General indications for functional surgery of the hand in tetraplegic patients

Functional surgery of the upper limb is a recent, specialized surgery. In 1987, Moberg [1] wrote, "A totally new way of thinking was needed to overcome strong resistance against surgery." Today, functional surgery of the upper limb plays an important role in the rehabilitation of tetraplegic patients. During the past 30 years, this surgical concept has developed continuously, having been shaped by the experience of a small number of specialized teams throughout the world who meet regularly for international conferences [2-4]. An almost unlimited number of variations are now possible in this rapidly expanding field of hand surgery [5]. In this article, the author presents his experiences and stresses his-current point of view, which is still evolving. Functional surgery of the upper limb in tetraplegic patients is not only a reconstructive operation but also a surgical rehabilitation. One must forget the classic concepts of surgical reconstruction and turn toward the patient's personal desires to lead better tetraplegic life with its myriad problems. The surgical rehabilitation of the tetraplegic patient is always a challenge, because each one is unique, with his or her own remaining physical abilities, wishes, and expectations. Thus, establishing surgical indications based solely on the level of the anatomic lesions and the possibilities of the remaining muscles is a course of action that indicates only what can be done, not what should be done. The surgeon must take into account the individual patient's requirements. Additionally, this surgery cannot be based only on experience. The number of cases performed by any surgeon will not be high. Because each case is different, experience is acquired only after several years of surgical practice during which the knowledge of the surgeon was challenged repeatedly. Furthermore, several years are necessary to arrange a team of surgical and other professionals to treat the patient. This type of surgery can be practiced only in a specialized environment with a panel of physiotherapists and ergotherapists in highly specialized centers. Finally, when dealing with the general indications for hand surgery in tetraplegic patients, one must answer three main questions: When?, Who?, and What?