Travelling Fellowship to Instituto de Cirugía Plástica y de la Mano Santander, Spain

Supervisor: Dr Francisco Del Piñal
Dates: 25th May 2014 to 25th July 2014
Fellow: Richard Baker (Plastic Surgery Final Year Resident, UK)

Introduction

Dr Piñal is one of Europe’s most eminent Hand Surgeons and is famed for his experience in complex hand reconstruction which will be discussed in detail later. Dr Piñal’s practise is in Santander on the north coast of Spain. He has built his practise over twenty years as a lone surgeon although in recent years he has employed plastic and orthopaedic surgery associates (now numbering five), physiotherapists and nurses to help him manage a very busy private practice. He has a private clinic on the sea front where he sees referrals from other Spanish cities and occasional international referrals and a clinic at the local ‘Mutua’ hospital, ‘Mutua Montanesa’. This group of hospitals provides insurance-funded care for workers. In Spain employers provide health insurance for their workers and if an employee suffers a work-related injury they are treated in Mutua hospitals which are effectively private and separate from the public hospital system. Dr Piñal sees insurance-funded patients with hand and wrist conditions at this clinic. He has two operating lists at this hospital (Tuesday and Thursday) and two operating lists at a private hospital on the outskirts of the city, ‘Mompia Hospital’ (Tuesday and Friday). As well as these lists he provides emergency cover for workers and other referrals seven days a week. These cases are usually managed within his planned lists but occasionally require surgery outside of these times. These operations are undertaken by either Dr Piñal or members of his team depending on the complexity of injury. Dr Piñal has no public hospital commitments and as such his practice is entirely private. This gives him considerable flexibility and control over his practice and effectively no waiting list. In addition, private hospitals generally do not have the layers of bureaucracy associated with ethics committees in public hospitals. These factors have combined to give Dr Piñal the freedom and opportunity over twenty years to shape his practice on his own terms, develop new procedures unfettered by bureaucracy and to perfect cutting edge procedures such as toe to hand transfers.

Dr Piñal’s operating theatre
The view from Dr Piñal’s operating theatre. Surely this calming view has helped him devise so many creative solutions to surgical challenges?

Why I Chose to Go to Santander

I wanted to go on a fellowship in Europe where I would be exposed to philosophies and procedures that were at the cutting edge of hand surgery. Dr Piñal is an opinion leader in hand surgery and in my mind foresees the future of hand surgery namely: microvascular reconstruction (free toe transfers, free joint transfers, free cartilage and bone transfers), minimally invasive wrist surgery (dry arthroscopy and expansion of arthroscopy’s limits), minimally invasive fracture management and complete rethinking (and repudiation) of complex regional pain syndrome.

What I Learnt from Dr Piñal

1. Principles, Philosophy, Way of Thinking

Dr Piñal emphasises that a junior surgeon’s duty is to study. If a surgeon is widely read they are less likely to repeat the mistakes of others and ‘re-invent the wheel’. But he also reminds his fellows that not all the answers are in the books, not everything that is written in the books is true and if one limits solutions to a clinical problem to those that are already described in the books then newer better treatments will never be considered. For example, in a patient with a significant cartilage defect or step-off in a distal radius where most surgeons would fuse the wrist, Dr Piñal would reconstruct the defect with a free bone and cartilage graft (‘free’ means microvascular transplantation) from the foot or simply shave the step-off to resurface the joint.

Dr Piñal does not give up on procedures, be they struggling replants, misbehaving flaps or unco-operative fractures. This was enlightening. There were several occasions particularly in relation to microsurgery where I thought the situation was hopeless but that Dr Piñal turned round with a little creativity and persistence.

medial femoral condyle bone
a) A free medial femoral condyle bone graft being harvested from the knee (the red arrow points to the kneecap) before transplantation to the thumb (b).

2. Microvascular Reconstruction

Dr Piñal believes that microvascular surgical expertise is essential for a hand surgeon because it opens up many more treatment possibilities. His approach to a clinical problem is to ask what tissue/structure is damaged or deficient, whether it can be repaired satisfactorily and if not where in the body he can find a replica for the tissue in question. Thus if a digit is missing a pulp, nail, joint, nerve or whatever he will simply perform a free tissue transfer of that missing component(s) (and no more) from an expendable donor site (often the foot) to replace that component. Similarly if a first webspace (between thumb and index) is contracted he doesn’t use the conventional skin graft or pedicled flap but transfers a free webspace flap from the foot. Dr Piñal does not limit his options to flaps that have already been described he simply asks what tissue he needs and raises that as a flap. He believes too that microvascular skills free the surgeon from the compromises of pedicled flaps, that is the inevitably poor vascularity and the shaping of defects to fit the flaps rather than vice versa.

Special mention must be made of toe to hand transfers of which I saw several. Dr Piñal has performed almost four hundred and therefore probably has more experience of this procedure than anyone else in the World. He pushes this procedure to its limits and reconstructs very distal fingertip amputations or partial amputations where most surgeons would accept terminalisation. But the reconstruction of the fingertips restores near normal sensation, power, the ability to manipulate small objects and aesthetic acceptability for a lifetime. These toe transfers are performed within fours hours under regional blocks with negligible donor site effects. Thus the traditional arguments of prolonged GA and donor site problems just don’t exist in his hands. I have thus completely reconsidered my attitude to microvascular reconstruction of the hand and now view it the gold standard rather than last resort.

fingertip
a) An amputated fingertip being prepared for toe transfer, b) a second toe being harvested, c) the toe being transferred to the stump of the amputated finger.

3. Minimally Invasive Wrist Surgery

In addition to microsurgery, Dr Piñal also believes that arthroscopy (key hole surgery) is an essential tool for the hand surgeon and represents the future for wrist surgery. Arthroscopy avoids the scarring of the skin and soft tissues associated with open surgery and therefore is associated with less pain, swelling, stiffness and faster rehabilitation. Dr Piñal invented the technique of ‘dry’ arthroscopy as an alternative to the conventional ‘wet’ arthroscopy in which saline is circulated within the wrist joint to create a working cavity. Instead he uses traction on the wrist which opens up an air filled cavity. The advantage of this is that there is no fluid extravasation into the soft tissues and it can be combined with open procedures which is impossible in the ‘wet’ technique because the saline drains out through the wounds. For example, an intra-articular distal radius fracture can be fixed with volar plate whilst simultaneously observing the articular surface with an arthroscope to ensure no articular step-offs or defects. Dr Piñal peforms all carpal surgery under arthroscopy because the dry technique makes it considerably easier to place bone graft. In fact I saw him perform the first total wrist fusion entirely arthroscopically with the use of headless cannulated compression screws.

thumb joint
a) Using an arthroscope to look into the thumb joint to fix a fracture of the base of the thumb with a screw (b).

4. Minimally Invasive Fracture Management

The challenge in managing hand fractures is to achieve rigid fixation to allow immediate mobilisation (otherwise stiffness sets in) whilst minimising soft tissue injury (which causes scarring and hence stiffness) and periosteal dissection (which impairs vascularity of fractures and hence delays healing). Dr Piñal has devised a method that achieves each of these ideals. He performs fixation of phalangeal and metacarpal fractures using percutaneous headless cannulated compression screws inserted via the dorsal part of the head of the phalanges or metacarpals. Although insertion is via the articular surfaces the volar surfaces which are more important in load-bearing are avoided and the screws are buried hence congruency is undisturbed. I saw this procedure several times and I believe in the years to come the advantages of this method will mean it becomes the predominant method of hand fracture management throughout the world.

Boxer’s fracture
A typical metacarpal neck fracture (‘Boxer’s fracture) of the little finger. b)The same fracture treated with a percutaneously inserted cannulated compression screw.

5. CRPS

Complex regional pain syndrome (CRPS) type I is a condition of chronic pain with no identifiable cause usually following trauma or surgery to the hand. Dr Piñal has published a famous editorial in which he puts forward his argument against the existence of this condition. He also presented it at the Federation of the European Societies for Surgery of the Hand (FESSH) in Paris whilst I was one of his fellows. While I was in Santander I saw several patients that had been referred with CRPS that Dr Piñal had treated and cured. Dr Pinal’s belief is that these patients do not have a pain syndrome but actually have a source of ongoing pain that can be found if it is looked for and treated. For example, patients with distal radius fractures are particularly prone to this syndrome but if CT scans and arthroscopies are performed then these patients often have a step-off or gap in the articular surface of the radius that causes ongoing pain. Dr Piñal operates on these patients to correct the abnormality with resolution of their pain. Furthermore, patients with CRPS often have a swollen flexed wrist, a scenario in which you might expect the median nerve to be compressed and cause carpal tunnel syndrome. Dr Piñal believes that is indeed what many of these patients have even if their symptoms are atypical and indeed he performs carpal tunnel release in these patients and alleviates their pain. Dr Piñal’s position with relation to CRPS is highly controversial especially as operating on these patients is supposed to make their condition worse. Yet he does operate on them and makes them better. I believe that he’s right and in time we will label fewer patients with CRPS because we will look harder for causes of pain that we subsequently treat.

6. Tips and Tricks

Aside from the technical pointers I learnt about the procedures already discussed, I also learnt tips and tricks about other conditions. Dr Piñal’s reputation for complex hand reconstruction is such that routine hand surgery forms only a small part of his practise. However, he has much to teach about these conditions nevertheless and seems to have ways of making associated procedures quicker. For example, for Dupuytren’s contracture of the digits (in which the fingers become fixedly flexed into the palm) he uses a needle to divide the cords and straighten the finger rather than the conventional complex open procedure. Although this is not an uncommon technique, he pushes it to its limits by also performing the procedure in the finger where convention wisdom is that the sensory nerves are vulnerable to being lacerated by the needle. He has not found this complication to occur at all. Another example is treatment of trigger thumb in which the thumb flexor tendon catches painfully on a narrowed ‘pulley’ or tunnel. Rather than trying two or three steroid injections over several months before open surgery, Dr Piñal simply uses a needle to divide the pulley in clinic. Once again his experience rebuffs conventional teaching that the nerves are at excessive risk in this procedure. A final example is carpal tunnel release. This is a very routine hand operation that is performed in the same old-fashioned way in all of the many UK hand units I’ve worked in. In contrast, Dr Piñal uses a short incision technique that has the advantages of not crossing the wrist crease and causing less cutaneous nerve damage thereby reducing the risk of painful or hypertrophic scars.

What I can take back to my own practice within the NHS?

This fellowship has been a brilliant opportunity to change my beliefs and learn new ways of thinking as well as technical knowledge. However there are challenges to putting into practice what I have seen in the NHS. The first is my own technical expertise. I’m not yet capable of repeating all of the procedures I have seen. However, on my return to the UK I will be undertaking a year’s fellowship in hand and wrist surgery at Nottingham in which I can get some experience in wrist surgery and also undertake an arthroscopy course. Although I’ve already received training in microvascular surgery I’m not ready to undertake toe transfers. However, I could begin with partial toe or pulp transfers for partial finger amputations in which the ‘stakes’ aren’t as high as for full toe transfers until my skills and confidence are sufficient. The second challenge is the NHS itself which can be resistant to change and new procedures. However, I think this can be overcome with patience and diplomacy. But there is much I could put into practice for the benefit of patients from day one. First is the less constrained, more creative way of thinking about clinical problems. Second is the higher standard I will now set myself. For example, I think I am now much less likely to take a ‘that will do’ attitude during a fracture fixation or management of an amputated finger for example. Thirdly, I will manage hand fractures with cannulated compression screws. Fourthly, I will manage some of the common hand conditions as I have seen Dr Pinal do. This will mean I can treat the numerous patients with Dupuytren’s disease that I will see very much more quickly. Lastly, by subscribing to Dr Pinal’s attitude to CRPS I will investigate these patients exhaustively until I can find and treat the cause of their pain.

sarcoma (cancer)
This patient had a sarcoma (cancer) of the wrist bones. He was scheduled for amputation of the hand. He came to see Dr Piñal who removed the tumour and reconstructed the wrist with a fibula bone transplanted from his leg.

Conclusion

This fellowship exceeded my expectations enormously and has made it much more likely I will visit other leading lights in my specialty. Although already set on a career in hand surgery, I feel more enthused than ever. I have no doubt that my practise will be broadened, particularly in relation to arthroscopy and microvascular surgery, as a direct result of this fellowship. I will also treat certain hand conditions including CRPS differently (and better) than I could have before. In short, in just a brief period I have become a better surgeon which my patients will benefit from over the next 30 years and I highly recommend that other surgeons visit Dr Pinal in Santander.

Queen’s Medical Centre
Dr Piñal on the left and myself on the right.