COLUMBUS, Ohio (Ivanhoe Newswire) – Sixty five thousand Americans will lose a limb this year, and that's not counting the men and women serving in our armed forces. Now, a new FDA approved technique is helping to reattach hands and give patients control that could have been lost forever.
From sanding walls to laying tile and installing toilets, Pat Marvin's done it all.
"I fell in love with [my] house," Pat Marvin told Ivanhoe.
But it's the back patio she'll never forget.
"I was doing my final cut on [a] miter edge." Pat said. "When I came down with the miter I saw something fly by me and I turned around and I looked and it was my hand laying on the floor."
With her hand severed, Pat was able to make it up the stairs, out the door and call for help - hoping she'd be able to have it reattached and use it again.
"It's a whole different level to put it on, and make it work," Lawrence Lubbers, M.D., a hand and microvascular surgeon at Riverside Methodist Hospital said.
Surgeon Lawrence Lubbers has been reattaching hands for 30 years. The trick is the tendons.
"When you put the suture in, it slips out, and when you put the knot in, it makes it 50 percent weaker immediately," Dr. Lubbers said.
That's why he created a new suture-free fix.
"It's an all stainless steel device that's like a corkscrew that screws into the tendons and grabs the fibers like having the fibers wind the corkscrew up," Dr. Lubbers said.
"The nerves regenerate in about a millimeter a day, an inch a month," Dr. Lubbers said.
It will take three to four years for the tissues to regenerate completely. After just seven months of physical therapy, Pat was reunited with her tools and her railing is finished.
"I said I wanted to be able to hold a hammer. I can hold a hammer," Pat concluded.
And she said she will use the saw again.
Dr. Lubbers said if a limb or finger is put on ice immediately and preserved correctly, doctors have up to 24 hours to reattach a finger, but just six hours for a hand or arm.
BACKGROUND: Thousands of Americans face accidental limb amputations yearly, but not all are fortunate enough to have a successful reattachment. Common accidental amputations include; arms, feet, legs, scalps, faces, and fingers. In May 23, 1962, Dr. Ronald A. Malt, a Boston surgeon at Massachusetts General Hospital oversaw the first partial limb reattachment surgery. Prior to this surgery the extent of limb repair was limited to severed arteries, broken bones, or damaged muscle tissue or nerves. Until 1962 doctors had never been able to fully reattach a body part. (SOURCE: health.howstuffworks.com, www.nytimes.com)
CAUSES: Accidental amputations can happen almost anywhere and few are prepared for this kind of injury. Common limb loss occurs during accidents such as automobile crashes, machine malfunctions, falls, natural disasters, demolition of buildings, tree cutting, work and recreational accidents.(SOURCE: www.injury.com)
HOW TO PRESERVE A SEVERED LIMB: If you witness an accidental amputation, the first thing to do is contact emergency services. After calling for help stabilize the victim; try to stop the bleeding, have the person lie down in a comfortable position, and make sure to elevate the body part. The next step is to locate and care for the amputated part; make sure your hands are clean, and gently rinse the amputated body part. Do not scrub the amputated part, wrap the body part in a damp towel and place it inside a bag, place that bag inside a container of ice, but do not allow the amputated part to come in direct contact with the ice, make sure the amputated part is given to emergency personnel so that doctors can attempt to reattach it at the hospital.(SOURCE: www.injury.com)
NEW TREATMENT VS. OLD: Traditional therapies for accidental amputation reattachments involves suturing the tendons together, the problem surgeons have with this is that the sutures do not hold in the tendons and it causes the victim to loose movement in his or her body part. The new Teno fix tendon reattachment system is a breakthrough in the limb reattachment industry because it will allow immediate active motion, no increased work of flexion, it is a mechanical and repeatable repair, and requires minimal tendon handling once inserted.(Source: www.aip.org)
HOW TENO FIXWORKS: Teno Fix uses an innovative soft-tissue anchor system, and a multifilament stainless steel suture. The device places an anchor within proximal and distal segments. Next, the anchors gather tissue as they are placed, harnessing the intrinsic strength of the tendon. Then, the stainless steel suture connects both anchors. The stop beads provide a secure hold for the suture after the suture is inserted through the anchor. After these steps are completed the severed tendon ends are reattached.(SOURCE: www.ortheon.com)
Dr. Lawrence Lubbers, Hand Surgeon with Hand and Microsurgery Associates, Columbus, Ohio talks about hands being reattached after a traumatic injury
How many hand reattachments do you do in a year?
Dr. Lubbers: We're known for our expertise in hand trauma and hand reconstruction especially after what they call mutilating injuries. So in any one week we may have two to eight of mutilating injuries, not all of them are complete amputations. The techniques embody the same procedures we would do for somebody who had a complete amputation. But you can think of it as a partial amputation where selected structures that are injured or repaired or grafted or reconstructed in some fashion, sometimes by taking parts from other areas of the body and transplanting them with microsurgery to the upper extremity for reconstruction.
How many partial or complete hand reattachments have you done this week?
Dr. Lubbers: In any one given day we'll see usually two to ten emergency cases that we'll have to take to surgery. And of those probably two to eight a week on average will need a significant procedure that may last anywhere from two to four, six hours.
When was your first full reattachment?
Dr. Lubbers: Well I was unique because I was able to train even while I was a resident with Doctors Kleinert and Kutz in Louisville, Kentucky where they are particularly well known for hand reattachment. Louisville is also my home town. And also I'm the only fellow that trained there as a medical student a research fellow and a clinical fellow out of about thirteen hundred fellows over the last forty to fifty years. And so with that expertise I was the first orthopedically trained microsurgeon in town even though I was still in training. So my first hand replant was when I was a third year resident Ohio State University. I would be on call for the nights. I was on call regularly and then if there was a big injury I would have to come in on my nights off call to operate with other surgeons. I was the only person in town essentially with microsurgical skills. So, after completing my 2 additional hand fellowships, I was on call every night for four years to build the foundation for our group, it's now five doctors-Hand and Microsurgery Associates.
How has it changed between then and now?
Dr. Lubber: We're much more effective now and we're better individually. An operation that used to take two of us eight to twelve hours to do, one of us can do in four to six hours. So we've just gotten more facile at it. A lot of the equipment surprisingly is the same as we used in the seventies. The same types of needles, sutures, microscopes, needle holders, most of that has stayed fairly much the same.
So what's changed is you've just had more practice?
Dr. Lubber: We've had more practice and there have been a lot of discoveries in the areas of reconstruction for what we can do. The science of knowing where very small blood vessels are that we can base tissue transplants on has expanded considerably. When I first started there were probably only four to six popular different types of free flaps as we call them, which are more or less the same as transplanting a kidney only involving skin and muscle. You're going to take a kidney out and reconnect it, it gives you the blood flow with the arteries and veins so they have circulation. That's what we're doing when we transplant one part of the body to the other. For instance: taking a big toe and making it a thumb. Taking a muscle out of the back and covering the front of the leg for a bad motorcycle injury. Or transplanting a portion of from one arm to the other arm. For skin grafts you can just shave off a little bit of thin skin and put it on an area that doesn't need too much thickness. But if you need all of layers of the skin you have to do a microsurgical transplant which is essentially also the same as putting a finger back on. You have to first attach the bones then you repair the tendons and finally the microsurgical part with the nerves the arteries and the veins to restore circulation then you can finish up the last of it.
What's the success rate with the hand reattachment?
Dr. Lubbers: A lot of it depends on the mechanism of injury: if it was crushed in a machine and there's segmental damage the success rate for that will be less than for instance one like Pats where it was fairly cleanly cut off even though it was a saw as opposed to a cutting blade. We can re-amputate the edges and have fresh tissue and put that limb back on. Our success rate for these situations probably nearly a hundred percent.
Are you working against time with that?
Dr. Lubber: Definitely, anytime a part has been amputated. Cooling doubles the time you have to work on it especially if it's cooled soon after injury. And that's where Pat had significant advantage because her hand was put on ice almost immediately which gave us extra time to work. Not uncommonly because our group gets referrals from all over the state and sometimes surrounding states when a patient gets injured in a field in northwest Ohio and then makes a stop at the emergency room and is then possibly life flighted here and then is rechecked out in our emergency room you may have used up a lot of your so called ischemia time, the time the part doesn't have blood. So when it's cooled for instance you have up to twelve hours traditionally for a finger but only six in a hand or arm. Cooling nearly doubles that time. So it's important to get that patient to the right place initially if possible. And because of that we have actually trained nearly all of the EMS that are on our various staffs and fire departments throughout central Ohio. We've trained pretty much each and every one of them so that they know how to take care of things in the field and they can bring these and many patients directly to a center where we have the skill and expertise and infrastructure to do the repair primarily. We are serious about our work but you have to stay a little bit light and there was a patient who was in a motor vehicle wreck who was ejected from their vehicle and lost part of end part of the arm, the humerus at the site of the accident. And they were saying they should send out the dogs to find the part so we could put it back in and they actually did find the part.
Were you able to put it back in?
Dr. Lubbers: We were not able to put that one back in. But it's important to bring everything, all damaged or amputated tissue so we can harvest additional parts if needed from the amputated part (skin, bone, tendon grafts).
Are things like stem cells and things like that going to change the way that this happens in the future?
Dr. Lubbers: Definitely this area of science will change in the future. There's so much going on at the molecular level and with gene manipulation, as well as fabrication of body parts. We might be able to take a mold of a part we want and then stick it inside the body. For instance under the skin in the upper chest and put the right components in there and have it make a new bone for us or maybe even a new joint. And all that's coming but it's probably five to twenty years away. For instance the first attached toe to hand transplant was done by Dr. Nicolardoni in the late 1800's, the 1890's. The first really successful toe transplant with microvascular techniques was done in the 1970's. So it took seventy plus years to go from where we started with the technology to where it was practical and more routinely successful. So it will take us a few more years to get to the point where the things you just referred to are in reality and in practice. But it will be amazing what we can do in another decade or two.
What were the key parts to reattaching Pat's hand?
Dr. Lubbers: Well the first thing is we have to make sure that it's taken care of properly which hers was and it is cooled well. Often we take the hand or the amputated part to the operating room and start working on that right away before the patient even gets up to the operating room floor. That way we can identify the structures that we need to, all the tendons, nerves, arteries, etc. We first start working on the bones first. In an injury like that we have to shorten it a little bit and so we work on setting up the bones and putting the plates on one side so that when we start the attachment we can first get bone stability. And you just have to start with that so you have a foundation on which to work. Then you want to put the tendons and muscles together and there are a lot of them. So identifying each and every one of them sometimes is a little hard when the tissues have not been cut really cleanly. Finally there is the microsurgical work and then skin closure or grafting.
How many would someone like Pat have?
Dr. Lubbers: The total structures it would be about thirty that we would fix.
How many hours was she in the operating room?
Dr. Lubbers: Hers I think was about eight. It was long for today's standards. One of the problems we had was that she was a smoker and so people who smoke have a lot of vaso spasm associated with the tone of their vessels. And even though you're working to get a vessel connected and flowing sometimes as you get it going it clamps down and then the tiniest of clots will shut it down and then you're out of business unless you can revive it again. We had to declot Pats two or three times and the bone fixation was a little tough and that took us some extra time. So it should have taken four to six and it took about eight. But still that's amazingly fast for what we used to do, and her case is a good example of how persistence leads to success.
I was amazed to see her hand so movable four months out.
Dr. Lubbers: I'm pleased with her progress it's probably average. Of course I always want more than average and I'm a perfectionist so I like to see things moving better faster quicker. And hers is coming along very nicely it takes about a year to really get a very good result. And three to four years to really get the best out of it that you can get. The tissues just take that long to regenerate. We tend to not put that much emphasis on age, at least in our group. At some centers, probably half the centers in the United States they would have done a one arm amputation of Pats arm. Either they don't have the technology or the faith and belief that they can do it and do it routinely and do it well. They think a prosthesis is a better alternative. But when you think about it a modern day myoelectric prothesis like we're getting for our veterans from Iraq and Afghanistan will cost somewhere between twenty and seventy five thousand dollars for one. And they're still pretty delicate, the technology is still evolving there. They're amazing they can now have individual finger motion it's phenomenal but it has no feeling and it has to be continually replaced. So you take a younger person that's in their twenties or thirties and gets a myoelectric prothesis well they might get ten of them in their lifetime saying an average of fifty thousand dollars a pop. Replantation is so much more cost effective. And the results are usually so much better because they do get some feeling.
How much is the cost?
Dr. Lubbers: You could probably get everything done and out the door barring follow up operations for about twenty five thousand dollars. And that's almost permanent, it does take some therapy.
There's something about having your own hand too.
Dr. Lubbers: Well body image, just the ability to use it better, you have the feedback to the brain. For somebody who has a prothesis they have to look at everything they're doing to touch it and pick it up. There is no sensory feedback: research is still coming and they're starting to make some gains on that. The challenge is to be able to tell the brain I'm touching this and I'm holding it just this hard, I'm not crushing it and I'm not dropping it. And just that little fine difference is huge when you compare the results of a replanted arm or a digit to a standard or even myoelectric prothesis.
What's next for a hand reattachment?
Dr. Lubbers: I think we'll have better connectors, things that will allow us to attach the muscles and tendons quicker, easier and stronger. The same with blood vessels, there have been efforts to use laser welding, and tiny devices to put the vessels together. We're still sewing things we sit there and tediously repair stitch by stitch all of these structures. Of course plates and screws on the bones, sometimes external fixation where pins go in the bones and there's an external bar on the outside to hold it in place. But for the most part we're still using 1920's technology for a lot of this.
Is there anything that one of your patients has done post-surgery that's pretty much amazed you?
Dr. Lubbers: Yes, there was a gentleman who was working on a dairy farm. In a dairy farm they often have a lagoon to catch all the excrement from the animals, the manure and the urine. And then they use that material to recycle in to the fields for fertilizer. So they had a pump mechanism that would pump the manure out in to the fields to fertilize the fields to be a green operation. There was a methane gas explosion inside the pipe that carries the liquid out to the fields and it amputated his leg in the manure pit. And everything went under the water, leg, boot, patient, head to toe everything completely covered. So they asked me can you do that one and I said well rinse it off under the faucet and send it out and we'll see what we can do. Unfortunately we couldn't give the patient a bath before we went to the OR so the OR smelled like manure for the whole case. But we did a shortening and cleaned the edges of the amputation and reattached the leg and two days later the cultures were sterile, no infection at all. Unfortunately that leg was an inch and a half short already from a congenital problem so then he was three inches short after the amputation which he didn't like. He had to wear a huge shoe lift and it was very awkward to get around. And he said he didn't like that he wanted his leg lengthened. So with another colleague of mine we ended up lengthening his leg back to the regular length and he still had forty five degrees of ankle motion and went out and built his own house from scratch.
Talk about the device that you've come up with about the tendons.
Dr. Lubbers: The device that I've come up with, with my engineers is called a Teno Fix produced here in Columbus by a company called Ortheon. The intent of that device is to be able to repair tendons so that we can move them immediately. Traditionally when we repaired them with thread or suture the tendon fibers are parallel so as you put the suture in the tendons just slip out. Then also when you tie a knot in the suture it reduces its holding power by fifty percent right off the bat. So I felt the knot was bad and that we had a materials problem with the suture because you want rope but you're got thread. So I came up working again with my engineers with an all stainless steel device that's like a corkscrew that screws in to the tendon and it grabs the fibers by having the corkscrew wind the fibers up tighter and tighter against a core screw if you will. And that's threaded on a longitudinal stainless steel strand that's adjusted with stop beads that are more or less like split shots on a fishing line. So we can adjust the length and it goes pretty quickly, you make a little incision in the tendon, screw in the device and then put the steel core filament through it and adjust the length, clip it off and it's repaired.
Did you do that with Pat?
Dr. Lubbers: Yes we did, we were able repair I think four of her main tendons with the Teno Fix.
Normally you would just close but you were able to keep it open, do you do that?
Dr. Lubbers: There's a lot of challenging nuances, to be able to replant the hand is one thing because there are many doctors that could put it on and make it live. There's a whole different level to put it on make it live and then make it work. In Pats case because the nerves were transected the nerve input to the little muscles in the hand that keep the hand in balance are not working yet. And when they're not working the hand goes in this posture called intrinsic minus posture. And if we let that happen it gets stuck there. So when the nerves finally regenerate and the muscles are finally working there's nothing left to do with it because everything has turned in to cement. So we put pins across the middle joints of the fingers to hold them in position while we're waiting for the nerves to regenerate. Now they haven't regenerated yet but I felt it was time to take those out in Pat's situation so we could start getting the tendons and muscles up here to work and then bracing and therapy to maintain a subtle hand so as everything comes back you won't have the problem of having to go back and do three or four operations to get the hand in the position in which it did the first time can now work. Formal hand therapy by certified therapists is critical for a great result.
Does the corkscrew stick stay in there forever?
Dr. Lubbers: Yes it will stay in.
You are fifty percent of the equation and there's something that the patient has to do.
Dr. Lubbers: The surgery is 50% of the quality of the result and the other fifty percent that's the responsibility of the patient and the therapist. We have, I believe nine certified hand therapists that work with us just like we have a certificate for added qualification for hand surgery. They have certification in hand therapy. You can be an orthopedic or plastic surgeon or even general surgeon but to be a hand surgeon you have to pass another qualifying exam, take a one year fellowship and be in practice for a few years and then have enough case distribution to qualify to take the exam. And so the therapists are pretty much the same way, even once you're a certified licensed occupational therapist it still usually takes another two to five years to get the certificate. So working with a therapist we keep the patient on track and keep them out of trouble in that we don't let the hand collapse, we are able to make splints right on the spot that are custom molded out of plastic if needed. And then have them move so they're moving just enough. Another problem with repairing tendons with suture if you move it too hard too fast or with too much force the tendon snaps now you have to go back and start all over. All of these things are very delicate until they get to the three to ten week time post op and so if you can keep the patient out of trouble during that first phase and then prevent the contractures, they can have a good balanced hand as more function returns. And, you can get a really amazingly and almost normal result in a hand that's been completely amputated with such attention to detail in a center that routinely does these procedures.
Then they have to take care of themselves health wise, no smoking?
Dr. Lubbers: No smoking: nicotine is a powerful vasal constrictor. So as soon as we repair those vessels I've seen one cigarette kill a part it's that powerful. And we've done studies where we take little blood pressure cuffs and put them on the fingers and you can have a smoker take a few puffs and the pulse will just flat line. You'll hear the little beep go off because there's almost no more circulation. It's that impressive even though you don't really see it and realize it. So absolutely no nicotine of any sort. Caffeine has been debated but usually we try to have them off caffeine at least for several days. Hand position is important in the beginning and no cold exposure which will also cause vessel spasm in the earliest days. You have to have a blanket around the arm and go to a warm car and not go outside in cold weather unless you're going to the doctor for a while. After that they just have to keep up with their exercises. Another problem we have with these patients is in the beginning they also do not have any feeling until the nerves grow back. The nerves regenerate at about a millimeter a day or an inch a month. So for an amputation at the mid forearm it will take six to twelve months for the signals to get back down to the fingers. Meanwhile if they grab a hot pot on the stove they don't know it until they smell the flesh burning, or they get too close to a flame. So we have to keep them instructed early on to avoid any types of these injuries where they don't know it's happening until it's too late. It's usually either a pressure sore from laying their hand down on a table and it will just erode the ends of their fingers or something hot or cold exposure.
FOR MORE INFORMATION, PLEASE CONTACT:
Hand and Microsurgery Associates
(614) 262-HAND (4263)