During the four decades after my fellowship with Robert Carroll in New York, Hand Surgery has changed significantly due to extended knowledge and technical improvements.
For example, in the early 1970s, intimate knowledge of the wrist joint and the carpus in Germany was restricted to a few centers. As a result, a major group of our patients presented with late stages of carpal collapse, needing a salvage procedure like a 4-corner fusion, which represented a large segment of our spectrum. With improved awareness of ligament injuries the spectrum of problems shifted towards earlier stages.
The same applies to correction osteotomies for malunited distal radial fractures. Conservative treatment used to be the standard for this common fracture. The need for correction arose quite often. With the advance of primary open reduction and internal fixation, correction osteotomies after non-operative treatment through a palmar approach with interposition of a bone graft became less frequent. The need for correction, however, shifted to cases that were primarily operated on.
Another example for change seems to be specific for the German health system: around the turn of the millennium we were surprised by the high incidence of revision surgery necessary after carpal tunnel release operations. We believe that some special features of the German Health System were responsible for this fact, including:
- Physicians in Germany are organized in a self-administration body, the Board of Physicians, acting much like a medieval gild. Training, accreditation and certification of medical specialists are regulated by this board. The influence of scientific societies, especially of small ones like the German Society for Surgery of the Hand, is limited. Thus it took years to
establish an acknowledged trade mark for hand surgeons.
- Since the introduction of the German Health System by Chancellor Otto von Bismarck in 1890 the system is divided in two categories: one is the network of physicians in private practice, taking care of their patients exclusively on an outpatient basis. This category is dominated by family physicians, but also by surgeons, who usually do surgery on outpatients.
As a result many CTRs were done by surgeons without special training in Hand Surgery. CTR is considered to be an easy operation. But training helps to avoid possible traps and pitfalls. The number of CT revisions decreased after a special certification in hand surgery was established in a niche between orthopedics, trauma surgery and plastic surgery in 1992.
With the advent of microvascular surgery, the need of a new organization of Hand Surgery Units became evident. The care for hand trauma cases didn’t allow any delay necessitating a new organization of Hand Trauma Units.
Hospital centers run by the Workman Compensation Organization were among the first to establish such hand centers. In university hospitals and big city hospitals, however, it turned out to be difficult to impossible to fit such hand units into the existing organization. I was lucky to have the opportunity to establish a new hospital entirely devoted to Hand Surgery with a minimum of six surgeons trained in hand and microvascular surgery in which we were able to provide a stand-by service around the clock. This hospital, meanwhile, became one of the biggest of such institutions in Germany.
Looking back on 45 years of practicing hand surgery, I feel privileged to have been the soil in which the seed was planted by Robert Carroll, being able to be part of the progress that Hand Surgery has made since.