“Follow-up care is just as important as surgery itself”

Dr. med. Jörg Witthaut is a hand surgeon with his own practice in Wasserburg am Inn, Germany. He is also the head of the hand surgery department at the local RoMed Hospital. He is competent in the whole range of surgical techniques, and he relies on removable orthoses for post-operative care. The expert , who has studied in France and worked in Sweden among other places, enjoys fitting such aids himself.

Bauerfeind life: What makes hand surgery special for you compared to other surgical disciplines?

Dr. Witthaut: The hand is an organ of expression and it is our most important tool. I’m fascinated by its microcosm of bones, muscles, nerves and ligaments. It’s a small area filled with the greatest challenges. This is true of ligaments and tendons even more than it is of bones. Internal fixation is often the smaller part of the problem. The field offers a diverse surgical spectrum, and I’m able to operate while sitting down.

Who are your patients?

Dr. Witthaut: I come across all types of hand conditions: malformations, old ligament ruptures, osteoarthritis – and unfortunately severe injuries caused by buzz saws that require flexor tendon reconstructions, partial joint stiffening, as well as amputations and stump treatment are not a rare occurrence either. Typical injuries caused by falls are also very common, such as skier’s thumb, which is a rupture of the ulnar collateral ligament , or radius fractures.

What does post-operative care for these typical injuries look like?

Dr. Witthaut: For skier’s thumb I like to work with a thumb orthosis such as the RhizoLoc. It stabilizes and protects the sutured ligament for about five weeks. Mobilization can then be initiated gradually. Radius fractures often occur with concomitant injuries, such as a fracture of the scaphoid bone or an injury to the SL ligament between the scaphoid and lunate bone. Fracture treatment tends to have a secondary role in this context. A typical scaphoid fracture can be treated with a Herbert screw, nearly completely restoring the bone’s load-bearing capacity. Reconstruction is more difficult in the case of a ligament lesion, especially if it’s not detected soon enough. The ManuLoc or ManuLoc long, depending on the length of the forearm, is very effective for protective immobilization in the case of a radius fracture. I start mobilization once the initial pain is gone, the wound has consolidated and the internal fixation doesn’t show any problems. This is usually the case after three or four days. Being able to simply take off the orthosis by opening the Velcro fastenings is a clear advantage for everyone: the physician, the patient and the occupational therapist. Traditional bandages and thermoplastic splints are very different in this regard.

What are the other benefits of removable orthoses?

Dr. Witthaut: Compliance is better. ManuLoc orthoses are padded and they have no sharp edges. Patients often praise the aspect of hygiene. It’s a blessing to them to be able to wash the orthosis, as well as their arms and hands. An advantage for me is that I’m able to adjust it right on the patient. I cannot do this with the thermoplastic splints, because I do not have a hot-air gun here. I also appreciate the modular design of the orthoses that allows for them to be quickly altered or adjusted as needed. Take the finger support on the ManuLoc long Plus. If it’s necessary that the wrist is largely extended during the night , for example in non-surgical treatment of carpal tunnel syndrome, or in post-operative care following reconstructions, the flat support for the whole hand will provide protection. During the day this can be easily removed to allow for exercise. It’s flexible and it also allows me to apply the Intrinsic Plus position myself that is easy on the ligaments, for example in the case of fractured fingers. Protection of the ligaments is very important to me. On the long run we would shorten the ligaments, because the flexor tendons are stronger than the extensor tendons. The Intrinsic Plus position is perfect for counteracting such stiffening (see box).

How do you decide between immobilization and mobilization?

Dr. Witthaut: The general rule here is that follow-up care is nowadays just as important as the surgery itself. Immobilization should only take place for as long as it is absolutely necessary. After this period it’s important to focus on movement without strain. Orthoses safeguard the results achieved. The sooner the better, is our motto when it comes to mobilization. Ideally this should take place under the supervision of an occupational therapist or a physiotherapist with extra qualifications for treating hands. If a surgery wound is free of irritation, I’m sometimes able to start as soon as on the first or the second day after the operation. The regular consolidation phase is around 14 days.

Do you use the ManuLoc long Plus in pre-operative care, too?

Dr. Witthaut: It’s always worth trying to avoid surgery, for example in a typical case of tenosynovitis. This morning I saw a floor tiler whose rubbing tendon sounded like snow crunching. In a case like this, it’s an essential therapeutic concept to provide immobilization by means of an orthosis. The same applies for a simple wrist sprain that just causes pain during movement. Orthoses are suitable for all indications that call for protection.

Images: Conny Kurz