Severe arthritis in his right wrist caused ongoing pain and prevented Mr. Eisen, who lives in Atlanta, from engaging in activities he enjoys. He is right-handed, which makes it even more difficult. Seven years ago, he started to investigate treatments and learned about total wrist replacement surgery. But unlike knee and hip replacements, which are common and have excellent outcomes, wrist replacement surgery has not enjoyed the same degree of success.

Mr. Eisen’s online research prompted him to take his first trip to New York for a consultation with Dr. Wolfe in 2014. Mr. Eisen had read about Dr. Wolfe’s extensive research into how the wrist moves and learned that he and his long-time colleague and co-inventor, Joseph J. (Trey) Crisco, III, Ph.D., Director of Bioengineering at the Warren Alpert Medical School, Brown University and Rhode Island Hospital, were working on designing a new, more durable wrist replacement. Mr. Eisen has been following their progress for the past seven years.

Last year, the KinematX™ Total Wrist Arthroplasty System, which is manufactured by Extremity Medical, LLC, received 510(k) clearance from the US Food and Drug Administration (FDA). The design is the culmination of three decades of award-winning research by Dr. Wolfe and Dr. Crisco. Over the years, they and their colleagues have received more than $10 million in research grants from the National Institutes of Health to study the wrist.

Mr. Eisen is looking forward to regaining the use of his wrist. “It had become more painful over the years, with the pain often radiating up to my forearm,” he explains. “My wrist movement was severely restricted, making it difficult to do anything that required me to bend my wrist. Everyday activities like cooking, working around the house or picking up a pot of coffee with my right hand were difficult and painful.”

Dr. Wolfe believes the KinematX™ has advantages over traditional implants. “Our extensive research into how the wrist moves helped us design a device that more closely matches the anatomy and motion of a normal wrist,” he explains. “This should allow for more natural movement and increased durability compared to currently available implants. Some studies report failure rates of 50% within 5 to 10 years, mainly due to loosening of the implant components.”

“In our view, the KinematX™ will be a game changer in the field of wrist replacement surgery,” said Doug Leach, managing director of Biomechanical Innovation at the HSS Innovation Institute. “Current wrist replacement devices are relatively dated. The new implant design leverages the clinical and bioengineering experience of Drs. Wolfe and Crisco, their seminal research, and modern-day engineering and design principals of total joint replacement in general.”

Wrist arthritis is one of the most common and debilitating conditions treated by hand surgeons, affecting about 5 million people in the United States, according to Dr. Wolfe. A fusion of the wrist bones can alleviate pain, but patients are often limited in performing some activities. Wrist joint replacement surgery was proposed five decades ago as an option to relieve pain and restore function.

When Drs. Wolfe and Crisco set out to design a better wrist replacement, the first step was to unravel the complexity of how individual bones move in a normal wrist and in one that has sustained an injury. Their research led to the design and validation of a noninvasive three-dimensional motion analysis system to measure wrist kinematics, which describes the wrist motions necessary for a wide range of activities. Armed with that information, they sat down at Dr. Wolfe’s kitchen table and started sketching out their idea for a novel wrist replacement.

The wrist is highly complex, made up of more than a dozen individual joints formed by eight small bones that collectively make up the wrist. It was previously believed that the wrist moved the hand in two different planes – up and down or side to side. The research by Drs. Wolfe and Crisco demonstrated that during many activities, such as throwing a ball, hammering a nail or pouring a glass of water, the wrist doesn’t move in just one of these directions. It accomplishes the action by combining movements in both planes.

“Traditional wrist replacements often constrain the wrist to move in one plane at a time, and this puts stress on surrounding joints," said Dr. Wolfe. “The increased loads on the implant-bone interface often lead to prosthesis loosening and mechanical failure. In addition, traditional implants often make it difficult or impossible to return to some activities, such as tennis or golf.”

The KinematX™ is the only wrist replacement that is computer-designed to mimic the kinematics, or motion, of a human wrist – movements that are instrumental in throwing, hammering and other high-performance activities, according to Dr. Wolfe. The unique design should enable the implant to be more durable than traditional wrist replacements.

Surgery with the KinematX™ entails replacing the proximal carpal row bones of the wrist, which are those most severely affected by osteoarthritis. The device utilizes modular components in various sizes to replicate the complex anatomy of the wrist and allow the motion necessary for occupational, recreational and household activities.

The Innovation Institute at HSS played a key role in the development of the new wrist replacement, working closely with Drs. Wolfe and Crisco to obtain a patent for their research and design ideas. The patent for the wrist replacement was licensed to Extremity Medical, LLC, a privately funded medical device company in New Jersey.

“Our goal is to work with talented HSS physicians, inventors and entrepreneurs to empower them to develop innovations in musculoskeletal health that could improve or even revolutionize patient care,” Mr. Leach said.

A patient registry will be established at HSS and other leading medical centers across the country to track data on outcomes. Mr. Eisen says he will gladly report his progress. After recovery, he looks forward to going back to playing golf, fishing, working around the house and waxing his car.

To see a video of Dr. Wolfe discussing the new wrist replacement, visit: https://www.youtube.com/watch?v=BWgd-NtW5PI

Parsonage-Turner Syndrome affects the nerves controlling the shoulder, arm and hand. “We published data on the first successful surgical treatment in patients who experienced some degree of paralysis due to this mysterious disorder,” said Scott W. Wolfe, MD, director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS and lead investigator.

Also known as neuralgic amyotrophy, Parsonage-Turner Syndrome most frequently manifests as sudden, severe pain in the shoulder and upper arm, often with no known cause. The intense pain, which usually subsides within a couple of weeks, is followed by progressive weakness. Many patients find they are unable to move their affected shoulder, elbow or hand. The area and degree of paralysis depend on the nerves affected and the muscles they control.

There is no known cure, but doctors generally prescribe pain medication, steroids and physical therapy to help relieve symptoms. Although many patients eventually recover and regain function of their arm, it sometimes takes several years.

For those who do not get better, limited use of their arm or even complete paralysis can be devastating. “Imagine going for months with this condition and not knowing if or when you’re going to get better. Because recovery can take a year or longer, patients have been told to wait, and there’s this feeling of uncertainty,” says O. Kenechi Nwawka, MD, director of the Division of Ultrasound Research at HSS, who performs ultrasound in PTS patients to locate the damaged nerves. “Many patients who come to HSS feel relieved because they have found a group of specialists that really understands their condition.”

Dr. Wolfe and colleagues set out to determine if patients who weren’t improving could be helped by neurolysis, a microsurgical procedure to repair the injured nerve. The doctors hypothesized that successful surgery would allow patients with PTS to regain strength and movement.

To help patients with Parsonage-Turner Syndrome, a multidisciplinary team of specialists is essential. The first step is for a physiatrist to identify which muscles are involved and assess the nerve injury and loss of function. This is achieved through electrodiagnostic testing, which is used again at a later date to look for signs that the nerve is recovering.

It is also critical to pinpoint the exact location of the damaged nerve or nerves with MRI and ultrasound. Hospital for Special Surgery is one of few centers nationwide with the highly specialized team of hand surgeons, physiatrists and radiologists who could pursue such an undertaking.

“Without this team of experts in these varied, but related fields, we could not have made as much progress in a relatively short period of time,” said Dr. Wolfe. “It is not only the members of the team, but the spirit of collaboration among my medical and surgical colleagues at HSS that sets us apart from other institutions.”

The HSS study enrolled 24 patients with PTS, all of whom had suffered paralysis of their arm or hand. A physiatrist performed electromyography (EMG) to measure muscle and nerve function in all the patients.

“EMG testing is first used to confirm and make the definitive diagnosis of PTS,” explained physiatrist Joseph H. Feinberg, MD, medical director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS. “A damaged nerve will generally start to recover in six to nine months, and additional EMG testing can indicate if there are early signs of nerve regeneration. If the nerve is starting to regenerate, the patient will likely regain muscle strength, so surgery is generally not needed. However, if there is no sign of regeneration within six to nine months of PTS onset, then recovery is less likely, and surgery may be considered.”

Patients in the study met the following criteria: 12 months had passed without improvement since the onset of Parsonage-Turner Syndrome, or there was no evidence of clinical or electrodiagnostic improvement after six months as documented by three successive EMG and clinical exams.

A high-resolution MRI technique known as magnetic resonance neurography (MRN) was performed to zero in on the location of the nerve damage. Previously, radiologists at HSS had documented “hourglass-like” constrictions of the nerve, an anomaly that is unique to patients with PTS. Essentially, a band squeezing the nerve makes it look like an hourglass on the digital image. The MRI, along with high-resolution ultrasound images, is essential in surgical planning.

“Magnetic resonance neurography and ultrasound images give the surgeons a roadmap, a target to treat,” explained Darryl B. Sneag, MD, director, Peripheral Nerve, MRI at HSS. “Instead of having to explore the entire nerve in an arm, the images pinpoint the exact location of the constriction, so the surgeon doesn’t have to spend hours searching for it.”

Hourglass-like constrictions of affected nerves were identified in each study patient, and the images were correlated with EMG findings. Eleven out of the 24 patients opted for neurolysis surgery by Dr. Wolfe and his colleague, Steve K. Lee, MD.

“Once we localized the tiny constrictions in the nerve with imaging, we could confine our surgery to that site, and we could locate the lesion with millimeter precision,” said Dr. Wolfe. “Looking through a microscope with 25X magnification, we then repaired the constricted nerve by releasing the compressive bands around it.”

The mean time from PTS onset to surgery was 12.5 months. At patient follow-up of almost 15 months after the procedure, nine of the 11 patients who had surgery showed clinical improvement, having regained muscle strength and movement. EMG testing revealed significant motor unit recovery from nerve regeneration.

Out of the 13 patients who did not have surgery, only three had recovered strength during follow-up, which took place almost three years after PTS onset.

“Microsurgical neurolysis to repair the hourglass constrictions was associated with dramatic and significantly improved clinical outcomes and nerve regeneration compared to nonsurgical management,” Dr. Wolfe noted. “Therefore, we recommend considering it as a treatment option for patients with chronic Parsonage-Turner Syndrome who have failed to improve with nonoperative treatment.”

The HSS Innovation Institute worked closely with Drs. Wolfe and Crisco to obtain a patent for their research and design ideas. The patent was then licensed to Extremity Medical, LLC, a privately funded medical device company in New Jersey.

“We believe the new wrist replacement, known as the KinematX™ Total Wrist Implant, has advantages over traditional implants,” said Dr. Wolfe, chief emeritus of the Hand and Upper Extremity Service at HSS. “Our extensive research into how the wrist moves helped us design a replacement that more closely matches the anatomy and motion of a normal wrist. This should allow for more natural motion and increased durability compared to currently available implants.”

“In our view, the KinematX™ will be a game changer in the field of wrist replacement surgery,” said Doug Leach, managing director of Biomechanical Innovation at the HSS Innovation Institute. “Current wrist replacement devices are relatively dated. The new implant design leverages the clinical and bioengineering experience of Drs. Wolfe and Crisco, their seminal research, and modern-day engineering and design principals of total joint replacement in general.”

Wrist arthritis is one of the most common and debilitating conditions treated by hand surgeons, affecting about five million people in the United States. A fusion of the wrist bones can alleviate pain, but patients are often limited in performing some activities. Wrist joint replacement surgery was proposed five decades ago as an option to relieve pain and restore function.

“Most people are familiar with total joint replacement in the knee or hip, which is much more common and highly successful,” said Dr. Wolfe. “Total wrist joint replacement has not enjoyed the same degree of success. Historically, some studies demonstrate failure rates of near 50% within 5 to 10 years, mainly due to loosening of implant components.”

Dr. Wolfe and his longtime colleague, Dr. Crisco set out to design a better wrist replacement 30 years ago. The first step was to unravel the complexity of how individual bones move in a normal wrist and in one that has sustained an injury. Their research led to the design and validation of a noninvasive three-dimensional motion analysis system to measure wrist kinematics, which describes the wrist motions necessary for a wide range of activities. Armed with that information, they sat down at Dr. Wolfe’s kitchen table and started sketching out their idea for a novel wrist replacement based on their research.

Over the years, Drs. Wolfe, Crisco and colleagues have received more than $10 million in research grants from the National Institutes of Health to study the wrist. They have published hundreds of papers in peer-reviewed journals. In 2017, they received the Kappa Delta Award from the American Academy of Orthopaedic Surgeons and the Orthopaedic Research Society, considered one of the highest honors for an orthopedic researcher.

The wrist is highly complex, made up of more than a dozen individual joints formed by eight small bones that collectively make up the wrist. It was previously believed that the wrist moved the hand in two different planes – up and down or side to side. The research by Drs. Wolfe and Crisco demonstrated that during many activities, such as throwing a ball, hammering a nail or pouring a glass of water, the wrist doesn’t move in just one of these directions. It accomplishes the action by combining movements in both planes.

“Traditional wrist replacements often constrain the wrist to move in one plane at a time, and this puts stress on surrounding joints," said Dr. Wolfe. “The increased loads on the implant-bone interface often lead to prosthesis loosening and mechanical failure. In addition, traditional implants often make it difficult or impossible to return to some activities, such as tennis or golf.”

The KinematX™ is the only wrist replacement that is computer-designed to mimic the kinematics, or motion, of a human wrist – movements that are instrumental in throwing, hammering and other high-performance activities, according to Dr. Wolfe. The unique design should enable the implant to be more durable than traditional wrist replacements.

Surgery with the KinematX™ entails replacing the proximal carpal row bones of the wrist, which are those most severely affected by osteoarthritis. The device utilizes modular components in various sizes to replicate the complex anatomy of the wrist and allow the motion necessary for occupational, recreational and household activities.

The Innovation Institute at HSS played a key role in the development of the new wrist replacement. “Our goal is to work with talented HSS physicians, inventors and entrepreneurs to empower them to develop innovations in musculoskeletal health that could improve or even revolutionize patient care,” Mr. Leach said.

Wrist replacement surgery with the KinematX™ will be performed on an outpatient basis. Dr. Wolfe says he already has a waiting list of individuals who are good candidates. A patient registry will be established at HSS and other leading medical centers across the country to track data on outcomes.

Extremity Medical, LLC will be responsible for the manufacture and distribution of the KinematX™ Total Wrist Implant, which is expected to be available before the end of the year.

The scapholunate is a critical ligament that connects and stabilizes the scaphoid and lunate, two small bones near the center of the wrist. When an injury, often a fall on an outstretched hand, causes the ligament to rupture, patients can experience pain, lose grip strength and develop arthritis that gets worse as time goes on.

“When the ligament tears, the scaphoid and lunate bones will separate, start to rotate and degenerate. Some patients can feel the scaphoid popping in and out of its normal position,” Dr. Wolfe explains. Without treatment to repair the torn ligament, people ultimately develop a condition known as SLAC wrist. SLAC, which stands for “scapholunate advanced collapse,” is the most common form of post-traumatic arthritis in the wrist, affecting about four million people. As the bones rub abnormally against each other, their protective cartilage wears away.

“The injury most often affects healthy active people. When the ligament ruptures, any activity that combines wrist motion and wrist strength becomes difficult, if not impossible,” Dr. Wolfe says. “Affected patients report problems performing jobs that require manual work. They can no longer play sports such as golf or tennis, do yoga or Pilates, or work out with weights at the gym.”

Until now, surgery to reconstruct a torn scapholunate ligament has not been ideal, Dr. Wolfe says. The most common repair, which entails the use of metal wires and pins, fails in about 30 percent of patients.

In searching for a better treatment, Dr. Wolfe and his research team studied what happens in the wrist after the ligament tears in his laboratory. Once they identified the mechanism and involved ligaments, they presented and published their research in international forums and medical journals. Dr. Wolfe and his associates have received awards for their work. At the same time, Dr. Michael Sandow, a colleague of Dr. Wolfe’s in Australia, developed a 3-D computer model to study the way the wrist bones move and identify the injury mechanism from a different perspective. Dr. Sandow arrived at the same conclusion and developed a novel technique to address all components of the injury. He published a paper documenting the surgery and outcomes in 10 patients at two years following surgery in the European Journal of Hand Surgery.

Dr. Wolfe is one of just a few hand surgeons in the U.S. performing the new procedure, known as ANAFAB (anatomic front and back repair). “The goal is to reconnect the bones and restore their normal motion to provide pain relief, make the wrist stable again and stop the arthritic process,” he explains.

Dr. Wolfe describes the surgery as a complex and highly technical procedure. “The critical ligaments in the front and the back of the wrist are reconstructed by using a portion of one of the tendons in the patient’s wrist, combined with a synthetic tape that’s 10 times stronger than steel, weight for weight. The tape is very strong, but also very lightweight and very thin,” he says. “The patient’s own tendon and this synthetic material are woven through the bones in such a way that the scapholunate ligament, as well as two other nearby ligaments, are repaired all at once. This brings the bones back into the proper position and stabilizes them, so abnormal movement is stopped.”

The new procedure is performed without the use of wires and pins, a major advantage, he says, as metal hardware in the wrist can loosen, become infected, fail and necessitate another surgery.

Dr. Wolfe has performed the ANAFAB procedure on 14 patients to date and is monitoring their progress. So far, so good. Fifty-eight-year-old Peter Shrair, a business/commercial real estate attorney from Longmeadow, Massachusetts, is doing well after having the surgery. He has sent Dr. Wolfe videos of himself doing pull-ups in the gym.

Mr. Shrair originally hurt his left wrist in 2017 while doing an exercise called a "power-clean" with a barbell. A steroid injection shortly after the injury provided relief, but by April 2018, he started having wrist pain that worsened as time went on. That’s when he was diagnosed with the ligament tear. He bought wrist wraps so he could continue to work out, tried physical therapy and saw a prominent hand surgeon at a highly regarded hospital in Boston Massachusetts. “He told me there was nothing I could do,” Mr. Shrair recalls.

It got to the point where his wrist felt sore all the time. To make matters worse, he was left-handed, and it became increasingly difficult for him perform basic activities, such as using a knife to eat, carrying a heavy book or exercising with his left hand. Mr. Shrair knew about HSS and decided to go online and do his own research. He found Dr. Wolfe, made an appointment and did not hesitate when Dr. Wolfe told him about the new surgery. "Dr. Wolfe explained the procedure and recovery protocol to be sure I understood it and would follow it."

Mr. Shrair had the procedure in November 2018 and says he has no regrets. “I’m 100 percent, I’m really doing great,” he says. “Dr. Wolfe's explanation was accurate. I followed his protocol and had an outstanding result.” Mr. Shrair is now back to snow skiing, water skiing and working out at the gym.

Forty-year-old Asad Spahic, a mechanical engineer from Southington, Connecticut, also found Dr. Wolfe online. His ligament injury, sustained nine years earlier, had led to worsening wrist instability and weakness. He enjoyed participating in sports, but his wrist felt like it was giving way during certain activities, and he began to experience a dull ache. X-rays showed that arthritis was developing.

“A local doctor said the arthritis would get worse, the longer I waited to have surgery. I searched online for the best doctor I could find, reading medical journals,” Mr. Spahic said. He knew that once arthritis became severe, a wrist fusion was the standard procedure for pain relief, but a fusion would limit wrist motion and curtail his athletic activities.

He opted for the new surgery with Dr. Wolfe in May 2019. “My experience has been nothing short of phenomenal,” Mr. Spahic says. “I don’t even think about my wrist. I go skiing, I play soccer, although I use a wrist brace in case I fall because it’s been less than a year since my surgery. I have zero pain, zero problems, and the same strength as in my other wrist.“

Dr. Wolfe says he will continue to conduct follow-up to gauge the outcomes of ANAFAB surgery to see how patients fare over the long term. “The results are preliminary, but in my 30-year career I have not been this excited about this kind of ligament repair. We’re seeing patients who are now pain-free and back to activities they enjoy.”

AFM tends to present in the fall and move across the U.S., disappearing in winter time.

She reports that Scott W. Wolfe, MD, hand and upper extremity surgeon at HSS, has developed a delicate form of surgery in which healthy nerves are transferred to paralyzed areas of the body to help AFM patients regain useful function. Dr. Wolfe recently published his research involving two AFM cases in the journal Pediatric Neurologyto demonstrate to the medical community that young people do not have to endure paralysis.

Read the full article at Newsday.com. This also appeared in the February 22, 2019 print issue.

Kale underwent two nerve transfers and a tendon transfer surgery with Scott W. Wolfe, MD, hand and upper extremity surgeon at HSS, that helped him regain his independence.

"We've been able to take completely normal nerves and we can go into those nerves and find the individual cables within the nerves, and rather than taking the entire nerve, we'll just take a small splice and move them over," Dr. Wolfe explains. "We will not lose function in the nerve we borrow from, and we will gain function in the nerve we connect the splice to."

"It's a world of difference," says Kale. "I'm able to extend my fingers so much better and grip a lot better than I was able to before… I don't think I would have been able to do that without the nerve transfer surgeries."

Read the full article at HealthDay.com.

Additional Coverage:

• U.S. News & World Report: Surgery Restores Movement to Kids With Polio-Like Illness

The Centers for Disease Control and Prevention (CDC) reported that there were 201 confirmed cases of acute flaccid myelitis (AFM) in 40 states last year alone.

"Most affected patients are children and teenagers," Dr. Wolfe tells Healthline. "Within a day or two, nearly all experience rapid, progressive paralysis — a partial or complete loss of muscle function in their arms or legs. While some patients regain function, many suffer some degree of permanent paralysis. No nonsurgical treatment has been shown to be effective," he explains.

One of Dr. Wolfe's patients, Kale Hyder, was 15 when he was diagnosed with transverse myelitis (of which AFM is a subcategory). After being told he had no options, Dr. Wolfe performed two nerve transfers in his arms and then a tendon transfer. Kale continues intensive post-operative therapy to this day but has restored muscular function in his hands.

"What Dr. Wolfe did for Kale is absolutely amazing. He gave him his independence," explains Kale's mother Marcy Hyder.

Read the full article at Healthline.com.

Dr. Scott Wolfe, an orthopedic surgeon specializing in nerve injuries at Hospital for Special Surgery (HSS), has restored arm movement and function in a number of young AFM patients   previously told their paralysis would be permanent.

The journal Pediatric Neurology published two AFM case studies by Dr. Wolfe and colleagues. The report documents patients, ages 12 and 14, who had suffered partial paralysis and regained movement in their arms after nerve transfer surgery at HSS. 

"We published the case studies to raise awareness in the medical community," said Dr. Wolfe. "Since the procedure is so highly specialized and performed by very few surgeons, most people, even doctors, are unaware that nerve transfer could potentially help AFM patients. But there is a window of opportunity, and the surgery should ideally be performed within six to nine months of disease onset."

Cases of acute flaccid myelitis, which is considered a subtype of transverse myelitis, have been on the rise in the United States since 2014, according to the Centers for Disease Control and Prevention. The illness, which is most common in children and teenagers, appears to occur after a viral infection. Within a day or two, inflammation within the spinal cord leads to muscle weakness and rapid, progressive paralysis of the arms and/or legs. In 2014, and again in 2018, a disturbing spike in cases was reported in certain regions of the United States. 

Patients suffer different degrees of paralysis, and while some regain function, most suffer some degree of permanent paralysis. No nonsurgical treatment has been shown to be effective.

At age 15, Kale Hyder of Davenport, Iowa was not only the picture of health, but an accomplished athlete. At 6-foot–two, the active teenager played on his school’s basketball team and on an elite traveling team in the summer. One day in June 2015, he woke up with a stiff neck and asked his mother for a new pillow. By the next day, he could not move his arms and could barely stand up. His mother rushed him to the emergency room. Soon after, he was paralyzed from the chest down.

Kale was diagnosed with transverse myelitis. After days and months had passed, Kale and his family were shocked to receive a terrible prognosis. "We went to an excellent neurologist in the Chicago area, and he said, 'I’m so sorry, you’re not going to regain function of your hands.' It was devastating, I’ll never forget receiving that news," recalls Marcy Hyder, Kale’s mother. "Here’s my basketball player, sitting next to me in a wheel chair. Everything changed in the blink of an eye. When we got out of there, we all just sobbed."

At that time, Kale was receiving occupational therapy at Shriners Hospitals for Children in Chicago, and the therapist told them about another young girl in her care who had been helped by Dr. Wolfe at HSS. In March 2016, the Hyders made the trip to New York.

Although several doctors had indicated that Kale would require assistive devices and a caregiver to help with activities of daily living, Dr. Wolfe gave them another option. And he gave them hope. 

Dr. Wolfe performed nerve transfers to each arm, followed by tendon transfer surgery a year later to restore function in Kale’s hands and enable him to lift his arm over his head. Nerve transfer surgery entails taking all or part of a working nerve with a less important or redundant function and transferring it to restore function to one or more muscles that have been paralyzed. The delicate and painstaking surgery requires hours of muscle and nerve testing and meticulous planning by the surgeon and his team beforehand. It’s not uncommon for Dr. Wolfe to work much of the day and into the night to plan the surgery. Performed under a microscope, each set of nerve transfer surgeries can take five to seven hours. 

"We have been performing nerve transfers for patients with brachial plexus injuries, so it made sense to try it for AFM patients," Dr. Wolfe said. "But it’s more challenging. Since the disease causes almost random patterns of muscle paralysis, there’s no roadmap to follow and we have to come up with a creative solution for each patient. We take a full inventory of what’s working and what’s not working in each limb by checking each muscle. We look for donor nerves, so if two muscles move an elbow, for example, we can take one of the nerves controlling that function and use it to restore function to a hand or shoulder."

Marcy says she is extremely grateful to the Shriners occupational therapist and a physician there who told her about HSS and Dr. Wolfe. "We would never have known. We would have missed that window of opportunity for surgery. Without it, Kale would not be functioning as he is today," she says. "Think of everything you do with your hands; he couldn’t do it. But he can now. What Dr. Wolfe did for him is absolutely amazing. He gave him his independence."

Now Marcy is on a mission to raise awareness that nerve transfer surgery could be an option for transverse myelitis and AFM patients, but they need to be evaluated sooner rather than later. 
Kale, now a freshman at Johns Hopkins University, credits Dr. Wolfe with enabling him to follow his dreams. A pre-med major, he plans to be a neurologist and a researcher so he can help others. He attends classes, engages in volunteer work on campus, types on a keyboard, shops for food and does his own laundry. 

"Dr. Wolfe has been a role model and I admire him for the way he works with patients. They have such serious conditions, yet he finds hope in every case and gives his patients hope," Kale says. "And he’s a very great problem solver, the way he knows anatomy and physiology. Those problem-solving skills are something that I hope I can have at least half of, one day. It’s crazy what he can do."

Anyone who would like more information on nerve transfer and reconstruction is invited to visit https://www.hss.edu/brachialplexuscenter-treatments.asp.

The goal of the surgery is to restore movement in the arms and legs of children with the disease.

"You have to be very creative in terms of using even remaining nerves and muscles that are there… It's a bit of an art and no two cases are going to be the same and you use what you can," said Dr. Wolfe.

The article referenced a study by Dr. Wolfe who successfully performed nerve transfer surgery on two patients with AFM.

Read the full article at washingtontimes.com. This also appeared in the November 7, 2018 print edition.

"Of people who cut tendons and nerves in their hands, we usually guess that it's an avocado injury," said Dr. Wolfe.

Not only is the injury increasingly common, Dr. Wolfe said it's also serious. "The hand is an incredibly complex organ. There are so many tendons and so many nerves and arteries immediately below the skin," he noted.

His patient, Jim Fitzgerald, accidentally injured his finger when he attempted to remove a pit using a sharp knife.

Dr. Wolfe recommends holding the avocado on a cutting board with one hand, cutting all around the fruit at the equator then rolling it halfway over and cutting it again, thus allowing the avocado to come apart in quarters with the pit popping right out.

Watch the full segment at newyork.cbslocal.com. This also aired during the September 3, 2018 broadcast.

According to the article, the condition causes a layer of tissue underneath the palm of the hand to thicken.

If the disease gets worse and starts interfering with hand function, Dr. Wolfe explained that cortisone injections and surgery could be beneficial.

Read the full article in the September 2018 print issue.

His surgeon, Dr. Scott Wolfe, chief emeritus of the Hand and Upper Extremity Service at Hospital for Special Surgery (HSS), was in the audience. Mesmerized by the music, Dr. Wolfe marveled at the way the virtuoso’s hands raced across the piano keys.

Mr. Dichter won the silver medal in the International Tchaikovsky Competition in Moscow while a student at Julliard in 1966, and a brilliant career ensued. In 2005, he noticed a small lump in the palm of his right hand. By 2006, he found he could no longer play the opening of a Brahms ballade. A visit to a hand specialist and subsequent diagnosis struck fear in his heart.

He had the same disease that had affected his father: Dupuytren’s contracture. The condition, which has a strong genetic component, causes the tissue in the palm of the hand to thicken and tighten, forcing the fingers to curl inward. Over time, as the disease progresses, people may not be able to straighten their fingers at all.

Mr. Dichter thought of his father and the two botched surgeries that failed to correct the problem. "They left his fingers on both hands terribly deformed," he recalls, "they looked like forks."

The first hand specialist recommended that Mr. Dichter take a "wait and see" approach. But "wait and see was not working," he explains, "since I couldn’t play half of the musical pieces I used to be able to play. I realized I had to do something."

After conducting some research and talking to friends, he found Dr. Wolfe at HSS, who told him about a surgical procedure that could correct the problem. "Dupuytren’s contracture is one of the most common conditions hand surgeons treat," Dr. Wolfe notes. "In advanced stages, it can be severely debilitating. People are unable to wash their face, hold a glass of water or shake someone’s hand. When correcting the problem surgically, it’s better to have the procedure sooner rather than later."

Understandably, Mr. Dichter approached the thought of surgery with a great deal of trepidation. "Remembering my father’s situation and the doctor at the other hospital telling me 'let’s just leave it alone for a while,' I was afraid, but I had to make a radical change. To stop playing the piano would destroy me as a person, and Dr. Wolfe inspired confidence."

In an intricate two and a half hour surgery, Dr. Wolfe removed the excess tissue in Mr. Dichter’s hand, carefully protecting the surrounding blood vessels, nerves and tendons.

He had his first surgery on his right hand in March 2007, and it was a success. After weeks of intense physical therapy, he was back to practicing and later, back in concert. He could resume playing duets with his wife, Cipa, an acclaimed pianist in her own right. At the recent Carnegie Hall concert, she joined him for duets by Schubert and Copland, and they often play the piano together at home.  

Dr. Wolfe and Mr. Dichter are now good friends. However, when Mr. Dichter first went for a consultation in 2007, his physician didn’t realize he’d be operating on an acclaimed virtuoso. Still, there was an immediate connection between them, Dr. Wolfe recalls. "I believe there was an unconscious recognition of the parallels of our two professions and, more importantly, a mutual respect for the critical link of our hands and our worlds," he says. "For both the musician and the surgeon, an impairment of their hands has a profound impact on the very core of their being."

Years later, the disease struck Mr. Dichter’s other hand, and Dr. Wolfe performed another successful surgery in September 2016.

Dr. Wolfe often attends his patient’s concerts, and Misha Dicthter says he feels like a "pianist reborn" thanks to the surgery. "Every day I’m grateful to Scott Wolfe. When I see him in the audience, I know it’s going to go well."

Due to his restricted hand movement, the article reported that Dichter had difficulty playing the piano and sought treatment from HSS hand and upper extremity surgeon Scott W. Wolfe, MD.

"He was not going to give up until his hands were back on the piano keys," said Dr. Wolfe.

According to the article, Dr. Wolfe performed corrective surgeries on both of Dichter's hands and prescribed physical therapy.

Currently, Dichter is recovered and will perform his first solo program since 1999 at Carnegie's Weill Recital Hall this week.

Read the full article at wsj.com [subscription required]. This article also appeared in the February 21, 2018 print issue.

The research and the copyrighted questionnaire were published in the Journal of Bone & Joint Surgery today.

The brachial plexus is a network of nerves that extends from the spinal cord in the neck, under the collarbone and down the arm. These nerves control the shoulder, arm, elbow, wrist and hand. A brachial plexus injury (BPI) can be life-altering. People often suffer from severe, unrelenting pain and can lose the use of their arm and hand.

"A brachial plexus injury has a profound impact on quality of life," said Carol A. Mancuso, MD, a senior scientist at HSS and lead investigator. "Patients are usually young adults who sustained trauma, such as from a motor vehicle accident or sports injury."

Dr. Mancuso and orthopedic surgeons specializing in complex nerve reconstruction surgery for BPI sought to develop a questionnaire to thoroughly understand the injury’s impact on patients. "The sudden nature of the injury can lead to a realm of psychological challenges, such as emotional distress, loss of independence, and depression, that can overwhelm patients and potentially hamper recovery," said Dr. Mancuso, who specializes in developing surveys and questionnaires at HSS. "Capturing these psychological elements is necessary to thoroughly understand disability and recovery from this complex condition."

"The questionnaire is important because it moves beyond the surgeon’s interpretation of the outcomes of surgery and gets to the heart of patient needs, expectations, and functional satisfaction," said Scott W. Wolfe, MD, director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS. "It probes the emotional as well as the physical impact of the injury and realizes data that is not identified in any other outcome measure."

Dr. Mancuso developed the questionnaire based on patient input, with preoperative and postoperative versions. Patients with BPI who were undergoing or had already undergone surgical reconstruction were enrolled during routine office visits at HSS.

The study had three phases. Phase 1 included interviews with patients using open-ended questions addressing the impact of BPI and improvement expected before surgery (preoperative patients) or received (postoperative patients). Phase 2 involved assembling a draft questionnaire and administering it twice to establish test-retest reliability. Phase 3 involved selecting final items, developing a scoring system, and assessing validity. Patient scores using the questionnaire were assessed in comparison with scores of the Disabilities of the Arm, Shoulder and Hand (DASH) and RAND-36 measures.

The HSS preoperative and postoperative surveys both include questions rating the severity of BPI symptoms; assess difficulty with activities of daily living, such as getting dressed; address psychological issues, such as depression; and ask how the injury has affected school or work. The preoperative questionnaire also assesses how much improvement patients expect from treatment, while the postoperative version asks how much improvement patients believe they received from surgery or another treatment.

Dr. Mancuso noted that the questionnaire has the potential to improve patient care. "First, it provides a template from which patients can discuss the spectrum of physical and emotional effects of BPI with their surgical team. This, in turn, offers providers the opportunity to comprehensively address patients’ needs directly or through a referral," she said. "Second, the questionnaire fosters discussion of realistic outcome expectations, which are necessary to maintain motivation and ensure long-term participation in rehabilitation. This also enables patients to make appropriate plans for school or work activities."

"We will be able to tell what matters most to patients and then see if we achieved their goals," said Steve K. Lee, MD, director of research, Center for Brachial Plexus and Traumatic Nerve Injury. "Other outcomes measurements were not specific enough to this unique, complex patient population."

Dr. Wolfe noted, "The questionnaire will, without a doubt, improve patient care by aligning surgical and treatment alternatives with patient needs and expectations."

In addition, the survey plays a role in assessing outcomes of highly specialized nerve reconstruction surgery to repair brachial plexus injury, according to Dr. Mancuso. "The questionnaire provides a valid and standardized method for clinicians and researchers to document and compare patient-reported outcomes from specific or novel surgical interventions."

This work was supported by the J.W. Kieckhefer Foundation, the Howard J. Golden Family Research Fund, and a Richard Menschel institutional award.

Institutions that wish to receive a copy of the questionnaire, which is copyrighted, are invited to contact Dr. Mancuso via email: MancusoC@hss.edu.

About the Center for Brachial Plexus and Traumatic Nerve Injury at HSS

The Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery is a national resource for men and women of all ages, providing diagnostic and reconstructive options for patients with injuries to or dysfunction of the peripheral nerve and brachial plexus. Using a multidisciplinary approach, the center utilizes the expertise of a wide range of health care professionals including orthopedic surgeons, physiatrists, neurologists, radiologists, psychiatrists, rheumatologists, pain management specialists, physical therapists and anesthesiologists, so that patients can benefit from a coordinated treatment experience. For more information, visit: http://www.hss.edu/brachialplexuscenter

While historically used to determine SLAC progression, plain radiographic methods are not always sensitive. Researchers from Hospital for Special Surgery assessed the prevalence of radiolunate (RL) ligament wear in SLAC/SNAC patients by comparing operative findings to MRI and plain radiographs to determine diagnostic accuracy.

This retrospective study looked at 41 patients who underwent wrist surgery between 2006 and 2016 and were diagnosed with SLAC or SNAC with preoperative imaging. This ten-year review utilized operative reports as well as radiographs graded by radiologists using the Kelgran Lawrence Joint Grading Scale.

According to operative and MRI findings, the study found that RL wear occurs in late SLAC/SNAC patients. It was determined that plain radiograph findings underestimate the degree of involvement and that MRI has a potentially higher diagnostic accuracy for detection of RL wear. MRI findings had a stronger correlation with operative pathologic findings than radiograph (p = 0.158 vs. p = 0.337).

The study’s results suggest that surgeons should consider taking a high-resolution MRI prior to joint preserving surgery in the wrist. This knowledge can potentially change the surgical management of SLAC/SNAC osteoarthritis.

Abstract Title: Magnetic Resonance Imaging Findings Correlate with Operative Findings in Patients with SLAC/SNAC Osteoarthritis

Authors: Danielle Christine Marshall, BA; Schneider K. Rancy, BA; Alissa J. Burge, MD; Hollis G. Potter, MD; Scott W. Wolfe, MD; Steve K. Lee, MD.

While there are multiple techniques to achieve this, there are no recent studies that analyze which is optimal for patients to regain elbow flexion. Researchers from Hospital for Special Surgery set out to determine the best method to improve elbow flexion strength after BPI.

The study looked at data from 12 patients who underwent a nerve transfer for elbow flexion reconstruction after a BPI. The data was collected between 2005 and 2013 and includes physical examination and electromyographic (EMG) data.  There were no demographic differences between the patients.

The researchers found that the ulnar fascicular nerve transfer to brachialis and median fascicular nerve transfer to biceps brachii motor branch appeared to have more advantages when compared to an ulnar fascicular nerve transfer to biceps brachii and median fascicular nerve transfer to brachialis motor branch. After this method, patients saw a British Medical Research Score (BMRC) grade 4 elbow flexion strength earlier than expected, as well as increased motor unit recruitment of the brachialis muscle EMG. Elbow flexion strength did eventually equalize at 36 months regardless of surgical technique.

With a lack of available literature on this specialized injury, this study provides valuable insight to surgeons who had no prior indication of the most optimal nerve transfer for their patients.

Abstract Title: Elbow Flexion Restoration in Brachial Plexus Injuries: What is the Optimal Nerve Transfer?

Authors: Natalia Fullerton, MD; Eliana Saltzman, MD; Joseph T. Nguyen, MPH; Anum Lalani, MPH; Steve K. Lee, MD; Scott W. Wolfe, MD