Practice News

Last November, 2011, New Jersey reconstructive surgeon Dr. Matthew Kaufman of the Institute for Advanced Reconstruction, performed his pioneering phrenic nerve surgery on Don Bird of Australia. Bird, who in his never-give-up search to improve his medical situation, had found Dr. Kaufman through the Internet–sent an update (featured below) to Heather O’Neill , Dr. Kaufman’s practice manager. Bird, like nearly all of the patients at The Plastic Surgery Center and The Institute for Advanced Reconstruction, developed a close and friendly relationship with all of the staff. Click here to read more on Bird’s procedure and patient stories.

Dear Heather, Hope everyone is well in your  family and at clinic.  Can you please say a big hello to everyone and I have some news that you can pass on for me please. Have just had Lung Function tests today at Austin Hospital and compared with tests done at same place in December of 2010. I have attached these results and I am sure that Dr Kaufman will be happy to see a marked difference in the results. I also have had other improvements. Prior to Surgery I was only able to sleep on my right side ( which was damaged side), I now can sleep on both sides and my back as well. I have also noticed my ability to talk without getting a husky voice due to low air has gone and now I can talk the legs off a table!!!  I have been getting more active as weeks pass and have only had one short stay in Hospital due to Pneumonia and I recovered from that much quicker than I used to. I am starting new program of Rehabilitation and hope to achieve a higher standard of fitness than before. I will keep the updates coming and hope to hear from you soon. I hope you can tell that I was very happy today and pleased with results. PS Also pass on that Dr Kaufman”s scar is very neat and muscle is flattening out as he said it would.

Cheers Don Bird

Dr. Kaufman shares his reaction to Bird’s email:

“All of us at the Institute for Advanced Reconstruction are excited to learn that Don has been experiencing early clinical benefits from the nerve transplant surgery performed in November 2011.  Although we expect this regenerative process to take at least one year, these early signs of improvement increase the chances that he will continue to improve over this time period.  We will be following his progress very closely to completion and are happy that he has already detected some recovery in his respiratory function.”

Correcting Clenched Fist and Arm Paralysis and Foot Drop

By Walt Kilcullen: Original article found here

After a stroke, some survivors experience paralysis of one arm along with a clenched fist. If a nerve is injured preventing that nerve from sending signals to a muscle or muscles, the result is paralysis and loss of muscle function. This result is virtually no use of the affected arm and hand, and, in some cases discomfort. When a nearby tendon is not effected, it may be possible to transfer a functional tendon from its original attachment to a new attachment restoring some use to the non-functioning area.

What exactly is hand tendon transfer surgery? Below the elbow, there are between forty and fifty muscles. When a muscle or muscles are neurologically destroyed due to the stroke, they can no longer signal the arm or hand to function. There are three major nerves in the hand: the ulnar nerve, the radial nerve, and the median nerve. When any of these are injured or destroyed, paralysis, loss of feeling, and clenched fist is the result.

How successful is hand tendon surgery? Hand tendon transfer may be successful in restoring some function to the hand or arm. In a 2008 study in the Netherlands (LC Heijnen et. al.) six patients were followed who had hand tendon transfer surgery for clenched fist.

After the surgery, all six could passively open their hands in a resting position, and some flexible movement was gained in each case. There were no complications after nineteen months and all six patients were still able to keep their hands open. There was also permanent improvement in pain reduction and hygiene.

I asked Dr. Andrew Elkwood how much success he has had doing this surgery. Dr. Elkwood practices plastic surgery at the Plastic Surgery Center in Shrewsbury, New Jersey. He is considered an expert in nerve reconstruction surgery for patients who have lost the use of a limb due to nerve damage.

He has also been featured on the T.V. show, “The Doctors.” Dr. Elkwood was reluctant to profile what a good tendon transfer surgical candidate looked like because diagnosis depends on so many factors, such as how many nerves and or muscles are damaged, and to what degree they are damaged. He stated, “I like to examine, evaluate, and then give my assessment as to the expected results of surgery.”

Dr. Elkwood also told me that the hand is more difficult than the arm to restore. After surgery, even if function cannot be restored, at the very least, the patient will be able to open the hand. “No one gains 100% of function but there are some who show great improvement, some who cannot be helped at all, and many who fall in between these two categories.”

Tendon Transfer Surgery for Foot Drop

Seven years ago, Sandy Smethers, a stroke survivor that I was mentoring (and still am), was recommended by a neurologist to consider tendon transfer for her drop foot. We went to Pennsylvania University Hospital in Philadelphia to see Dr. Maryann Keenan, an orthopedic surgeon.

Dr. Keenan recommended tendon transfer surgery and she performed it shortly after our visit. Sandy’s surgery was only partly successful. Her foot was restored to a more normal position, but she still walks with a brace and a considerable limp. Her balance improved and she walks freely without a cane,

Foot drop, or drop foot has many causes and varied symptoms. A stroke survivor who has foot drop as a result of a stroke has difficulty lifting the front of the foot. As a result, the patient may drag the affected foot on the ground making walking difficult. Many patients will trip with a drop foot.

To compensate, one may raise the thigh unusually high, and may swing the affected foot out to the side to avoid lifting the thigh upward. The immediate aid is to wear a brace from the upper calf, down past the ankle extending under the entire foot. This will keep the foot in a normal position.

I was able to reach podiatric foot and ankle surgeon, Dr. Lawrence DiDomenico by telephone. Dr. DiDomenico is a podiatric physician and surgeon at the Ankle and Footcare Center in Youngstown, Ohio. Dr. DiDomenico stated,”withclassic foot drop, the common peroneal nerve is affected and leads to anterior and lateral (front and outside muscles of the leg) muscle group weakness which controls the foot.”

Diagnosis of the cause is imperative as that will determine the course of treatment. Dr.DiDomenico told me that treatment options for foot drop include prescribing a brace, gait training, physical therapy, and tendon transfer surgery.

You, as a patient must discuss these options with your podiatric surgeon or orthopedic surgeon. But once the diagnosis calls for tendon transfer, the tendon transfer surgery is performed with the goal of restoring the function of the foot and ankle to a more normal anatomical alignment so that the patient can walk on the sole of the foot with the heel touching the ground, improving gait and balance when walking in a shoe and without a brace.

Dr. DiDomenico told me that the large majority of tendon transfers for foot drop are done by podiatric surgeons and orthopedic surgeons that have an expertise and interest in foot and ankle surgery. “The surgery involves rerouting the posterior tibial tendon, a tendon that functions well from the back of the leg, and transferring it to the front of the leg and connecting it to the top of the foot. This compensates for the loss of muscle function in the front of the leg as a result of the stroke. Although 100% improvement is not expected, between 40% and 50% is typical.”

The Institute for Advanced Reconstruction’s New Jersey plastic surgeons, Doctors Matthew Kaufman, Andrew Elkwood, Tushar Patel and Russell Ashinoff have had their collective work published in Clinical Neurology and Neurosurgery. The full article, entitled “Diaphragm paralysis caused by transverse cervical artery compression of the phrenic nerve: The Red Cross syndrome” can be found by clicking the front page image above.

(Beachwood, NJ- April, 12, 2012) – When Fran Wisnewski fell in her own kitchen, she had no idea what her future would hold. After landing on her knees, two months later she had foot drop. “I could feel everything to the touch, but I couldn’t move my foot,” she reports.

Foot drop describes the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot. As a result, individuals with foot drop drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the scuffing, which causes what is called a “steppage” gait. Foot drop can be unilateral (affecting one foot) or bilateral (affecting both feet).

Although foot drop has a variety of causes, it can be the result of nerve damage alone, such as in Wisnewski’s case.

Wisnewski, a 45-year-old Beachwood, New Jersey resident, who works as a manager of a group home for the mentally disabled, started off at her primary care physician, who then sent her to an orthopedist. The orthopedist sent her to a neurologist, who gave her a brain scan to rule out any neurological problem. “It’s very frustrating when they can’t tell you what’s wrong,” she says. Finally, the neurologist referred her to Dr. Michael Rose of The Institute for Advanced Reconstruction located in Shrewsbury, New Jersey.

Fortunately for Wisnewski, Dr. Rose is among a handful of plastic surgeons trained in nerve decompression surgery for those suffering from all forms of neuropathy. He felt Wisnewski had suffered nerve damage in the knee caused by her fall. It could either be rectified by a nerve graft, or by the removal of scar tissue around the nerve. The latter, more conservative approach, worked for her.

Wisnewski is one of nearly 20 million Americans who suffer from neuropathy, a chronic condition that results from damage to or compression of the nerves outside the spinal cord and brain, and also referred to as peripheral neuropathy. According to Dr. Rose, traumatic neuropathy is common –and he sees a good deal of in his practice.

Within a week after surgery, Wisnewski had some movement in her foot. “Today,” she reports, “I feel like nothing happened.”

Says Dr. Rose, “I think the best advice is not to automatically accept it when you are told there is nothing that can be done. It took Fran Wisnewski three doctors until she was sent to the proper person. It’s just fortunate that her neurologist was aware of the work I do, and so she was sent to me. Many doctors would simply say: Learn to live with it; there is nothing we can do. It’s hard to believe, but often even very good doctors don’t know what cutting-edge procedures that other specialists are doing. There is simply so much to know, and so much new being discovered all the time.

“In an ideal world, Fran would somehow know to call me directly, but the reality is, most people to their general practitioner first for some direction, It wasn’t a straight line, but she did, in fact, end up at the right place in the end.”

Wisnewski appreciated Dr. Rose’s demeanor and knowledge. “You can tell he knows what he’s talking about. I had immediate confidence in him. He told me the surgery was not 100 percent guarantee, but he still gave me hope.”

Dr. Michael Rose gave Fran Wisnewski more than hope; he gave her a “rescue after a fall.”

Paul Nese with Dr. Michael Rose of the Institute for Advanced Reconstruction

Imagine your body—bones, muscles and skin—collapsing like a building. Now, imagine an actual building doing the deed. That’s what happened to construction worker Paul Nese, when, in October of 2011, he went into a building to oversee a job—a simple task that would be over in 15 minutes from when disaster struck. From 22 feet above him, 60 trusses, weighing 300-500 pounds each, came down, some of them landing directly on top of him.

The results were tibia and fibula (major bones) broken in his right leg, which also tore through his skin, a broken femur, fractured ribs, bone chips in his spine and severe herniated disks in his lower back. The 39-year-old Plainsboro, New Jersey, resident was rushed to the hospital, where he underwent several surgeries, lasting a total of approximately 15 hours.

Among those surgeons treating Nese, at this point at Jersey Shore Medical Center, was Dr. Michael Rose, who repaired the leg in which the bones had torn through muscle and skin. Dr. Rose salvaged what he could of the damaged muscle and did a skin graft from Nese’s thigh to his lower leg.

After undergoing some months of rehab, and additional surgery for what became the need for a full titanium hip replacement, Nese realized he had yet further damage. “When bones tore through my leg, they also tore tendons and caused nerve damage.” This caused Nese to experience foot drop as a result of the traumatic nerve damage, and also a severe case of traumatic neuropathy. “It was so painful from the calf to the tip of my toes. You know that painful tingling you experience when coming in from the cold? That’s what I had, only 24 hours a day.”

“This type of neuropathy is often overlooked in the aftermath of a life-changing injury when there are more pressing issues to which to attend. That being said, Paul (and others like him, who come into contact with me and our practice) was fortunate that I am familiar with and skilled at treating traumatic nerve injuries,” said Dr. Rose.

In all of Paul Nese’s misfortune, he had a stroke of good luck: a connection to Dr. Rose, who is among a handful of plastic surgeons trained in nerve decompression surgery for those suffering from all forms of neuropathy.

Nese is one of nearly 20 million Americans who suffer from neuropathy, a chronic condition that results from damage to or compression of the nerves outside the spinal cord and brain, and also referred to as peripheral neuropathy.

However, cases like Nese’s are more complicated because medical experts have to deal with the other injuries and make timing decisions for surgery for neuropathy. That being said, Dr. Rose points out that although one has to wait for other injuries to improve before working on the nerves, for the best surgical result for neuropathy, “the sooner the better in most cases.”

On Februrary 17, 2012, Nese underwent surgery with Dr. Rose, who did a tendon transfer on his toes, allowing his right big toe–that was completely hanging limp–to be connected and work with the rest of his toes. Dr. Rose also repaired the nerve in his ankle and on top of his foot.

Relief was immediate. “I experienced a huge result. It is so much better than it was,” says Nese. Of his overall recovery, Nese reports, “I’m able to sleep more comfortably, and not on constant pain killers. I’m looking forward to more future progress.”

In his 22 years working construction, Paul Nese had never had an accident prior to an event that so radically altered his life. But for those like Nese, who experience such life-altering events, medical experts such as Dr. Michael Rose can return part of the normalcy that was taken away.