- Email: [email protected]
2004–2005 Sterling Bunnell Traveling Fellowship Report
2004 –2005 Sterling Bunnell Traveling Fellowship Report Alexander Y. Shin, MD From the Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN.
The Bunnell Traveling Fellowship was established in 1982 with the purpose of sponsoring a young hand surgeon in the development of national and international relationships that contribute to his/her pursuit of higher learning and that foster the principles of scholarship of the American Society for Surgery of the Hand. I was fortunate to be selected as the 24th Sterling Bunnell Fellow, and I had the opportunity to follow in the footsteps of the 23 former fellows. In Bunnell’s Surgery of the Hand, Fourth Edition (Boyes JH, ed. Philadelphia, Lippincott; 1964:561-567), a man with a brachial plexus injury was described. The recommended treatment was shoulder arthrodesis and transhumeral amputation, followed by fitting of an above-elbow prosthesis. Sterling Bunnell has been quoted as saying, “To someone who has nothing, a little is a lot.” Nowhere in the field of hand surgery is this more true than in patients with brachial plexus injuries. The theme and purpose of my traveling fellowship was to evaluate the status and advances of adult brachial plexus surgery throughout the world, to determine the utility of the contralateral C7 nerve transfer, to evaluate the optimal reconstruction of grasp, and finally to determine the philosophies of experts around the world regarding the treatment of these patients. (J Hand Surg 2006;31A:1226 –1237. Copyright © 2006 by the American Society for Surgery of the Hand.) Key words: Sterling Bunnell Traveling Fellowship.
t gives me great pleasure to present to the membership of the American Society for Surgery of the Hand the 24th Sterling Bunnell Traveling Fellowship report. My Sterling Bunnell Traveling Fellowship took place over 3 continents (North America, Europe, Asia) and encompassed 7 countries, 12 cities, 19 institutions, and a total of 40 nonconsecutive days away from my practice and family. My first stop was Bangkok, Thailand. In this city with a population of close to 9 million people, one quarter of the population use motorcycles, with many families using the motorcycle as their primary mode of transportation. It is not uncommon to see a family of 4 riding a single motorcycle, speeding in and out of cars and other motorcycles on the major highways of Bangkok. This tremendous reliance on motorcycles has resulted in a very large number of brachial plexus cases in Bangkok. The first institution I visited was the Siriraj Hospital of the Mahidol University. The brachial plexus team, which is headed by Dr. Panupan Songcharoen, is a world-renowned center. During my visit with Dr. Songcharoen, I had the
I
1226
The Journal of Hand Surgery
ability to evaluate and participate in surgical cases of hemi– contralateral C7–to–median nerve transfer for hand function (Fig. 1). In evaluating some of his best cases, I was able to see and observe that he had obtained independent hand and finger flexion in a select number of patients after use of the contralateral C7 nerve prolonged with a vascularized ulnar nerve graft to the median nerve. Dr. Songcharoen discussed his experience of nearly 20 years in brachial plexus reconstruction. Because the number of patients with plexus injuries far exceeds the resources available, the goals for reconstruction are limited. These limited goals include neurotization procedures for shoulder nerve function (suprascapular nerve) and for elbow flexion (musculocutantous nerve). The contralateral C7 nerve was used for grasp by prolonging it with a vascularized ulnar nerve graft with neurotization to the median nerve. Also commonly used sources of neurotization include the spinal accessory nerve, intercostal nerves, and phrenic nerve. For late brachial plexus reconstruction, the free functioning gracilis transfer for elbow flexion was a commonly per-
Alexander Y. Shin / 2004 –2005 Fellowship
1227
Figure 1. (A) In the operating theater of Siriraj Hospital, Bangkok, Thailand, I (second surgeon from the left) had the privilege of assisting Professor Panupan Songcharoen (third surgeon from the left) in a contralateral hemi–C7 transfer prolonged with a vascularized ulnar nerve graft to be neurotized to the median nerve to restore hand function. (B) In the clinic, Professor Panupan Songcharoen (middle) examines one of his contralateral C7 patients.
formed procedure. Dr. Songcharoen has achieved several excellent results with end-to-side transfers of the motor branch of the biceps to the ulnar nerve, which resulted in excellent M4 elbow flexion in a handful of patients. After many discussions of the brachial plexus injuries and the ability to reconstruct them using his philosophy, I left Siriraj Hospital with high admiration for what Professor Panupan Songcharoen has done in the past 20 years for the field of brachial plexus surgery. The next institution that I visited in Bangkok was Lerdsin Hospital. Under the tutelage of Dr. Somsak Leechavengvongs, I had the opportunity to observe firsthand what he and his partner, Dr. Kit Witoonchart, described in the American volume of The Journal of Hand Surgery in 2003.1,2 The triceps branch–to–axillary nerve transfer that they described is a highly novel transfer that restores function to the denervated deltoid in patients with upper trunk (C5– C6) injuries. A former student of Professor Christophe Oberlin, Dr. Somsak Leechavengvongs directed an extremely busy general hand and brachial plexus practice. In the clinic, he detailed the importance of careful and detailed clinical examination and evaluation of the upper extremity in patients with brachial plexus injuries. The surgical cases he planned for me highlighted his approach to the upper-arm–type of brachial plexus injury (Fig. 2). After evaluating a dozen of his patients with upper-arm–type brachial plexus injuries (C5,6 avulsions) who had ulnar fascicle–to– biceps transfer and triceps branch of the axillary nerve transfer in addition to the spinal accessory nerve–to–the suprascapular nerve transfer, I was quite impressed. His results were outstanding
and have recently been published in The Journal of Hand Surgery.3 Among the many clinical dilemmas we discussed, the role of neurotization of the long thoracic nerve to prevent scapular winging was the most interesting. Dr. Somsak Leechavengvongs was extremely gracious in allowing me to evaluate his patients. His honesty and his clinical observation skills were superb. The results of his neurotizations for upper-trunk injuries resulted in excellent return of function. It was a privilege and honor to be able to participate in several brachial plexus surgical cases with Dr. Somsak Leechavengvongs. In addition to visiting with Dr. Leechavengvongs, I had the opportunity to visit some of his colleagues including Drs.
Figure 2. At the Lerdsin Hospital, Professor Somsak Leechavengvongs (right) demonstrates to me (middle) an upper-trunk reconstruction using multiple neurotizations, including the triceps branch–to–axillary nerve transfer, which he described.
1228
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 3. The Lerdsin Hospital Hand Surgeons. From right to left, Drs. Chairoj Uerpairojkit, Somsak Leechavengvongs, Alexander Shin, Kit Witoonchart, Kanchai Malungpaishrope, Rattavuth Raksakulkiat, and Asamon Ukrit.
Chairoj Uerpairojkit and Kanchai Malungpaishrope, who also demonstrated their skills as expert hand and peripheral nerve surgeons (Fig. 3). My next stop was mainland China. I had planned a quick weekend visit in Beijing followed by several days in Shanghai. In Beijing I had the opportunity to visit the China/Japan Friendship Hospital and visited with Professor Yungting Wang, the Secretary of the Chinese Association of Hand Surgery. During my visit at the Japanese/Chinese Friendship Hospital, I had the opportunity to present our work on carpal instability followed by the opportunity to observe the role of traditional Chinese medicine in the treatment of peripheral neuropathies. I also had the unique lifetime experience of climbing the Great Wall of China, observing the manufacturing of silk, and touring the Forbidden Palace. After a quick weekend in Beijing, I was off to Shanghai to visit the Huashan Hospital and the People’s Sixth Hospital. In Shanghai, I was met by Dr. Huan Wang, a protégé of Professor Yu-Dong Gu, and was taken to the new Huashan Hospital to visit with Professor Yu-Dong Gu. Professor Gu is a leader, pioneer, and innovative thinker among brachial plexus surgeons. His tremendous experience with brachial plexus injuries and his large number of publications made for an extremely interesting discussion on the future and current status of brachial plexus injury reconstruction in adult patients. Professor Gu described to me how he first decided to use the contralateral C7 in the reconstruction of the injured complete brachial plexus injury and related the story of a young man
who had such a severe injury with no potential sources for nerve grafting or neurotization that he decided to approach the uninjured contralateral C7 and use it to neurotize targets of the injured side (Fig. 4). After a wonderful discussion on the results of contralateral C7 transfer, I had the opportunity to visit the Huashan operating room. I observed a surgery where multiple neurotizations of a patient with an injured brachial plexus were performed. The ability to sit and discuss brachial plexus injuries with one of the pioneers of brachial plexus surgery was one of the highlights of my Bunnell Traveling Fellowship. The Shanghai People’s Sixth Hospital, the famous hospital known for the tremendous number of toeto-hand transfers performed, was my next visit in Shanghai. I had the opportunity to meet with Profes-
Figure 4. In Shanghai, China, at the Huashan Hospital discussing brachial plexus surgery and the contralateral C7 transfer with Professor Yu-Dong Gu.
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 5. Professor David C. C. Chuang and I at the Chang Gung Memorial Hospital in Taipei, Taiwan.
sor Bing Fang Zeng, Chief of the Department of Orthopedic Surgery and the vice president of the hospital, who described and has used multiple composite flaps for complex hand reconstruction.4,5 After hearing an excellent lecture on reconstruction of the hand by composite free-tissue transfers by Professor Zeng, I was able to visit with Dr. Cunyi Fan at the Shanghai People’s Sixth Hospital and had the opportunity to see many cross-leg flaps and upper-hand replantations and reconstructions. The famous statue of the thumb that has been recognized by western hand surgeons as the symbol of the People’s Sixth Hospital has been removed to construct a new parking structure. The next trip was to the Republic of China, Taiwan. In Taiwan I had the opportunity to visit 2 cities, Taipei and Kaoshuing. It was in Taipei that I had the opportunity to visit Professor David C.C. Chuang at the Chang Gung Memorial Hospital. Professor Chuang has performed over 1,400 adult cases, over 300 obstetric cases, and over 120 contralateral C7 cases. I had the opportunity to observe a contralateral C7 with a vascularized ulnar nerve graft for median nerve function and to spend several days in his clinic observing his brachial plexus patients (Fig. 5). He described to me the importance of contracting the donor nerve muscle as much as possible to obtain a better outcome in the target muscle. Professor Chuang’s tremendous experience of free functioning muscle transfers for brachial plexus surgery was evident, and I was able to evaluate a number of his patients who had excellent results. When asked about his results of the contralateral C7 transfer, Professor
1229
Chuang said that he uses the entire contralateral C7 in restoring function to the injured brachial plexus. Although independent function was not often observed, the motion gained was important to his patients. After several days in Taipei, I visited the southern city of Kaoshuing. Professor Yuan-Kun Tu was my host. Professor Tu is the president of the E-Da EShou Hospital and a highly skilled microsurgeon. During my first day with Professor Tu, I had the opportunity to participate in an upper-trunk brachial plexus reconstruction and to observe other microsurgical procedures (Fig. 6). One microsurgical procedure was the use of a composite rib, serratus, and latissimus free flap, not only to provide a vascularized bone graft to a bone defect but also to provide muscle coverage over the vascularized bone graft. This was a very enlightening case that was soon applied to one of my patients on returned my return to the United States. Professor Tu also demonstrated a combined gracilis and adductor longus functioning muscle transfer based on a single nerve pedicle and vascular pedicle for brachial plexus reconstruction. This combined gracilis adductor longus free functioning muscle transfer was transferred for elbow flexion and also for finger flexion. Professor Tu was a spectacular host and demonstrated new techniques in microsurgery that have been integrated into our Mayo Clinic practice. My next trip took me to the country of my ancestors, South Korea. In a 1-week visit to Seoul, I toured 4 university centers including the Samsung Medical Center, Seoul National University, Catholic University, and the Seoul Microsurgery Hospital. The first stop was Samsung Medical Center, where I was hosted by the Associate Professor Ming Jung Kim, who is an accomplished hand surgeon and a rising star in Korean hand surgery. After an excellent day in the operating room, I was treated to a traditional Korean meal, which brought back many fond memories of my childhood. The second day was spent at Seoul National University, where I was hosted by Associate Professor Goo-Hyun Baek (Fig. 7). Dr. Baek’s congenital hand practice was incredible, and I was presented with many excellent cases and research studies that further stimulated discussions with Dr. Baek and his staff. The next day I had the privilege of visiting with Professor Sang Soo Kim at the Seoul Microsurgery Hospital. Professor Kim was the president of the Korean Society for Surgery of the Hand in 2005 and has over 26 years of experience in brachial plexus reconstruction. After his training by
1230
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 6. (A) Professor Yuan Kun Tu of the E-Da E-Shou Hospital and I in Kaoshuing, Taiwan. (B) Surgery on an upper-trunk brachial plexus injury with Professor Tu.
Figure 7. With the famous Seoul National University Hospital as a backdrop, a picture of Professor Goo-Hyun Baek (second from left), me, and his hand surgery staff (Dr. Il Kyu Han [left], Dr. Jae Kwang Kim [second from right], and Dr. San Ki Lee [right]).
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 8. Professor Sang Soo Kim and I discussing the surgical options with a patient with a complete brachial plexus avulsion at the Seoul Microsurgery Hospital.
both Professors Narakas and Millesi, Professor Kim returned to Seoul to be one of only a few brachial plexus surgeons. He has performed over 100 brachial plexus cases per year over the last 26 years of his career. He has performed over 150 contralateral C7 transfers and arranged for me to evaluate his contralateral C7 patients. After I had the opportunity to evaluate his patients, we discussed the different philosophies of reconstruction and the use of the contralateral C7 and other techniques to regain grasp (Fig. 8). Professor Kim showed me cases where patients had the contralateral C7 prolonged with a vascularized ulnar nerve graft that was banked for 6 months, followed by a second-stage surgery that included transfer of the banked ulnar nerve to the musculocutaneous nerve and median nerve. Several of his patients had independent motion of the target muscle without the need to activate any of the C7mediated musculature on the contralateral side. Despite this, he readily agreed that independent motion is a rarity and that grasp has been difficult to achieve using this technique. He also showed the importance of routine neurotization of the triceps branch to gain improved upper-extremity control and challenged our philosophy of not making elbow extension a priority. His procedure of choice for obtaining grasp has been the free functioning muscle transfer as described by Doi.6 The day ended with a traditional Korean feast with Professor Kim, Dr. Min Jung Park from Samsung Medical Center, Professor Duke Whan Chung from the Kyung Hee University, and Dr. Soon Tak Oh, Co-president, Seoul Micro Hospital (Fig. 9). My last stop in Seoul was the Catholic University.
1231
The hand surgeons of this University included Professor Seung Koo Rhee, the 2006 President of the Korean Society for Surgery of the Hand; Professor Hyoung Min Kim, the 2005 President of the Korean Society for Microsurgery; and Professor Seok Whan Song, Chairman of Orthopedic Surgery (Fig. 10). My host at Catholic University was Associate Professor Yang Guk Chung, who was a former Mayo Clinic research fellow. I had the opportunity to discuss and perform a vascularized bone grafting of a scaphoid nonunion using the 1,2 intercompartmental supraretinacular vessel (Fig. 11). This was followed by an excellent didactic lecture in which we discussed carpal instability and scaphoid fractures among other topics of general hand surgery. Our evening ended after excellent academic discussions at a traditional Korean barbecue, where again I was treated to many of the foods that I grew up with. It was an extreme pleasure and a trip that I will not soon forget. The next city I traveled to was Toronto, Canada to visit Associate Professor Dimitri Anastakis at the University of Toronto. In previous reports, Dr. Anastakis and his mentor, Professor Ralph Manktelow, described the use of the free functioning gracilis for deltoid reconstruction.7 The goal of this trip was to determine if the free functioning gracilis muscle could be applied in deltoid reconstruction in patients with brachial plexus injuries. I had the opportunity to evaluate several patients with tumor resections of the
Figure 9. After a traditional Korean dinner, Associate Professor Min Jung Park, MD (Samsung Medical Center, back row left), Professor Duke Whan Chung, MD, PhD (Kyung Hee University, back row right), Professor Sang Soo Kim (Seoul Micro Hospital, front row left), me (front row, middle), and Dr. Soon Tak Oh (Co-president, Seoul Micro Hospital, front row, right).
1232
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 10. The Catholic University of Seoul, Korea Orthopedic Surgeons and Hand Surgeons. From the left, Dr. Ki Won Kim, Dr. Joo Yup Lee, Dr. Il Jung Park, Professor Hyoung Min Kim (President, 2005 Korean Microsurgery Society), me, Professor Seung Koo Rhee (President, 2006 Korean Society for Surgery of the Hand), Associate Professor Yang Guk Chung, and Professor Seok Whan Song (Chair, Department of Orthopedic Surgery).
deltoid reconstructed by the gracilis using the native axillary nerve. Unfortunately, these patients did not have brachial plexus injuries, and I soon learned that the application of this technique to patients with complete brachial plexus injuries was probably untenable because of the lack of normal axillary nerve function. I did, however, observe Dr. Anastakis’s modified trapezius transfer for late brachial plexus shoulder instability. Instead of performing a traditional or modified Saha technique,8,9 which detaches
Figure 11. At the Catholic University in Seoul, performing a 1,2 intercompartmental supraretinacular vascularized bone graft for a scaphoid nonunion with Dr. Yang Guk Chung.
the end of the acromion and uses the acromial bone block to attach the humerus for a trapezius transfer, Dr. Anastakis prolonged the end of the tendon of the trapezius with a strip of fascia lata. The fascia lata strip was placed underneath the acromion and clavicle, overtop the rotator cuff, and was inserted into the humerus through drill holes. I observed the technique in his surgical theater and had the opportunity to evaluate several of his patients who had had surgery performed a year earlier (Fig. 12). All of his patients were extremely pleased with the outcome, and their shoulder pain and instability had disappeared. Dr. Anastakis further emphasized that the purpose of the trapezius transfer was to provide a dynamic shoulder stabilizing procedure and that any motion obtained afterwards was a bonus. He further emphasized that the purpose of the procedure was not to obtain shoulder abduction or forward flexion but to create a stable shoulder in which patients can have relief of pain from their chronic shoulder subluxation. Despite a short visit in Toronto, the information gained was tremendous and was quickly and successfully applied to our patients on my return to Rochester, MN. The next trip took me across the Atlantic to Paris, France. A day visit with Dr. Phillipe Saffar gave me the opportunity to observe a scapholunate ligament reconstruction and to discuss controversies in wrist reconstructive surgery. The remainder of the week
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 12. Associate Professor Dimitri Anastakis at the University of Toronto shows the outstanding results of the trapezius tendon transfer for chronic subluxation of the glenohumeral joint in patients with brachial plexus injuries.
was spent at the Hospital University Bichat with Professor Christophe Oberlin, a pioneer and expert in brachial plexus and hand surgery. Professor Oberlin described the ulnar fascicle transfer to the biceps motor branch, which has been named after him, and how he came to create this transfer. He showed me the importance of neurotizing the triceps as a priority for patients to be able to extend their arms, and he challenged our reconstructive priorities, which do not include triceps neurotization. In discussing obtainment of grasp, he demonstrated a novel method for obtaining grasp. In his practice he recommends neurotizing both the biceps and triceps. When adequate strength returns, he detaches the biceps insertion and extends it with a tendon graft that is transferred to the finger flexors. Arthrodesis is then performed on the wrist. The result is a bicep that flexes the elbow and fingers, and when necessary to obtain improved grasp, extension of the elbow strengthens grasp via a tenodesis effect. This was a concept that was highly unique and one that was quickly modified and adapted to our practice in Rochester, MN. Professor Oberlin’s philosophy of brachial plexus reconstruction is that both elbow flexion and extension are priorities, that the shoulder should be managed by arthrodesis, and that finger flexion can be obtained by transfer of the biceps with prolongation by a tendon when strong enough. Because wrist motion diminishes force, wrist arthrodesis is necessary in the future. In addition to his excellent discussions and didactics with his residents and with me, I had the opportunity to observe multiple surgeries and to discuss many important brachial plexus issues with a true innovative leader of brachial plexus surgery in the world (Fig. 13).
1233
The final stop of my Bunnell Traveling Fellowship was a whirlwind tour of southern Japan. This visit included a 5-day tour through 4 cities including Hiroshima, Nara, Ogori, and Kyoto. In Hiroshima, I visited the Department of Orthopedic Surgery at the University of Hiroshima under the guidance of Professor Mitsuo Ochi. The hand division included Drs. Toru Sunagawa, Osami Suzuki, and Osamu Ishida. I observed Dr. Ishida performing a resurfacing of an osteochondral defect of the elbow, which was followed by an excellent didactic session with the department. The evening ended with a traditional Japanese meal with Professor Ochi and his hand surgery staff (Fig. 14). The next morning, before departing for Ogori, I had the opportunity to spend time with Professor Yoshikazu Ikuta. Professor Ikuta is a pioneer in microsurgery, the developer of many microsurgical instruments, and the first to report free functional muscle transfers. In 1979, he reported the first free functioning gracilis transfer in a 9-year-old boy for Volkmann’s ischemia.10 He soon applied this technology and performed free functioning gracilis transfers in patients with brachial plexus injuries to obtain elbow flexion. He described to me his multiple surgical techniques and his philosophies of restoring upper-extremity function by use of intercostal nerves, spinal accessory nerves, and free functioning muscles (Fig. 15). It was then off by bullet train to visit Dr. Kazuteru Doi at the Ogori Daiichi General Hospital. In this visit I had the opportunity to
Figure 13. Professor Christophe Oberlin, from the clinic at University Hospital Bichat, and I had enlightening discussions regarding the philosophies of reconstruction of the brachial plexus during my visit to Paris, France.
1234
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 14. The Chairman of Orthopedic Surgery at the University of Hiroshima, Professor Mitsuo Ochi (front row, left), and hand surgeons (Drs. Toru Sunagawa [front row, right], Osami Suzuki [back row, right], Yu Mochizuki [back row, middle], and Osamu Ishida [back row, left]).
visit Dr. Doi’s incredible rehabilitation unit for patients with brachial plexus and watched a number of patients train their newly functioning gracilis muscles (Fig. 16). Dr. Doi, who is an innovator and leader in brachial plexus surgery, in particular with the description of the double free functioning muscle transfer to obtain elbow flexion, elbow extension, grasp, and release, demonstrated his technique in the
Figure 15. A morning of lectures and clinic in Hiroshima, Japan with Professor Yoshikazu Ikuta, a pioneer in microsurgery who described the first use of the gracilis muscle as a free functioning muscle transfer.
operating room with Dr. Yansunori Hattori (Fig. 17). During the observation of the first-stage surgery and harvest of the gracilis, despite having personally performed nearly 75 free functioning gracilis muscles, I was reschooled in the art of harvesting the gracilis muscle by these 2 masters. After I returned back to
Figure 16. The brachial plexus rehabilitation unit at the Ogori Diichi Hospital under the direction of Dr. Kazuteru Doi (left) was one of the most intense brachial plexus rehabilitation units I had the opportunity to visit. The patients are admitted for weeks to participate in various exercises to optimize the function of their reconstructed arms.
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 17. In the operating room, observing Dr. Yansunori Hattori (left) and Dr. Kazutero Doi (right) performing the stage I Doi procedure (free functioning gracilis muscle for elbow flexion and finger extension).
Minnesota, I applied many of the techniques that were newly demonstrated during my visit at Ogori. The third city I visited in Japan was Nara. Associate Professor Hiroshi Yajima was my host, and I had the opportunity to observe several microsurgical procedures followed by an opportunity to meet with
1235
and discuss the history and future of microsurgery with Professor Susumu Tamai (Fig. 18). In fact, I even had the opportunity to see the original microscope that Professor Tamai used to replant the thumb in the first reported case of a thumb replantation. My final visit was to the oldest University in Japan, Kyoto University. Hosted by Associate Professor Ryosuke Kakinoki, I was taken to visit several of his brachial plexus patients and to participate in several surgeries. I had the opportunity to present our work on brachial plexus injuries to the hand surgery community. The evening ended with a spectacular dinner at a Japanese steakhouse with Professor Takashi Nakamura, Chairman of Orthopedics at Kyoto University, and Professor Emeritus Yasuo Ueba, the former chairman (Figs. 19, 20). Professor Ueba is given credit for performing the first free fibula surgery; however, it was Dr. Taylor who first reported it in the literature.11 Professor Ueba described to me how he demonstrated the free fibula surgery to Dr. Taylor when Dr. Taylor was visiting his brother in Kyoto. The wonderful discussions we had on the history of microsurgery and the future of microsurgery and brachial plexus surgery was very enlightening. I finally returned back to Minnesota after completing my Bunnell Traveling Fellowship. I had gained a wealth of information, met leaders in brachial plexus
Figure 18. The Nara Medical University Department of Orthopedic Surgery is home to many hand surgeons. A photograph at dinner with the chairman, Professor Yoshinori Takakura (front row, left), Professor Emeritus Susamu Tamai (front, right), Dr. Koji Shigematsu (back, left), Dr. Shohei Omakawa (back, middle), and Associate Professor Hiroshi Yajima (back, left).
1236
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
surgery, and had experiences that could have never happened without the fellowship. Over the next several months after completion of the fellowship, the information that I had gained was rapidly being incorporated into our brachial plexus and microsurgical practice at the Mayo Clinic. Over a 40-day nonconsecutive period, I had the opportunity to visit 3 continents, 7 countries, 12 cities, and 19 institutions. During this period of time, I participated in 31 surgeries, gained approximately 5 to 10 pounds by eating high-calorie meals too numerous to count, attended 52 lectures, toured 22 laboratories, and most importantly had 26 personal discussions with leaders in the field of brachial plexus and hand surgery. I had the opportunity to learn of the culture, art, and history of the leaders in brachial plexus surgery. I had the opportunity to bring back to my practice novel surgical techniques learned during the fellowship. Most important, this fellowship made my world of brachial plexus surgery smaller and more personal, and it has fostered new lifetime friendships for me and the American Society for Surgery of the Hand. After participating in nearly 30 brachial plexus surgeries around the globe, I had the opportunity to evaluate, learn, and apply to my current practice numerous surgical procedures and techniques. Essentially, the more I saw the more complex were the questions I sought to answer. The 24th Sterling Bunnell Traveling Fellowship was a true honor and a
Figure 20. Professor Emeritus Yasuo Ueba, who is given credit for performing the first free fibula transfer, described to me the history of the free fibula at the final dinner of my Bunnell Traveling Fellowship.
once-in-a-lifetime experience. This experience not only will benefit our brachial plexus patients, but also will hopefully make our world a smaller place for communication among brachial plexus leaders. I would like to thank all those who mentored and supported me before, during, and after the fellowship. I would especially like to thank my wife and children for their understanding and support and for the sacrifices they made so I could spend time away from home pursuing the Sterling Bunnell Traveling Fellowship. Received for publication March 23, 2006; accepted in revised form April 17, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Alexander Y. Shin, MD, Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 First St SW, Rochester, MN; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A07-0031$32.00/0 doi:10.1016/j.jhsa.2006.04.013
References
Figure 19. The final stop of my Bunnell Traveling Fellowship was the city of Kyoto, Japan, at the Kyoto University Department of Orthopedic Surgery. Professor and Chairman Takashi Nakamura (left) and Associate Professor Ryosuke Kakinoki (right) were my gracious hosts.
1. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg 2003;28A:633– 638. 2. Witoonchart K, Leechavengvongs S, Uerpairojkit C, Thuvasethakul P, Wongnopsuwan V. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg 2003;28A: 628 – 632. 3. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thu-
Alexander Y. Shin / 2004 –2005 Fellowship
4.
5.
6.
7.
vasethakul P, Malungpaishrope K. Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg 2006;31A:183–189. Fan CY, Jiang J, Zeng BF, Jiang PZ, Cai PH, Chung KC. Reconstruction of thumb loss complicated by skin defects in the thumb–index web space by combined transplantation of free tissues. J Hand Surg 2006;31A:236 –241. Zeng B, Sui S, Peizhu J. [Application of free flaps in combined transplantation]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2005;19:508 –510. Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin 1999;15:757–767. Manktelow RT, Anastakis DJ. Free functioning muscle
8. 9.
10.
11.
1237
transfers. In: Green DP, Pederson WC, Hotchkiss RN, Wolfe SW, eds. Green’s operative hand surgery. Vol 2. 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:1757–1776. Saha AK. Surgery of the paralysed and flail shoulder. Acta Orthop Scand 1967;Suppl 97:5–90. Ruhmann O, Schmolke S, Bohnsack M, Carls J, Wirth CJ. Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique. J Bone Joint Surg 2005;87B:184 –190. Ikuta Y, Yoshioka K, Tsuge K. Free muscle graft as applied to brachial plexus injury-case report and experimental study. Ann Acad Med Singapore 1979;8:454 – 458. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533–544.
The Bunnell Traveling Fellowship was established in 1982 with the purpose of sponsoring a young hand surgeon in the development of national and international relationships that contribute to his/her pursuit of higher learning and that foster the principles of scholarship of the American Society for Surgery of the Hand. I was fortunate to be selected as the 24th Sterling Bunnell Fellow, and I had the opportunity to follow in the footsteps of the 23 former fellows. In Bunnell’s Surgery of the Hand, Fourth Edition (Boyes JH, ed. Philadelphia, Lippincott; 1964:561-567), a man with a brachial plexus injury was described. The recommended treatment was shoulder arthrodesis and transhumeral amputation, followed by fitting of an above-elbow prosthesis. Sterling Bunnell has been quoted as saying, “To someone who has nothing, a little is a lot.” Nowhere in the field of hand surgery is this more true than in patients with brachial plexus injuries. The theme and purpose of my traveling fellowship was to evaluate the status and advances of adult brachial plexus surgery throughout the world, to determine the utility of the contralateral C7 nerve transfer, to evaluate the optimal reconstruction of grasp, and finally to determine the philosophies of experts around the world regarding the treatment of these patients. (J Hand Surg 2006;31A:1226 –1237. Copyright © 2006 by the American Society for Surgery of the Hand.) Key words: Sterling Bunnell Traveling Fellowship.
t gives me great pleasure to present to the membership of the American Society for Surgery of the Hand the 24th Sterling Bunnell Traveling Fellowship report. My Sterling Bunnell Traveling Fellowship took place over 3 continents (North America, Europe, Asia) and encompassed 7 countries, 12 cities, 19 institutions, and a total of 40 nonconsecutive days away from my practice and family. My first stop was Bangkok, Thailand. In this city with a population of close to 9 million people, one quarter of the population use motorcycles, with many families using the motorcycle as their primary mode of transportation. It is not uncommon to see a family of 4 riding a single motorcycle, speeding in and out of cars and other motorcycles on the major highways of Bangkok. This tremendous reliance on motorcycles has resulted in a very large number of brachial plexus cases in Bangkok. The first institution I visited was the Siriraj Hospital of the Mahidol University. The brachial plexus team, which is headed by Dr. Panupan Songcharoen, is a world-renowned center. During my visit with Dr. Songcharoen, I had the
I
1226
The Journal of Hand Surgery
ability to evaluate and participate in surgical cases of hemi– contralateral C7–to–median nerve transfer for hand function (Fig. 1). In evaluating some of his best cases, I was able to see and observe that he had obtained independent hand and finger flexion in a select number of patients after use of the contralateral C7 nerve prolonged with a vascularized ulnar nerve graft to the median nerve. Dr. Songcharoen discussed his experience of nearly 20 years in brachial plexus reconstruction. Because the number of patients with plexus injuries far exceeds the resources available, the goals for reconstruction are limited. These limited goals include neurotization procedures for shoulder nerve function (suprascapular nerve) and for elbow flexion (musculocutantous nerve). The contralateral C7 nerve was used for grasp by prolonging it with a vascularized ulnar nerve graft with neurotization to the median nerve. Also commonly used sources of neurotization include the spinal accessory nerve, intercostal nerves, and phrenic nerve. For late brachial plexus reconstruction, the free functioning gracilis transfer for elbow flexion was a commonly per-
Alexander Y. Shin / 2004 –2005 Fellowship
1227
Figure 1. (A) In the operating theater of Siriraj Hospital, Bangkok, Thailand, I (second surgeon from the left) had the privilege of assisting Professor Panupan Songcharoen (third surgeon from the left) in a contralateral hemi–C7 transfer prolonged with a vascularized ulnar nerve graft to be neurotized to the median nerve to restore hand function. (B) In the clinic, Professor Panupan Songcharoen (middle) examines one of his contralateral C7 patients.
formed procedure. Dr. Songcharoen has achieved several excellent results with end-to-side transfers of the motor branch of the biceps to the ulnar nerve, which resulted in excellent M4 elbow flexion in a handful of patients. After many discussions of the brachial plexus injuries and the ability to reconstruct them using his philosophy, I left Siriraj Hospital with high admiration for what Professor Panupan Songcharoen has done in the past 20 years for the field of brachial plexus surgery. The next institution that I visited in Bangkok was Lerdsin Hospital. Under the tutelage of Dr. Somsak Leechavengvongs, I had the opportunity to observe firsthand what he and his partner, Dr. Kit Witoonchart, described in the American volume of The Journal of Hand Surgery in 2003.1,2 The triceps branch–to–axillary nerve transfer that they described is a highly novel transfer that restores function to the denervated deltoid in patients with upper trunk (C5– C6) injuries. A former student of Professor Christophe Oberlin, Dr. Somsak Leechavengvongs directed an extremely busy general hand and brachial plexus practice. In the clinic, he detailed the importance of careful and detailed clinical examination and evaluation of the upper extremity in patients with brachial plexus injuries. The surgical cases he planned for me highlighted his approach to the upper-arm–type of brachial plexus injury (Fig. 2). After evaluating a dozen of his patients with upper-arm–type brachial plexus injuries (C5,6 avulsions) who had ulnar fascicle–to– biceps transfer and triceps branch of the axillary nerve transfer in addition to the spinal accessory nerve–to–the suprascapular nerve transfer, I was quite impressed. His results were outstanding
and have recently been published in The Journal of Hand Surgery.3 Among the many clinical dilemmas we discussed, the role of neurotization of the long thoracic nerve to prevent scapular winging was the most interesting. Dr. Somsak Leechavengvongs was extremely gracious in allowing me to evaluate his patients. His honesty and his clinical observation skills were superb. The results of his neurotizations for upper-trunk injuries resulted in excellent return of function. It was a privilege and honor to be able to participate in several brachial plexus surgical cases with Dr. Somsak Leechavengvongs. In addition to visiting with Dr. Leechavengvongs, I had the opportunity to visit some of his colleagues including Drs.
Figure 2. At the Lerdsin Hospital, Professor Somsak Leechavengvongs (right) demonstrates to me (middle) an upper-trunk reconstruction using multiple neurotizations, including the triceps branch–to–axillary nerve transfer, which he described.
1228
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 3. The Lerdsin Hospital Hand Surgeons. From right to left, Drs. Chairoj Uerpairojkit, Somsak Leechavengvongs, Alexander Shin, Kit Witoonchart, Kanchai Malungpaishrope, Rattavuth Raksakulkiat, and Asamon Ukrit.
Chairoj Uerpairojkit and Kanchai Malungpaishrope, who also demonstrated their skills as expert hand and peripheral nerve surgeons (Fig. 3). My next stop was mainland China. I had planned a quick weekend visit in Beijing followed by several days in Shanghai. In Beijing I had the opportunity to visit the China/Japan Friendship Hospital and visited with Professor Yungting Wang, the Secretary of the Chinese Association of Hand Surgery. During my visit at the Japanese/Chinese Friendship Hospital, I had the opportunity to present our work on carpal instability followed by the opportunity to observe the role of traditional Chinese medicine in the treatment of peripheral neuropathies. I also had the unique lifetime experience of climbing the Great Wall of China, observing the manufacturing of silk, and touring the Forbidden Palace. After a quick weekend in Beijing, I was off to Shanghai to visit the Huashan Hospital and the People’s Sixth Hospital. In Shanghai, I was met by Dr. Huan Wang, a protégé of Professor Yu-Dong Gu, and was taken to the new Huashan Hospital to visit with Professor Yu-Dong Gu. Professor Gu is a leader, pioneer, and innovative thinker among brachial plexus surgeons. His tremendous experience with brachial plexus injuries and his large number of publications made for an extremely interesting discussion on the future and current status of brachial plexus injury reconstruction in adult patients. Professor Gu described to me how he first decided to use the contralateral C7 in the reconstruction of the injured complete brachial plexus injury and related the story of a young man
who had such a severe injury with no potential sources for nerve grafting or neurotization that he decided to approach the uninjured contralateral C7 and use it to neurotize targets of the injured side (Fig. 4). After a wonderful discussion on the results of contralateral C7 transfer, I had the opportunity to visit the Huashan operating room. I observed a surgery where multiple neurotizations of a patient with an injured brachial plexus were performed. The ability to sit and discuss brachial plexus injuries with one of the pioneers of brachial plexus surgery was one of the highlights of my Bunnell Traveling Fellowship. The Shanghai People’s Sixth Hospital, the famous hospital known for the tremendous number of toeto-hand transfers performed, was my next visit in Shanghai. I had the opportunity to meet with Profes-
Figure 4. In Shanghai, China, at the Huashan Hospital discussing brachial plexus surgery and the contralateral C7 transfer with Professor Yu-Dong Gu.
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 5. Professor David C. C. Chuang and I at the Chang Gung Memorial Hospital in Taipei, Taiwan.
sor Bing Fang Zeng, Chief of the Department of Orthopedic Surgery and the vice president of the hospital, who described and has used multiple composite flaps for complex hand reconstruction.4,5 After hearing an excellent lecture on reconstruction of the hand by composite free-tissue transfers by Professor Zeng, I was able to visit with Dr. Cunyi Fan at the Shanghai People’s Sixth Hospital and had the opportunity to see many cross-leg flaps and upper-hand replantations and reconstructions. The famous statue of the thumb that has been recognized by western hand surgeons as the symbol of the People’s Sixth Hospital has been removed to construct a new parking structure. The next trip was to the Republic of China, Taiwan. In Taiwan I had the opportunity to visit 2 cities, Taipei and Kaoshuing. It was in Taipei that I had the opportunity to visit Professor David C.C. Chuang at the Chang Gung Memorial Hospital. Professor Chuang has performed over 1,400 adult cases, over 300 obstetric cases, and over 120 contralateral C7 cases. I had the opportunity to observe a contralateral C7 with a vascularized ulnar nerve graft for median nerve function and to spend several days in his clinic observing his brachial plexus patients (Fig. 5). He described to me the importance of contracting the donor nerve muscle as much as possible to obtain a better outcome in the target muscle. Professor Chuang’s tremendous experience of free functioning muscle transfers for brachial plexus surgery was evident, and I was able to evaluate a number of his patients who had excellent results. When asked about his results of the contralateral C7 transfer, Professor
1229
Chuang said that he uses the entire contralateral C7 in restoring function to the injured brachial plexus. Although independent function was not often observed, the motion gained was important to his patients. After several days in Taipei, I visited the southern city of Kaoshuing. Professor Yuan-Kun Tu was my host. Professor Tu is the president of the E-Da EShou Hospital and a highly skilled microsurgeon. During my first day with Professor Tu, I had the opportunity to participate in an upper-trunk brachial plexus reconstruction and to observe other microsurgical procedures (Fig. 6). One microsurgical procedure was the use of a composite rib, serratus, and latissimus free flap, not only to provide a vascularized bone graft to a bone defect but also to provide muscle coverage over the vascularized bone graft. This was a very enlightening case that was soon applied to one of my patients on returned my return to the United States. Professor Tu also demonstrated a combined gracilis and adductor longus functioning muscle transfer based on a single nerve pedicle and vascular pedicle for brachial plexus reconstruction. This combined gracilis adductor longus free functioning muscle transfer was transferred for elbow flexion and also for finger flexion. Professor Tu was a spectacular host and demonstrated new techniques in microsurgery that have been integrated into our Mayo Clinic practice. My next trip took me to the country of my ancestors, South Korea. In a 1-week visit to Seoul, I toured 4 university centers including the Samsung Medical Center, Seoul National University, Catholic University, and the Seoul Microsurgery Hospital. The first stop was Samsung Medical Center, where I was hosted by the Associate Professor Ming Jung Kim, who is an accomplished hand surgeon and a rising star in Korean hand surgery. After an excellent day in the operating room, I was treated to a traditional Korean meal, which brought back many fond memories of my childhood. The second day was spent at Seoul National University, where I was hosted by Associate Professor Goo-Hyun Baek (Fig. 7). Dr. Baek’s congenital hand practice was incredible, and I was presented with many excellent cases and research studies that further stimulated discussions with Dr. Baek and his staff. The next day I had the privilege of visiting with Professor Sang Soo Kim at the Seoul Microsurgery Hospital. Professor Kim was the president of the Korean Society for Surgery of the Hand in 2005 and has over 26 years of experience in brachial plexus reconstruction. After his training by
1230
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 6. (A) Professor Yuan Kun Tu of the E-Da E-Shou Hospital and I in Kaoshuing, Taiwan. (B) Surgery on an upper-trunk brachial plexus injury with Professor Tu.
Figure 7. With the famous Seoul National University Hospital as a backdrop, a picture of Professor Goo-Hyun Baek (second from left), me, and his hand surgery staff (Dr. Il Kyu Han [left], Dr. Jae Kwang Kim [second from right], and Dr. San Ki Lee [right]).
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 8. Professor Sang Soo Kim and I discussing the surgical options with a patient with a complete brachial plexus avulsion at the Seoul Microsurgery Hospital.
both Professors Narakas and Millesi, Professor Kim returned to Seoul to be one of only a few brachial plexus surgeons. He has performed over 100 brachial plexus cases per year over the last 26 years of his career. He has performed over 150 contralateral C7 transfers and arranged for me to evaluate his contralateral C7 patients. After I had the opportunity to evaluate his patients, we discussed the different philosophies of reconstruction and the use of the contralateral C7 and other techniques to regain grasp (Fig. 8). Professor Kim showed me cases where patients had the contralateral C7 prolonged with a vascularized ulnar nerve graft that was banked for 6 months, followed by a second-stage surgery that included transfer of the banked ulnar nerve to the musculocutaneous nerve and median nerve. Several of his patients had independent motion of the target muscle without the need to activate any of the C7mediated musculature on the contralateral side. Despite this, he readily agreed that independent motion is a rarity and that grasp has been difficult to achieve using this technique. He also showed the importance of routine neurotization of the triceps branch to gain improved upper-extremity control and challenged our philosophy of not making elbow extension a priority. His procedure of choice for obtaining grasp has been the free functioning muscle transfer as described by Doi.6 The day ended with a traditional Korean feast with Professor Kim, Dr. Min Jung Park from Samsung Medical Center, Professor Duke Whan Chung from the Kyung Hee University, and Dr. Soon Tak Oh, Co-president, Seoul Micro Hospital (Fig. 9). My last stop in Seoul was the Catholic University.
1231
The hand surgeons of this University included Professor Seung Koo Rhee, the 2006 President of the Korean Society for Surgery of the Hand; Professor Hyoung Min Kim, the 2005 President of the Korean Society for Microsurgery; and Professor Seok Whan Song, Chairman of Orthopedic Surgery (Fig. 10). My host at Catholic University was Associate Professor Yang Guk Chung, who was a former Mayo Clinic research fellow. I had the opportunity to discuss and perform a vascularized bone grafting of a scaphoid nonunion using the 1,2 intercompartmental supraretinacular vessel (Fig. 11). This was followed by an excellent didactic lecture in which we discussed carpal instability and scaphoid fractures among other topics of general hand surgery. Our evening ended after excellent academic discussions at a traditional Korean barbecue, where again I was treated to many of the foods that I grew up with. It was an extreme pleasure and a trip that I will not soon forget. The next city I traveled to was Toronto, Canada to visit Associate Professor Dimitri Anastakis at the University of Toronto. In previous reports, Dr. Anastakis and his mentor, Professor Ralph Manktelow, described the use of the free functioning gracilis for deltoid reconstruction.7 The goal of this trip was to determine if the free functioning gracilis muscle could be applied in deltoid reconstruction in patients with brachial plexus injuries. I had the opportunity to evaluate several patients with tumor resections of the
Figure 9. After a traditional Korean dinner, Associate Professor Min Jung Park, MD (Samsung Medical Center, back row left), Professor Duke Whan Chung, MD, PhD (Kyung Hee University, back row right), Professor Sang Soo Kim (Seoul Micro Hospital, front row left), me (front row, middle), and Dr. Soon Tak Oh (Co-president, Seoul Micro Hospital, front row, right).
1232
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 10. The Catholic University of Seoul, Korea Orthopedic Surgeons and Hand Surgeons. From the left, Dr. Ki Won Kim, Dr. Joo Yup Lee, Dr. Il Jung Park, Professor Hyoung Min Kim (President, 2005 Korean Microsurgery Society), me, Professor Seung Koo Rhee (President, 2006 Korean Society for Surgery of the Hand), Associate Professor Yang Guk Chung, and Professor Seok Whan Song (Chair, Department of Orthopedic Surgery).
deltoid reconstructed by the gracilis using the native axillary nerve. Unfortunately, these patients did not have brachial plexus injuries, and I soon learned that the application of this technique to patients with complete brachial plexus injuries was probably untenable because of the lack of normal axillary nerve function. I did, however, observe Dr. Anastakis’s modified trapezius transfer for late brachial plexus shoulder instability. Instead of performing a traditional or modified Saha technique,8,9 which detaches
Figure 11. At the Catholic University in Seoul, performing a 1,2 intercompartmental supraretinacular vascularized bone graft for a scaphoid nonunion with Dr. Yang Guk Chung.
the end of the acromion and uses the acromial bone block to attach the humerus for a trapezius transfer, Dr. Anastakis prolonged the end of the tendon of the trapezius with a strip of fascia lata. The fascia lata strip was placed underneath the acromion and clavicle, overtop the rotator cuff, and was inserted into the humerus through drill holes. I observed the technique in his surgical theater and had the opportunity to evaluate several of his patients who had had surgery performed a year earlier (Fig. 12). All of his patients were extremely pleased with the outcome, and their shoulder pain and instability had disappeared. Dr. Anastakis further emphasized that the purpose of the trapezius transfer was to provide a dynamic shoulder stabilizing procedure and that any motion obtained afterwards was a bonus. He further emphasized that the purpose of the procedure was not to obtain shoulder abduction or forward flexion but to create a stable shoulder in which patients can have relief of pain from their chronic shoulder subluxation. Despite a short visit in Toronto, the information gained was tremendous and was quickly and successfully applied to our patients on my return to Rochester, MN. The next trip took me across the Atlantic to Paris, France. A day visit with Dr. Phillipe Saffar gave me the opportunity to observe a scapholunate ligament reconstruction and to discuss controversies in wrist reconstructive surgery. The remainder of the week
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 12. Associate Professor Dimitri Anastakis at the University of Toronto shows the outstanding results of the trapezius tendon transfer for chronic subluxation of the glenohumeral joint in patients with brachial plexus injuries.
was spent at the Hospital University Bichat with Professor Christophe Oberlin, a pioneer and expert in brachial plexus and hand surgery. Professor Oberlin described the ulnar fascicle transfer to the biceps motor branch, which has been named after him, and how he came to create this transfer. He showed me the importance of neurotizing the triceps as a priority for patients to be able to extend their arms, and he challenged our reconstructive priorities, which do not include triceps neurotization. In discussing obtainment of grasp, he demonstrated a novel method for obtaining grasp. In his practice he recommends neurotizing both the biceps and triceps. When adequate strength returns, he detaches the biceps insertion and extends it with a tendon graft that is transferred to the finger flexors. Arthrodesis is then performed on the wrist. The result is a bicep that flexes the elbow and fingers, and when necessary to obtain improved grasp, extension of the elbow strengthens grasp via a tenodesis effect. This was a concept that was highly unique and one that was quickly modified and adapted to our practice in Rochester, MN. Professor Oberlin’s philosophy of brachial plexus reconstruction is that both elbow flexion and extension are priorities, that the shoulder should be managed by arthrodesis, and that finger flexion can be obtained by transfer of the biceps with prolongation by a tendon when strong enough. Because wrist motion diminishes force, wrist arthrodesis is necessary in the future. In addition to his excellent discussions and didactics with his residents and with me, I had the opportunity to observe multiple surgeries and to discuss many important brachial plexus issues with a true innovative leader of brachial plexus surgery in the world (Fig. 13).
1233
The final stop of my Bunnell Traveling Fellowship was a whirlwind tour of southern Japan. This visit included a 5-day tour through 4 cities including Hiroshima, Nara, Ogori, and Kyoto. In Hiroshima, I visited the Department of Orthopedic Surgery at the University of Hiroshima under the guidance of Professor Mitsuo Ochi. The hand division included Drs. Toru Sunagawa, Osami Suzuki, and Osamu Ishida. I observed Dr. Ishida performing a resurfacing of an osteochondral defect of the elbow, which was followed by an excellent didactic session with the department. The evening ended with a traditional Japanese meal with Professor Ochi and his hand surgery staff (Fig. 14). The next morning, before departing for Ogori, I had the opportunity to spend time with Professor Yoshikazu Ikuta. Professor Ikuta is a pioneer in microsurgery, the developer of many microsurgical instruments, and the first to report free functional muscle transfers. In 1979, he reported the first free functioning gracilis transfer in a 9-year-old boy for Volkmann’s ischemia.10 He soon applied this technology and performed free functioning gracilis transfers in patients with brachial plexus injuries to obtain elbow flexion. He described to me his multiple surgical techniques and his philosophies of restoring upper-extremity function by use of intercostal nerves, spinal accessory nerves, and free functioning muscles (Fig. 15). It was then off by bullet train to visit Dr. Kazuteru Doi at the Ogori Daiichi General Hospital. In this visit I had the opportunity to
Figure 13. Professor Christophe Oberlin, from the clinic at University Hospital Bichat, and I had enlightening discussions regarding the philosophies of reconstruction of the brachial plexus during my visit to Paris, France.
1234
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
Figure 14. The Chairman of Orthopedic Surgery at the University of Hiroshima, Professor Mitsuo Ochi (front row, left), and hand surgeons (Drs. Toru Sunagawa [front row, right], Osami Suzuki [back row, right], Yu Mochizuki [back row, middle], and Osamu Ishida [back row, left]).
visit Dr. Doi’s incredible rehabilitation unit for patients with brachial plexus and watched a number of patients train their newly functioning gracilis muscles (Fig. 16). Dr. Doi, who is an innovator and leader in brachial plexus surgery, in particular with the description of the double free functioning muscle transfer to obtain elbow flexion, elbow extension, grasp, and release, demonstrated his technique in the
Figure 15. A morning of lectures and clinic in Hiroshima, Japan with Professor Yoshikazu Ikuta, a pioneer in microsurgery who described the first use of the gracilis muscle as a free functioning muscle transfer.
operating room with Dr. Yansunori Hattori (Fig. 17). During the observation of the first-stage surgery and harvest of the gracilis, despite having personally performed nearly 75 free functioning gracilis muscles, I was reschooled in the art of harvesting the gracilis muscle by these 2 masters. After I returned back to
Figure 16. The brachial plexus rehabilitation unit at the Ogori Diichi Hospital under the direction of Dr. Kazuteru Doi (left) was one of the most intense brachial plexus rehabilitation units I had the opportunity to visit. The patients are admitted for weeks to participate in various exercises to optimize the function of their reconstructed arms.
Alexander Y. Shin / 2004 –2005 Fellowship
Figure 17. In the operating room, observing Dr. Yansunori Hattori (left) and Dr. Kazutero Doi (right) performing the stage I Doi procedure (free functioning gracilis muscle for elbow flexion and finger extension).
Minnesota, I applied many of the techniques that were newly demonstrated during my visit at Ogori. The third city I visited in Japan was Nara. Associate Professor Hiroshi Yajima was my host, and I had the opportunity to observe several microsurgical procedures followed by an opportunity to meet with
1235
and discuss the history and future of microsurgery with Professor Susumu Tamai (Fig. 18). In fact, I even had the opportunity to see the original microscope that Professor Tamai used to replant the thumb in the first reported case of a thumb replantation. My final visit was to the oldest University in Japan, Kyoto University. Hosted by Associate Professor Ryosuke Kakinoki, I was taken to visit several of his brachial plexus patients and to participate in several surgeries. I had the opportunity to present our work on brachial plexus injuries to the hand surgery community. The evening ended with a spectacular dinner at a Japanese steakhouse with Professor Takashi Nakamura, Chairman of Orthopedics at Kyoto University, and Professor Emeritus Yasuo Ueba, the former chairman (Figs. 19, 20). Professor Ueba is given credit for performing the first free fibula surgery; however, it was Dr. Taylor who first reported it in the literature.11 Professor Ueba described to me how he demonstrated the free fibula surgery to Dr. Taylor when Dr. Taylor was visiting his brother in Kyoto. The wonderful discussions we had on the history of microsurgery and the future of microsurgery and brachial plexus surgery was very enlightening. I finally returned back to Minnesota after completing my Bunnell Traveling Fellowship. I had gained a wealth of information, met leaders in brachial plexus
Figure 18. The Nara Medical University Department of Orthopedic Surgery is home to many hand surgeons. A photograph at dinner with the chairman, Professor Yoshinori Takakura (front row, left), Professor Emeritus Susamu Tamai (front, right), Dr. Koji Shigematsu (back, left), Dr. Shohei Omakawa (back, middle), and Associate Professor Hiroshi Yajima (back, left).
1236
The Journal of Hand Surgery / Vol. 31A No. 7 September 2006
surgery, and had experiences that could have never happened without the fellowship. Over the next several months after completion of the fellowship, the information that I had gained was rapidly being incorporated into our brachial plexus and microsurgical practice at the Mayo Clinic. Over a 40-day nonconsecutive period, I had the opportunity to visit 3 continents, 7 countries, 12 cities, and 19 institutions. During this period of time, I participated in 31 surgeries, gained approximately 5 to 10 pounds by eating high-calorie meals too numerous to count, attended 52 lectures, toured 22 laboratories, and most importantly had 26 personal discussions with leaders in the field of brachial plexus and hand surgery. I had the opportunity to learn of the culture, art, and history of the leaders in brachial plexus surgery. I had the opportunity to bring back to my practice novel surgical techniques learned during the fellowship. Most important, this fellowship made my world of brachial plexus surgery smaller and more personal, and it has fostered new lifetime friendships for me and the American Society for Surgery of the Hand. After participating in nearly 30 brachial plexus surgeries around the globe, I had the opportunity to evaluate, learn, and apply to my current practice numerous surgical procedures and techniques. Essentially, the more I saw the more complex were the questions I sought to answer. The 24th Sterling Bunnell Traveling Fellowship was a true honor and a
Figure 20. Professor Emeritus Yasuo Ueba, who is given credit for performing the first free fibula transfer, described to me the history of the free fibula at the final dinner of my Bunnell Traveling Fellowship.
once-in-a-lifetime experience. This experience not only will benefit our brachial plexus patients, but also will hopefully make our world a smaller place for communication among brachial plexus leaders. I would like to thank all those who mentored and supported me before, during, and after the fellowship. I would especially like to thank my wife and children for their understanding and support and for the sacrifices they made so I could spend time away from home pursuing the Sterling Bunnell Traveling Fellowship. Received for publication March 23, 2006; accepted in revised form April 17, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Alexander Y. Shin, MD, Mayo Clinic, Department of Orthopedic Surgery, Division of Hand Surgery, 200 First St SW, Rochester, MN; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A07-0031$32.00/0 doi:10.1016/j.jhsa.2006.04.013
References
Figure 19. The final stop of my Bunnell Traveling Fellowship was the city of Kyoto, Japan, at the Kyoto University Department of Orthopedic Surgery. Professor and Chairman Takashi Nakamura (left) and Associate Professor Ryosuke Kakinoki (right) were my gracious hosts.
1. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg 2003;28A:633– 638. 2. Witoonchart K, Leechavengvongs S, Uerpairojkit C, Thuvasethakul P, Wongnopsuwan V. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg 2003;28A: 628 – 632. 3. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thu-
Alexander Y. Shin / 2004 –2005 Fellowship
4.
5.
6.
7.
vasethakul P, Malungpaishrope K. Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg 2006;31A:183–189. Fan CY, Jiang J, Zeng BF, Jiang PZ, Cai PH, Chung KC. Reconstruction of thumb loss complicated by skin defects in the thumb–index web space by combined transplantation of free tissues. J Hand Surg 2006;31A:236 –241. Zeng B, Sui S, Peizhu J. [Application of free flaps in combined transplantation]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2005;19:508 –510. Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin 1999;15:757–767. Manktelow RT, Anastakis DJ. Free functioning muscle
8. 9.
10.
11.
1237
transfers. In: Green DP, Pederson WC, Hotchkiss RN, Wolfe SW, eds. Green’s operative hand surgery. Vol 2. 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:1757–1776. Saha AK. Surgery of the paralysed and flail shoulder. Acta Orthop Scand 1967;Suppl 97:5–90. Ruhmann O, Schmolke S, Bohnsack M, Carls J, Wirth CJ. Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique. J Bone Joint Surg 2005;87B:184 –190. Ikuta Y, Yoshioka K, Tsuge K. Free muscle graft as applied to brachial plexus injury-case report and experimental study. Ann Acad Med Singapore 1979;8:454 – 458. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55:533–544.