Orthopedic Surgery

June 08, 2024

When Dr. Rhee's father had a stroke and developed upper extremity spasticity — including deformity and significant functional loss — Dr. Rhee set about finding a solution. Peter C. Rhee, D.O., M.S., a hand and microvascular surgeon at Mayo Clinic in Minnesota, knew that a solution to his father's new challenges must exist. The quest to find answers for his father and others with similar conditions served as impetus for a new clinical research focus: treating upper motor neuron injuries.

"I started this upper extremity reconstruction practice because of my dad," he says. "Typically, medical center policy wouldn't allow me to operate on him due to our relationship. Yet, I was the only one who performed this surgery, so Mayo Clinic allowed me to do it."

Surgery significantly improved his father's spasticity. His father now opens pill and water bottles he would have been unable to open before surgery and can function independently such that Dr. Rhee's mother can leave town and his father can fend for himself.

Pioneering in a wide-open, relatively hidden field

This quest to help his father not only led Dr. Rhee to pioneer in post-brain and post-spinal cord injury upper extremity reconstruction (UER), but later he also added lower extremity reconstruction.

Dr. Rhee and the Upper Limb Reconstruction in Upper Motor Neuron Syndrome Clinic team perform the most spasticity-related UERs in the U.S., with 2 to 3 of these weekly. The surgeries last up to 14 hours and include the complete, shoulder-to-fingertip range.

The small number of hand surgeons currently performing UER in the United States are individuals Dr. Rhee trained at Mayo Clinic. Fewer than 10 medical centers offer these surgeries.

"Worldwide, not many are doing this surgery to our volume," says Dr. Rhee. "With time, we're spreading out its influence."

Not only are few centers performing UER, but the surgery is still relatively unknown, says Dr. Rhee. Although thousands of individuals experience brain injury such as a stroke, many physicians are unaware of an option to address resulting spasticity. If aware, typically they have heard little about it, he says. Similarly, patients often are unaware of the potential to radically improve quality of life and enhance function.

Interventional need, timing, safety and outcomes

UER is critical as post-brain injury spasticity worsens without intervention. Muscle tone increases far beyond normal levels, causing severe deformities. Dr. Rhee also desires earlier restoration of patients' functions. Thus, he encourages patient referrals sooner rather than later.

"Patients say having upper extremity reconstruction has totally changed their lives," says Dr. Rhee. "Individuals with spasticity have lots to gain from this surgery."

Eligibility for spasticity-related UER

Dr. Rhee's patients with UER have brain injuries with a combination of paralyses from stroke, aneurysm, anoxic or traumatic brain injury, brain tumor, or spinal cord injury. All these conditions involve injury to a higher level of nerves, the upper motor neurons. These injuries gradually result in varying degrees of spasticity. The muscle is overly active and sensitive, resulting in fixed deformity. These patients range from living independently — sometimes self-sufficiently using just one hand — while others are completely dependent on others.

Though physiatry can help temporarily with botulinum toxin injections or stretching, these modalities often stop working eventually as muscles adapt, Dr. Rhee says. Botulinum toxin's additional limitation — its noxious potential — limits treatment time. UER surgery, however, provides patients much longer term effects and eligibility is broad.

According to his publication in the Journal of Hand Surgery in 2018, Dr. Rhee also assesses patients' cognitive and communication abilities to determine if they can follow instructions and rehabilitate postoperatively; these factors significantly impact outcomes.

Individualizing surgical goals

When performing UER, Dr. Rhee individualizes the surgical procedures based on the underlying pathology in every involved muscle spanning a joint. Primarily, he treats spastic muscles with nerve- or muscle-based procedures.

Beyond these overarching management principles, Dr. Rhee considers UER an individualized surgery tailored to each patient's wants and needs. Patients' surgical goals vary, such as achieving:

• More mobility for severely deformed arms.
• Better function in upper extremity regions with functional loss.
• Improved overall quality of life.
• Partial or complete independence.

"The reconstruction surgery can make patients who previously had significant spasticity quite functional," Dr. Rhee says. "For instance, surgery might give them a good helper hand where before it was inanimate."

An example of Dr. Rhee's patients with specific goals is a man who traveled with family to Mayo Clinic following a virtual appointment. This patient's arm was so bent that his family could not wash his elbow crease, causing hygienic and pain issues that UER addressed.

Why send patients to Mayo Clinic, what to expect

Physicians can expect a patient-centered, multidisciplinary approach when referring patients to Mayo Clinic in Minnesota for spasticity-related UER, says Dr. Rhee. They also can feel confident sending patients to a medical center promoting innovation in this field, such as intraoperative techniques and prospective clinical trials.

For patients who live far from Mayo Clinic, Dr. Rhee conducts a previsit video chat. This allows Dr. Rhee to see the deformity and speak to the patient and loved ones to determine if an in-person visit seems appropriate.

"We don't want patients to come to Mayo Clinic from a distance and tell them they're not surgical candidates," says Dr. Rhee.

In-person visits involve spending three hours in the Motion Analysis Laboratory for assessment and gait analysis. In the physical exam, Dr. Rhee looks for volitional movement and spasticity, as mentioned in a 2018 Journal of Hand Surgery article. He and team may use electromyography and selective nerve blockade to identify spasticity and voluntary muscle control. Dr. Rhee combines results from all these sources during the patient's office appointment and pinpoints the muscular deformity. He speaks to the patient about desires for surgery and then develops a plan he discusses with the patient in person, or virtually if more convenient for the patient.

For more information

Rhee PC. Surgical management of upper extremity deformities in patients with upper motor neuron syndrome. Journal of Hand Surgery. 2018;44:P223.

Refer a patient to Mayo Clinic.