruct smallvessels and nerves in the handin order to reestablish bloodflow and nerve transmission.

Under the direction of AvivaWolff, CHT, OTRL, (above)the Hospital’s Hand TherapyDepartment plays a prominentrole in the care of adults andchildren with acute hand andelbow injuries, chronic condi-tions, and those recoveringfrom surgery.

The Division of Rheumatology atHospital for Special Surgery isamong the top ranked in thenation. Rheumatologists such asLinda Russell, MD, participate incrucial collaborations with theHand Service. They play a keyrole in the care of patients witharthritis of the thumb, finger,and wrist joints, providingmedical management and non-surgical treatments to minimizepain and discomfort and maxi-mize function.

Physiatrist Joseph H. Feinberg,MD, performs electrodiagnosticstudies to localize the sourceof a patient’s neurologicalsymptoms – such as weakness,numbness, tingling, or lossof function in the hands – bydetermining if the site of theinjury is from the neck, brachialplexus, the elbow, or the wrist.They can also help to quantifythe extent of nerve injury anddysfunction.

Muscles, Nerves, Tendons, and Ligaments

Microsurgical Repair

Reconstructing Elbows

Evaluating Nerve Function

Maximizing Function

Medical Management

Many of the muscles that con-trol the hand start at the elbow,travel down the forearm, andcross at the wrist and hand.Some control motions of thewrist, while others allow thefine motor actions involving thefingers and thumb.

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says Dr. Athanasian. “Sometimes we’re in a situation where no textbookcan describe what to do. For example, instead of amputating an arm becauseof a tumor inside the patient’s elbow joint, I may take out the entire elbowas one piece and then reconstruct it with bone transplants, an artificialelbow, and some form of soft tissue coverage.” Dr. Athanasian and hiscolleagues are now pioneering the concept of thumb salvage. “We recentlycompleted a study showing that reconstruction following resection can resultin acceptable functional outcomes with a low risk of complication. This isimportant since the thumb accounts for about 50 percent of the functionof the hand.”

The Potential to Transform TreatmentWhen Mrs. Rosalie Van Cleef shattered her right wrist as the result of a fall,she sought out Aaron Daluiski, MD, for care. “I knew that if I had to havesurgery he would be the doctor for me,” recalls Mrs. Van Cleef. This pastSeptember, Dr. Daluiski performed a nearly hour and a half surgery duringwhich he repaired a distal radius fracture and ulna fracture using a steelplate and cadaver bone. Today, Mrs. Van Cleef’s fractures have healed andshe has complete use of her wrist.

Injuries such as Mrs. Van Cleef’s are of particular interest to Dr. Daluiski,a clinician-scientist who is conducting basic science research on the molecu-lar events of fracture healing that will have broad-based applications fororthopedic surgeons. “There is a set pattern in fracture healing and a cleardifference in how children heal versus adults that is remarkable,” saysDr. Daluiski. “Children’s fractures can potentially heal within three to fourweeks, while it can take six to seven weeks for the same fracture to healin adults.” Dr. Daluiski and his colleagues have already isolated several genesthat may be implicated in this disparity. “If we understand these differences,then we will be able to develop targeted therapies to replicate how a child’sfracture heals.” (more online at www.hss.edu/horizon)

A Perspective on Hand Surgery“The use of our hands is reflective of our talents and ourintellect – our hands are precise and functional,” saysLana Kang, MD, who has a special interest in hand andupper extremity trauma, carpal tunnel syndrome, andoveruse and work-related conditions.

Dr. Kang and her colleagues are continually engaged inoutcomes research to help further knowledge in the treat-ment of the hand and upper extremity. She has recentlybeen involved in the development of a patient database forcompression syndrome of the ulna nerve – one of the threemain nerves in the arm. “The condition can sometimes beassociated with elbow trauma, but it also occurs sponta-neously,” says Dr. Kang. “By evaluating information ofpatients enrolled in a database, we can better understandwhat affects these conditions and help determine whichtreatment method is best suited for a particular patient.” �

The newest Special Surgeryorthopedic residentsundergo a lesson in upperextremity casting byDr. Lana Kang.

Dr. Aaron Daluiski andhis colleagues have discov-ered a gene that appearsto inhibit a signalingpathway, which may bekey in bone growth andfracture healing.

Opposite page: TheHospital’s hand surgeonshave (clockwise) helpedPeggy Ogden return tosculpting after surgery forcarpal tunnel syndromeand basal joint arthritis;saved the hand ofChristopher Manno withmicrovascular surgery torestore circulation; enabledworld-renowned pianistMisha Dichter to again playhis favorite concerto aftersurgery for Dupuytren’scontraction; and sent NewYork Knicks Power ForwardMalik Rose quickly back tothe court after he sprainedhis wrist. (more online atwww.hss.edu/horizon)

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Editor-in-ChiefSara Kosowsky

Managing EditorLinda Errante

DesignArnold Saks Associates

Cover and Inside PhotographyRobert Essel

Hand IllustrationsAnatomical Chart Company

External Affairs DepartmentHospital for Special Surgery535 East 70th St., Suite 842WNew York, NY 10021horizon@hss.edu www.hss.edu

Hospital for Special Surgery is anaffiliate of NewYork-PresbyterianHealthcare System and Weill CornellMedical College.

This publication was printed with 100%renewable, non-polluting, wind-gener-ated power on 10% post-consumerrecycled paper that is certified by theForest Stewardship Council (FSC).

©2008 Hospital for Special Surgery.All rights reserved.

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When a torn ligament in his handnine years ago threatened to curbhis active lifestyle, businessman

and philanthropist Thomas L. Kempnersought treatment at Hospital for SpecialSurgery. “I’ve always known the reputation

of the Hospital’sphysicians and theinstitution,” saysMr. Kempner, whosedaughter Jessica hadbeen treated for aColles’ fracture byMichelle G. Carlson,MD. So when he

injured his hand, Mr. Kempner came toSpecial Surgery to see Dr. Carlson. “Peoplecan live the rest of their lives without thisligament, but there is a high risk of develop-ing arthritis,” he says. “I ride a bicycle 7,000miles a year and am active in sports. I wasafraid that losing the ligament would havelong-term consequences and would havelowered the quality and enjoyment of mylife.” Following surgery to repair the liga-ment, Mr. Kempner underwent six monthsof physical therapy. “My hand is 100 percentas good as it was,” he says. “Who wouldcomplain about results like this?”

Impressed as he was with Dr. Carlson’ssurgical skills, he also admired her work asDirector of the Hospital’s Children andAdolescent Hand and Arm (CHArm) Center,prompting him to become a major contrib-utor. The CHArm Center provides surgicaland nonsurgical treatments for sportsinjuries, congenital disorders, cerebral palsy,juvenile arthritis, and fractures.

Supporting Hospital for Special Surgery,says Mr. Kempner, is a way to help changepeople’s lives. “For most of us who havebusy jobs and can’t volunteer our time, theleast we can do is volunteer some money,”he says. “I’m happy to help empower peo-ple who I think are doing great things andhelping to make the world a concretelybetter place for others.”

Supporting ScienceRussell L. Carson would agree. Over thepast 35 years, he has been a patient atHospital for Special Surgery for varioussports-related injuries. His personal per-spective is complemented by a professionalinterest in health care. Mr. Carson’s firm isthe largest private investor in the healthcare industry in the country, and he hasbeen a member of the Board of Trusteesof The Rockefeller University since 1994,serving as Chairman since 2005. WhenRichard L. Menschel, Chairman Emeritusof the Hospital’s Board of Trustees, invitedhim to learn about a new clinician-scientistincubator that was to be launched atSpecial Surgery, Mr. Carson was intrigued.

“The whole area of trying to coordinatethe scientists and clinicians is very muchof interest to me,” says Mr. Carson. “How

do you get themworking together sothat you are askingpractical questionsand discovering prac-tical solutions to realworld problems?”A major gift fromMr. Carson and his

wife Judy helped to establish SpecialSurgery’s clinician-scientist incubator,including the laboratory of Aaron Daluiski,MD, a clinician-scientist specializing inhand and upper extremity surgery.According to Dr. Daluiski, Special Surgeryoffered him a unique opportunity to bothcare for patients and pursue basic research.

Says Mr. Carson, “I’d argue that theresearch makes the clinician a better doc-tor and the clinical side makes the doctor abetter researcher. When you have been apatient, you develop an appreciation forthe people who work in health care, butyou also recognize the necessity of contin-uing to find better ways of doing things.” �

Promoting Excellence in Health Care:

Perspectives of Two Philanthropists

Thomas L. Kempner

Russell L. Carson