"How are you about blood? Are you ready for this?”
That’s what Dr. James Calandruccio asks me, before scrolling through a series of photographs on his iPhone. Most people keep images of their kids, or their vacations, or other pleasant images on their phones. But sitting in his comfortable, cluttery office on the second floor of Campbell Clinic’s main complex in Germantown, Calandruccio wants to show me a couple dozen images depicting the surgery he recently performed on a patient who had lost the use of his right hand following an industrial accident.
A third of the man’s forefinger had been lopped off, and his thumb had lost all sensation. The accident happened years ago, and the patient came to Campbell to see what might be done for him.
Dr. James Calandruccio. Photograph by Michael Finger
“What we always want with a hand is mobility and sensation,” says Calandruccio, one of six hand specialists at Campbell Clinic. “He’s got no motion, no feeling, is in tremendous pain, and hasn’t been able to use his hand for three-and-a-half years, so what do you do?”
In this case, Calandruccio performed what is known in the world of hand surgery as a “neurovascular island pedicle flap.” This procedure involved removing the index finger with no sensation, and reattaching nerves, tendons, and other soft tissue — completely rebuilding the fellow’s hand. He’s missing a finger, but it’s hardly noticeable, and he has almost full use of his hand now.
“There are some patients that you just like, and I won’t forget him,” says Calandruccio. “He had to make a pretty big decision: ‘You’re going to take my finger off and do what now?’” But within 48 hours of surgery, the patient was able to touch the tip of his thumb to his remaining fingers, a simple motion he couldn’t do before.
X-rays from two different patients show the use of implants to repair several fractured fingers (above) and tiny screws inserted into fingertips to stabilize deteriorating joints. Images courtesy Campbell Clinic.
If that procedure seems extreme, it’s all in a day’s work for this doctor, who recalls working with other team members to re-attach the hand and arm of a two-year-old who fell underneath the riding lawn mower driven by his grandfather. Was that extensive operation — lots of operations, actually — a success? “Oh sure,” says Calandruccio, “he’s fine now,” as if the life-changing procedure was really no trouble at all.
Other times, he might be taping splints or prescribing a regimen of physical therapy for sprains or other wrist, hand, finger, and thumb problems that can be the result of accidents, injuries, or the natural process of aging, such as arthritis. As Calandruccio explains, “Most hand surgeons deal with everything from the elbow down.” Every day — every patient — presents a different challenge.
Since we’re talking about orthopaedics here, we can say that Calandruccio has “good bones.” His father, Dr. Rocco A. Calandruccio, served as the chief of staff at Campbell Clinic after founder Dr. Willis Campbell passed away. Following medical school at Yale, he came to Memphis for his general orthopaedic residency and, according to his son, “was offered a position at Johns Hopkins but he hit it off very well here and stayed on.” Among his many accomplishments during his 36-year career, he was professor of orthopaedic surgery at the University of Tennessee and served as president of the American Society of Orthopaedic Surgeons.
His son attended Central High School and earned a degree in physics at Vanderbilt, followed by a master’s degree in chemistry at then-Memphis State University. After getting his medical degree at UT-Memphis, he completed an orthopaedic residency at Campbell Clinic and a hand surgery fellowship in Indianapolis. Pondering where he might go next, he joined the Campbell Clinic staff in 1991.
Dr. Calandruccio is the proud owner of a rare textbook written by Dr. Sterling Bunnell, considered one of the pioneers of hand surgery. A row of inscriptions inside shows how the book has been passed down to other leaders in the field. Calandruccio’s crowded bookshelves also hold copies of Campbell’s Operative Orthopaedics, still considered the Bible of orthopaedic surgery.
The bookshelves in his office are crammed with textbooks, porcelain glove molds, casts of hands, photographs of patients, and medical gadgets. A vintage brass microscope sits in a wooden case atop a file cabinet, and a plastic skeletal arm dangles from a bookcase in a corner. Calandruccio pulls out a dog-eared copy of a book, Surgery of the Hand, by Dr. Sterling Burnell, and opens the cover. “The field of hand surgery as a specialty was begun by this gentleman,” he says, indicating the rows of inscriptions inside: “In 1949, this particular edition was given to the second staff member of the Campbell Clinic, Dr. Spencer Speed. In 1965, Speed passed it on to Dr. Lee Milford, who was the first true hand surgeon in the Memphis area, and a superb technician. And it just so happens he was my godfather.”
In 1993, Milford passed the book on to the present owner. The inscription reads, “To James Calandruccio — my godson, fellow hand surgeon, and friend.”
Diplomas, certificates, and awards cover the walls of Calandrucio’s office. He has been a co-author of at least six books on orthopaedics, maybe more (“I don’t really keep track,” he says). He’s also a contributor, in the hand and upper-extremity section, to Campbell’s Operative Orthopaedics, now in its 13th edition, and still considered the Bible of the field.
He talks about the range of injuries that can affect the hand, and as one might expect, many of them involve sports. Calandruccio describes a common condition called a “baseball finger” (also known as a mallet finger) that can happen when someone jams the tip of a finger into a baseball, football — “or you might even drop change out of your pocket and be sliding your hand behind a sofa cushion.” The finger gets snagged, tearing away a small tendon on the top called the terminal slip. When that happens, the larger tendon on the bottom pulls the finger into a hook shape. Though painful, he says, “Most of those do just fine with full-time splinting.”
Other sports injuries are far more serious. “The most devastating injury to an athlete is a ligament injury between two bones at the wrist,” Calandruccio says, “and that can be career-ending.” Not only does this affect wrist movement, the patient may endure constant pain. What’s more, when that ligament ruptures, “the wrist can progress through a predictable series of degenerative changes. We use all sorts of acronyms in orthopaedics, and that is called a SLAC deformity” (for “scaphoid lunate advanced collapse”). The treatment almost always requires surgery, followed by physical therapy.
This is where Campbell Clinic’s wide-ranging approach comes in, well, handy.
“Years ago, if you had an upper-extremity injury, you’d have a neurosurgeon do the nerve work, and a vascular surgeon fix whatever arterial damage there would be. Often you’d have to involve a plastic surgeon for soft tissue coverage,” Calandruccio says. Campbell went with a more specialized approach. “We decided to have training specifically for that area, to have one person or a group of persons that could do these things without having to coordinate the procedure with a lot of other folks.” Campbell offers one fellowship annually to a surgeon specializing in hands “to have them educated along different lines of pathology. Obviously there are some things you never see in a year, and some things you see maybe once in a decade. But the goal is to have a surgeon gain confidence so he can treat cases he’s never encountered before. That’s our goal.”
Obviously the treatment of hand injuries has come a long way from the days when it was easier to replace an injured hand with a prosthetic. “The goal is to avoid amputations,” says Calandruccio, “and we’ve come a long way.” But certain aspects of his field still need improvement.
“The restoration of sensation is probably the main concern,” he says. “Just moving nerves around to get feeling, and I’m not sure, really, that will ever be resolved.” He mentions unusual procedures done to restore “nerve gaps” — everything from taking nerves from other parts of the patient’s own body, to taking nerves from other bodies, such as cadavers. “A nerve graft from a cadaver is called an ‘autograft nerve’ and the results can be great,” he says.
Advances in technology have also helped, with better and stronger materials being used for implants inserted to treat fractures of the wrist bones and fingers. “But there’s certainly room for improvement in other areas, such as the use of silicone implants where the fingers join the hand,” a common treatment for arthritis.
He pulls up another series of images on his iPhone, which show a patient whose fingers were badly crooked at the tips, and says, “Her fingers were pointed in all different ways, and it was very painful for her.” The X-ray shows what look like spikes inserted into the tips of her fingers, but they are actually needle-thin screws, which link the tip of each finger to the next joint. She no longer has complete flexibility there, but the pain is reduced, and her hands now look normal.
With all the focus these days on preventing sports injuries, especially concussions, minor problems are still bound to happen. The most common ailment he sees, after sprains, are minor ligament injuries that are the result of what he calls “hard-stick sports” — baseball, hockey, even golf — which involve wrist movement. The mention of golf reminds him of another patient from years ago, one of his most challenging cases, and this one involved more than just a hand.
Some 15 years ago, a young man was brought to a local hospital with a horrific injury. While working at a printing company he got his arm caught in a press. “His arm was just mangled,” Calandruccio remembers. “His hand was in a very strange position, and he had all sorts of blue and black ink impregnated in his soft tissues.”
When the original Campbell Clinic building on Madison was demolished, Dr. Calandruccio salvaged some brass and personally crafted tiny hand-decorated pendants for use as gifts at a physicians’ conference.
The first thing doctors did is called debridement, which meant removing all of the soft tissue and seeing what could be done with what’s left. To keep the arm alive, the most immediate concern was re-establishing blood flow. “In order to do that for this person, I ended up shortening his arm by taking two inches off the forearm bones, to allow the soft tissue to come together so I could do vascular repairs. Some areas were so badly damaged that I did tendon transfers — taking muscles that would normally do one function elsewhere in the body and having them do something else.”
When it was all over, “it worked out remarkably well,” says Calandruccio. “In fact, he ended up challenging me to a game of golf.”
So who won that match?
“I never played him,” says the doctor. “I’m not good at golf, and I certainly didn’t want to lose to somebody with one arm shorter than the other.”
