Hand Surgery in Louisville
By Harold E. Kleinert, MD
How hand surgery as a specialty began in Louisville, Kentucky, or how I even became a physician, was an assortment of fortuitous events. I was born and raised on a ranch in Montana, some 11 miles from the nearest town of Sunburst. There was not much medical care available for humans or animals. My father tended to sick and injured animals, and a neighboring rancher, Dr. Thomas Clark, who interestingly received his medical education in his home state of Kentucky, treated local people and delivered me in my parents’ ranch house in 1921. He certainly had some influence on my medical interest and career decisions. When I started medical school in 1943, I was honored to receive Dr. Clark’s medical textbooks, which included articles such as how to treat arrow wounds.
I was further influenced by one of my father’s ranch hands who said he could tell by looking at my hands that I could be an excellent surgeon someday. Unbeknownst to us at the time, he was a medical doctor trained in Australia (or New Zealand), and to me, a very charismatic person. (As an aside, he married the local schoolteacher, who also lived on our ranch, and left to open a medical practice in Sunburst. A few years later, he and their family car disappeared. I remember my father having to go to Denver to testify at his trial for practicing medicine without a license—and bigamy! He was eventually deported from the United States.)
My father discouraged me from going to medical school, preferring that I become a rancher. Fortunately, my mother supported my decision. After attending a two-year college in Montana, our family doctor, who practiced in the bordering small towns of Coutts, Alberta and Sweetgrass, Montana, said I should go to a better-known, four-year college in order to be accepted to medical school, especially since there were no medical schools in either Montana or the surrounding states at that time. Coming West to take photos of cattle roundups and rodeos, a Detroit newspaper photographer who stayed at our ranch house suggested the University of Michigan. Since a great aunt lived in Caseville, Michigan, and could “watch over me” a bit, my father agreed. When it came time for medical school, I sought the advice of my Professor of Embryology at Michigan regarding which medical school to attend. He leaned back in his chair, smiled, and said, “Kleinert, you need a lot of polish. You’d better go as far East as you can go!” I chose Temple University in Philadelphia, which was about as far East as one could go.
The early principles of hand surgery were taught to me during my residency in Detroit by Joe Posch, who had spent three months with Koch, Mason and Allen; and also by one of the most technically precise and delicate plastic surgeons, William Lange, whose techniques I applied to vascular and hand surgery. At the end of my residency, one of my research projects was accepted for presentation at the Central Surgical Society meeting in Chicago. The presentation went well, and like many in the audience, at the afternoon break in the program, I decided to treat myself to a beer in the hotel lounge. The only empty seat was next to a man who said he enjoyed the presentation and asked what I was going to do now that I’d finished surgical training. I told him I was returning to Montana to practice medicine and surgery but first would like to spend two years gaining experience in a university hospital with a busy emergency room. That person was Dr. James Drye, a Professor of Surgery at the University of Louisville School of Medicine in Kentucky.
He invited me to interview for an open position, and as a result, in 1953, I became a Surgical Instructor at the University of Louisville School of Medicine with an office in the old Louisville General Hospital. Since I had asked to continue surgical research, one of my first "jobs" on joining the faculty was to clean the coal out of the basement of the “old” medical school building at First and Chestnut Streets in order to use it as a surgical research lab. (The building now houses the Ronald McDonald House and the Greater Louisville Medical Society.) Amongst my early studies was the repair of small vessels, 2-3 mm, using the smallest nylon sutures available, which produced superior results with less thrombosis at the anastomotic site than larger sutures. Subsequently, vascular repairs were done in severe injuries when indicated, and several of these cases were reported, most of which were incomplete amputations. (My first total finger replant in 1963 failed due to venous thrombosis.)
At the University of Louisville, I did a great deal of emergency surgery but was appalled to see that new residents on the service, rather than faculty, were taking hand injuries into the operating room, where the circulating nurse would turn to the pertinent pages in Gray’s Anatomy. Hand injuries were considered unimportant since the final result was usually a non-functional, stiff hand. This provided a strong personal stimulus to search for improved methods of treatment that might obtain better results. I asked Dr. Rudolf Noer, the Professor and Head of the Department of Surgery for permission to start a hand surgery clinic and document the results. At that time most tendon repairs were done as secondary procedures, which increased patient’s time away from work and necessitated more extensive surgery later. We began testing different primary tendon repair techniques on chickens and vascular repairs on dogs.
My salary at the University as an instructor was $7200 a year. After one year and falling further into debt, Professor Noer said there was no more money available for a salary increase, but he would allow 25% of my time in private practice and 75% at the University. By 1960 that percentage was reversed and to relieve guilt feelings of cheating the university, I decided to enter full-time private practice in hand surgery yet continue the university hand program as gratis faculty. This reduced my time with the surgical residents who desired more hand surgery experience; therefore, that same year, 1960, the Christine M. Kleinert Fellowship in Hand Surgery was initiated. The program began with one fellow and grew to be the largest, and hopefully the best, Hand Fellowship Program in the country. Some years, there have been as many as 28 fellows in the program at one time. These large numbers enabled 24-hour hand emergency coverage with the manpower to staff replantation teams (and now transplantation teams) as well as elective surgeries.
Dr. Joseph Kutz was a surgical resident in 1959, chief resident in 1962, became a hand surgery fellow in 1963, and my first partner in 1964. As a candidate member to the American Society for Surgery of the Hand in 1967, he was scheduled to present our 80% good-to-excellent results of primary repair of flexor tendons in “no-man’s land” (the tendon sheath area). The Program Chairman said the paper was too controversial for a candidate member and I instead should present the paper. Following the presentation, one of the leading hand surgeons of the time stood up and stated, “I don’t believe these results.” He was invited to come to Louisville and review our patients; hence, a committee of hand surgeons from the ASSH was gathered and sent to Louisville. The head of the committee was the distinguished New York hand surgeon, Dr. William Littler, who stated in his report, “If I injure a flexor tendon in a finger, I am getting on a plane and flying to Louisville.” The nicest compliment and support one could wish for.
Dr. Erdogan Atasoy, a co-resident of Dr. Kutz, returned to Louisville for a Hand Fellowship in 1966 after fulfilling his military obligation in his home country of Turkey and also joined the practice.
Because of the increased volume of hand surgery cases, some Jewish Hospital surgical staff discussed that the amount of hand surgery should be curtailed because other surgeons could not get OR time. Fortunately, the hospital administration decided they would increase the number of operating rooms instead. They also allowed us to schedule elective cases on Saturdays and run a double bed operating room, which one opponent said would increase our infection rate and we “would go to hell” for endangering patients. Interestingly, a study of our infection rate proved just the opposite.
Hand surgery and microsurgery became more and more specialized in the 1960s and 1970s with phenomenal improvements in techniques and instruments. We worked with the Weck instrument company to develop a double-head operating microscope and refined microsurgery instruments; and worked with Ethicon to develop a fine microsuture.
Foreign fellows and visitors to our program increased in number and one such visiting plastic surgeon from Canniesburn, Scotland, Graham Lister, was invited to return as a partner. He was a superb director of the Fellows’ Education Program; however, increasing morning lectures from five days per week to seven was not so popular with fellows and their families and thus was changed back to weekdays.
Dr. Thomas Wolff, an orthopaedic surgeon, spent a year with us as a fellow in 1976 and was asked to join the practice. Now the practice was complete in that there were general, plastic and orthopaedic surgeons complementing one another within one group in a fairly new specialty, hand surgery.
That diversity in the practice continues today.
Realizing our microsurgery teaching techniques needed improvement, Dr. Robert Acland, also from Canniesburn, was brought to Louisville in 1975 at the suggestion of Dr. Lister. Dr. Acland instituted a world-class Microsurgery Lab at the University of Louisville. Later the Fresh Anatomy Laboratory was organized by Dr. Herb Wald, Professor of Anatomy, and Dr. Acland. In both of these labs, fellows honed their skills, and new research was undertaken. Also in 1975, a Taiwan microsurgeon, Tsu-min Tsai, visited and astounded us with his ability to replant a fifth finger considered by us not technically replantable. He was quickly persuaded to stay in Louisville.
Many people have influenced my career and our practice: local colleagues, with their interaction and support; the talented surgeons who joined the practice; and many other hand surgeons, microsurgeons and visitors from around the world. I would also include our Fellows in Hand Surgery from the world over, with whom interchange of information and ideas greatly contributed to Louisville becoming a center for hand surgery. We also could not have accomplished a fraction of our successes without the support and encouragement of the leadership of Jewish Hospital and University of Louisville Department of Surgery.
In 2001, the Jewish Hospital opened what we believe is the only 24-hour Emergency Hand Care Center in the world, allowing the hand and upper extremity emergencies to be treated outside the main emergency room where life-threatening injuries take precedence, resulting in the even faster evaluation and care. Our group now numbers 16 surgeons in four locations, with plans to expand further.
Hand surgery has always been interesting to me - working with anatomical structures with many moving parts that have to perform both delicate and heavy tasks, overcoming scar tissue with proper postop care, splinting and therapy and salvaging nerve and vascular function. But whether caring for the hand, the whole patient, or even lab animals, I have kept these professional principles foremost in my life:
- Whatever you do, do the best job you possibly can, and when performing surgery, apply your thoughts and interest totally toward the patient you’re taking care of.
- If you do something well, develop new procedures, instruments, etc., you are obligated to share them with and teach others.
If anyone were to ask, what is my greatest accomplishment? It is the 1163 hand fellows from 55 countries who trained in Louisville, shared information with us, and returned to their countries to do and teach hand surgery.