Pioneering hand surgery

 

Pioneering hand surgery: ‘If I wanted to shake hands with you before, I couldn’t open them. I’d be offering you a claw’ (Regina Lavelle, Irish Independent, March 14, 2022)

Former professional referee John Purcell inherited a family gene which resulted in him not being able to straighten his hands. But a chance encounter with a consultant 70 years later led him to undertake pioneering surgery to fix his condition.

“Any chance you might be able to do something for me?”

John Purcell was sitting in the atrium of the National Orthopaedic Hospital when he enquired, half joking, whether consultant Noelle Cassidy might be able to help with his hands.

She said she would take a look. Only then did John pull his hands from his pockets for the consultant to inspect them. She said she didn’t work on hands herself, but she knew someone who would.

Since birth, John had been unable to straighten his hands, a genetic condition first known to his family from John’s grandmother, Mary Ellen Purcell.

“To all intents and purposes, they were like claws,” John says.

“If I wanted to shake hands with you before, I could offer you my hands, but I couldn’t open them. I would manoeuvre myself around but I couldn’t open my hand. I’d be offering you a claw.

“And I would know by the glance, although people would never say, that they would be thinking, ‘What’s wrong with his hands?’”

John’s grandmother Mary Ellen had been a seamstress in PJ Bourke’s theatrical costumiers beside the Olympia Theatre. She was born in 1875 and lived until 85.

“She had what we’d call ‘Purcell hands’,” says John.

“I remember her hands very well. She had six children, two boys and four girls. None of the girls had the hands, but the two boys had the hands.

“They were my father, also John Purcell, and his brother, Joe. Joe had the hands quite badly, but he stayed a bachelor all his life.

“My father had five children. I’m the eldest. Myself, I have the hands. My next brother, Martin, has them. The next three didn’t.”

The Purcells were raised in Whitehall on Dublin’s northside. He remembers going shopping for his grandmother in the days before supermarkets. Back then, her hands went unremarked upon. Indeed, John doesn’t directly recall much trouble himself, initially at least.

“As a child, it didn’t present itself as a problem. It did when I got into my teenage years and when I started working. You would notice people looking at your hands.”

John went into the printing business, which brought him in contact with Silicon Valley executives.

“We did a huge amount of work with Apple in Cupertino. I would go to meetings over there twice a year for around 12 or 13 years. We’d be in meetings with the best minds in America.

“There would be around 20 people around the table and I had my hands in my pockets because there was no way I could be demonstrable, even though everyone else would be pointing at the screens and the boards.

“I learned to manage it very carefully. It became second nature to me.”

Five years ago, John received lifetime achievement awards for his services to the printing industry. It stands alongside his other such award for refereeing.

“I did the international FIFA/UEFA games. I refereed the World Cup. I refereed the Champion’s League. I did big matches.

“Ironically, I was always very reluctant to give indirect free kicks because you had to put your hand up to indicate it.

“But the only way I could put my hand in the air was to basically make a fist. I refereed in the United States and in Israel but not one of my observer colleagues ever asked me, ‘What’s the story with the fist?’

“There was always a joke with my FIFA colleagues that whenever I was refereeing there were never indirect free kicks. It was either a direct free kick or a play-on.”

Having enjoyed such an illustrious career, John’s family were taken aback at his intention to chance the surgery.

“My wife thought I was stone mad,” John says.

“She says to me, ‘Do you know how old you are? Are you for the birds? You’re after going 70 years now and you’ve got through fine and life has been good to you and it hasn’t impacted you really.’

“It actually had, but I coped.

“Nobody who doesn’t have the condition would have a notion of what it was like.

“Even my two sisters and the other brother who doesn’t have it were saying, ‘I think you’re mad John. That’s serious surgery. No one’s ever had it done before. You don’t even know if it’s going to work’.”

John had seen specialists about his hand previously but none had good news.

The first time there was even a hint of optimism was that day in Cappagh when he asked, by chance, if anyone could help.

His youngest daughter happened to be undergoing surgery at the hospital and John was sitting with her surgeon, Ms Cassidy while his daughter was having an MRI.

“We were chatting about anything and everything and I just said, joking, ‘You don’t do hands Noelle, by any chance?’

“And she said, ‘What do you mean, John?’

“So I showed her.”

Ms Cassidy said that she knew the very person and suggested Ms Grainne Colgan, a colleague who had recently returned from the UK.

Some months later, John got a call from Ms Colgan’s private secretary to come in the following morning.

He was first seen by a doctor on Ms Colgan’s team, and then another. They advised him he might have to wait another hour.

“I said, ‘I don’t mind waiting. I’ve already waited 70 years’,” John recalls.

“About 20 minutes later, Ms Colgan arrives with about five other doctors in tow.

“She took a look at my hands and she went, ‘Wow’. She was asking, ‘Can you do this? Can you do that?’

“So anyway, we were chatting about it and then after a while we were sitting in her office.

“I said straight out to her, ‘Grainne, can you do anything for me? Can you do anything?’

“She didn’t bat an eyelid. She goes, ‘John. I can fix that for you.’ It was like she was saying she could fix a puncture. There was no ambiguity.”

From almost the beginning of her surgical training, Ms Colgan was fascinated by hands.

“I actually trained with plastic surgeons after my orthopaedic training because hands were always my real interest, but I also do trauma and emergencies,” she says.

“Hand surgery is bone and also soft tissue, so tendons and ligaments. I set my own fellowship here [in Ireland] — with the support of orthopaedic and plastic surgeons.

“It was the first fellowship of its kind and that’s where I really found my passion, which was more complex hand surgery — including paediatrics and cerebral palsy.

“It’s both bones and soft tissues, and very niche. That’s what I really loved.”

Ms Colgan explains that when it comes to surgery, “there’s a tendency to be a bit dismissive” about hands at the expense of the “big bones”.

But hands, she says, are “very intricate”.

“The outcome is very skill-based. It’s very intuitive. It’s very clinical. There’s an awful lot of examination. It’s really important you do the right operation.

“There’s a bit of everything, so it’s a challenge. Hands are so important. Hands for surgeons are so important. And I love the idea of hands operating on hands.”

The Purcells’ case was complicated by how well they had adapted to their condition. Whilst neither brother could straighten their hands, there was no pain, and the function of the hand was not unduly affected.

The power of their hands was not diminished.

“John’s first question to me was: ‘Can you straighten my hand?’,” Ms Colgan says.

“I said yes, because straightening is easy. It’s doing that and keeping the function that’s the challenge.

“There was huge potential to make it worse. And there is nothing on it in the literature. I asked lots of hand surgeons and none of them had seen it.

“I wanted to know if they would lose power, because I would have to lengthen all their tendons.”

In an ordinary hand, the muscle inserts into tendons which are attached to the fingers. The tendons control the opening and closing of the fingers. Tendons are made of the protein collagen. When the tendons are shortened, the fingers cannot open fully.

“I knew from examining them that the tendons were short in the forearm,” continues Ms Colgan.

“Each tendon is like a rope, like an elastic band. To lengthen it, I divided it in the centre, and stitched tendon to tendon. The intricate bit is judging it right. If I didn’t lengthen enough, they would still be tight. If I over lengthened, they would be weak, because the tendon would be slack.

“I had to cut every tendon in the hand, to suture, to repair and then to rehab them.”

Whilst the surgery itself was tricky enough, the repair and rehabilitation brought their own risks.

“One of the risks was getting something called a rupture,” the surgeon adds.

“The tendons were stitched but they could have pulled apart, which is a rupture. Or they could have got stuck to each other. It was really important we got them moving early at the risk of then rupturing. That was the fine balance.”

John’s hand and forearm was put in a cast while the team waited. There was uncertainty as to how the surgery would take.

“I wasn’t sure how it was going to turn out. There’s nothing written on this. We would do that operation for trauma, where individuals would have accidentally cut their tendons, but not in a case like this.

“Then when I saw John in recovery and everything was moving powerfully, it was quite astonishing.”

Both John Purcell and Ms Colgan both acknowledge that the care received at Cappagh made the surgery a success.

“Hand surgery is nothing without hand therapists,” Ms Colgan says.

“I would honestly credit Orla Brady and Carina Wiid-Kenny with doing the most amazing work. They did all the monitoring, all the strength checks, and all the objective measures and then link back in with me.

“That’s a huge part of it. You can’t do that type of operation without specialist therapy.

“The skill and support of the nursing staff was invaluable. All the nurses were so interested, one of the theatre nurses even swapped her shift to come scrub with me, which I really appreciated. I had senior trainees with me, and junior doctors, and their input was also vital.

“A surgery like this is not a single person. It’s the whole team, the anaesthetics, the admissions people pushing to get them in. It’s a small team in Cappagh and we think of ourselves as a small country but we have a huge wealth of expertise and talents.

“And it’s reflected in how well they’ve done.”

Back in Co Meath, John and I are back chatting over Zoom. He is wiggling his fingers. He says he is back playing golf and the power in his hands is almost fully returned.

He is now a patient representative on the board of Cappagh Hospital. Certainly, he already seems to have won hearts and minds on the wards.

“When we went down to John with the team after his first surgery to see if he was awake,” says Ms Colgan, “his reaction was so powerful that we were all choked, genuinely.

“It only really dawned on me then just how important it was to him, and how important surgery, and medicine can be.

“It was a moment that probably won’t be rivalled in my career.”

National Orthopaedic Hospital Cappagh is at the forefront of orthopaedic medicine, education and innovation.  www.nohc.ie