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The Most Complex Instrument

By Antonia Russomando, MD

I am an Italian hand surgeon, and I’m glad to have the opportunity to share my opinion with colleagues from all over the world about such a stimulating question, to which it is also very difficult to give an unequivocal answer.

I started my training in hand surgery when this branch had already developed extraordinary progresses and many new technologies had been introduced in routine (just think about wrist arthroscopy, locking plates, cannulate screws, microsurgery, free flaps and perforator flaps, tendons and nerve transfers in peripheral palsy and tetraplegia, the use of dynamic electro-miography in upper limb spasticity surgery, etc.)

We can consider the hand as the most complicated organ of motion in our body for anatomy, biomechanics, and connections to the central nervous system. The ancient Greek philosopher Aristoteles defined the hand as “the instrument (of mind) between instruments” to underline its complexity.

All these aspects make the study of the hand very interesting, stimulating and fascinating. But it is also for these reasons that surgical treatment of traumatic and non-traumatic hand diseases is everything but simple. Sometimes, reaching a complete recovery of anatomy and function, even though many technical and technological progresses have been achieved, it’s not predicted. This is a challenge every time for the hand surgeon.

For instance, wrist arthroscopy improved diagnosis and care of wrist disease, and doing so it opened brand new surgical perspectives in the field of TFCC lesions and repair. On the other side, in S-L tears, it allowed the discovery of lesions that MRI couldn’t show, and to describe various kinds of lesions. Several classifications were published, and different surgical approaches were proposed for each type, improving quality of treatment, but published evidence shows that no one is really effective and gives completely satisfactory and long-lasting results.

In treatment of osteoarthritis, total joint replacement is widening, used in knee and hip with good long term results. The published evidence doesn’t show the same results in wrist arthroplasty; in particular, it doesn’t show that carpo-metacarpal joint arthroplasty is better than trapeziectomy and tendon suspension-plasty. On the other side, this procedure allows for good pain relief and effective function with long lasting results, basing on ”biologic surgery” that it’s not possible in other joints.

With this instances I would like to underline how difficult is to assert absolutely in which areas hand surgery excels and where other fields fall short.

There are some fields of research that are closely related to surgery (study of anatomy, biomechanics, bioengineering, pharmacology, rehabilitation).

All progress in microsurgery and upper extremity reconstruction with perforator flap and nerve transfer wouldn’t be possible without progresses in anatomy knowledge, as well as in wrist and tendon surgery without developments in biomechanics knowledge. In the same way, improving results in tendon surgery wouldn’t be possible without rehabilitation, progress in spasticity surgery without development in neurology and neuro-science.

Moreover, where surgery lacks, it’s often because also other fields fall short.

I think that what makes hand surgery special and excellent when compared to other fields is the complexity of the organ we take care of, and this is why it requires a multidisciplinary approach where the relation with other fields is definitely mandatory.

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