Anders Björkman: attention to detail and a steady hand

In August 2020, Björkman became Professor of Hand Surgery and the subject representative for hand surgery at Sahlgrenska Academy. This position is combined with being Chief Physician in the Department of Hand Surgery at Sahlgrenska University Hospital.

“Being able to join this department in Gothenburg, which is the birthplace of hand surgery in Sweden, feels special. This is where Dr. Erik Moberg developed the discipline in the early 1950s. Later on, he became a professor, but of orthopedics,” Björkman says.

Björkman grew up in Skanör-Falsterbo, as far southwest as you can go in Sweden. In August 2020, he became Professor of Hand Surgery at our University. Most recently, he has been Adjunct Professor at Lund University and Chief Physician in the Hand Surgery unit at Skåne University Hospital (SUS) in Malmö.

Life and career start

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At the family home during his childhood, there was always openness to discussions about illness and care. This is hardly surprising, given that his father was a medical physicist in Malmö and his mother worked in the bacteriology department of the same hospital. In due course, Björkman and his sister broadly followed in their parents’ footsteps. Today, his sister works as a veterinarian in Skåne while Björkman, as we know, devoted himself to the medical profession.
On leaving high school, Björkman decided to study medicine. After his military service he met his future mentor, Åke Andrén-Sandberg, who shared his interest in sport and research.

“I think it was through him that my curiosity about the profession took off in earnest.”

Björkman recalls times past, when he worked at Andrén-Sandberg’s laboratory for cell and molecular biology. The scientists there were engaged in cancer research, especially pancreatic cancer.

Lab work the most satisfying
“My job was as Åke’s lab assistant, working on animal experiments. I learned lots about research conditions and the art of, for instance, operating on rats. For one intensive year I was constantly there in the lab, but unfortunately became extremely allergic to rats.”

Björkman had heard that there was a medical training program with a research specialty at the Karolinska Institute (KI) in Stockholm.

“That combination felt really perfect for me. I applied, and was quite surprised to get in on my first attempt. On top of the regular courses during the day, we took extra courses in the evenings and on vacations, to supplement our studies with research preparation at the same time, during the first two years at KI. Then I completed my training in Lund.”

Both during and after his medical training, completed in 1995, he kept his pre-existing research focus on pancreatic cancer.

From orthopedics in Eksjö to hand surgery in Malmö
During his internship, however, he felt that orthopedics was what he liked best. He later became an orthopedics resident (specialist in training) at Högland Hospital in Eksjö, where he remained for two and a half years. But he completed his residency in orthopedic surgery in Malmö with a period of specialized residency training in hand surgery.

“Professor Göran Lundborg there was wonderful, and in the second week we’d already drafted a research project together. That was how my thesis started. There’s a good mix in hand surgery: it combines orthopedics and plastic surgery, as well as microsurgery when it comes to vessels and nerves. You get the chance to handle the whole package, so to speak.”

There is a minor accident and a nerve in your hand gets severed. That can’t be very serious, you think; the nerves will grow together somehow, surely. But nerve damage affecting the hands causes major problems for those affected, in the form of impaired hand function, at worst for the rest of their lives.

“Despite microsurgical nerve-repair techniques where we use special instruments and microscopes, adult patients always get persistent discomfort with impaired or completely lost sensation, muscle weakness, and pain. In the long run, that can also affect society in terms of costs due to long-term sick leave.”

Brain plasticity and new treatments
What attracted Björkman to this research area also included the question of how nerve damage affects the brain — why, for example, young children who cut a nerve in the hand get very good manual functionality back, while from age 12‒13 this no longer happens.

“It’s a matter of slightly older brains being unable to interpret nerve signals from damaged nerves anymore. They don’t have the brain plasticity — the capacity to learn, like when neurons make new connections after an injury.”

In 2004, he became a hand surgery specialist. The year after, he completed his thesis, entitled Brain plasticity and hand function. He then got a five-year research position in neuroscience, with 50 percent research and 50 percent clinical practice at the hospital in Malmö, which is where hand surgery within Skåne University Hospital is performed. This meant that he was also able to pursue his research project and the same line of research, with a small research group of his own.

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Figure 1. The image shows the body map in the cerebral cortex, depicting the proportion of neurons in the sensory homunculus, which processes sensory impressions from a specific area only, and in the motor homunculus, which controls the muscles in a specific area. It is clearly visible that the majority of neurons process sensory impressions from, or motor skills in, only the hands and face.

“In our research group we used magnetic resonance imaging technology, for instance, to look at how the brain reacts to nerve damage in the hand. That meant studying the processes in the brain called plasticity. And we also used that knowledge to study the scope for using this plasticity for therapeutic purposes. In 2010, I became an associate professor, and continued doing part-time research.”

All their research is done on humans, not just because Björkman became allergic to rats, but because the plasticity of the brain differs in rats, mice, and humans. Björkman is also passionate about clinical research, which can directly benefit patients.

In 2018, he was appointed to a Clinical Fellowship, a 50 percent research position funded by the Wallenberg Centre for Molecular Medicine (WCMM) in Lund. He became an adjunct professor of hand surgery at Lund University in 2019.

Artificial hands interesting too
Björkman, who is also researching prosthetic hands, is on the advisory board of the newly established Center for Bionics and Pain Research (CBPR) here in Gothenburg. CBPR is an interdisciplinary center run jointly by the three collaborating partners: Chalmers University of Technology, Sahlgrenska University Hospital, and Sahlgrenska Academy at the University of Gothenburg.

“I’m part of a research group at the Faculty of Engineering at Lund University (LTH), which has been engaged in similar research on artificial hands, and how to use various technical solutions to improve rehabilitation after nerve damage, for more than 15 years. This research group differs from that of the CBPR researchers, who surgically insert electrodes in the patient. The LTH team primarily works on artificial hands that can read nerve signals on the surface of the skin.”

You only appreciate the functions when they’re gone

Nordic region’s first double hand transplant
Björkman was also involved in the double hand transplant that took place in Gothenburg in December. It was the first of its kind in the Nordic region, and one of almost 150 completed globally. A few years earlier, the patient had lost both hands due to a severe infection, and now received two new hand transplants from an organ donor. The operation took 18 hours and was performed by a large team of 15 surgeons plus surgical nurses, anesthesiologists, and anesthesia nurses at Sahlgrenska University Hospital’s Hand Surgery Clinic (source: Sahlgrenska University Hospital press release).

“For a while, I took my turn in operating. The team here in Gothenburg, under the leadership of Dr. Paolo Sassu, has long been working on the preparations — for several years, actually. And they also had a good plan for the research they wanted to do before, during, and after the operation. That includes neuroscience and studying how the brain reacts.

“One of the things they wanted to study was preparation of the patient, something that can determine how well the rehabilitation will go later on after the transplant. The brain has to be prepared for the arrival of two new hands, so it’s not like two prosthetics you attach. Aided by VR [virtual reality] technology and a computer program, the patient has been able to see and imagine having the hands, and think about how they move and work.”

A current doctoral student at the Hand Surgery Clinic, Per Fredriksson, will remain involved in the follow-up as well, since his prospective thesis partly focuses on hand transplantation. He is one of the specialist doctors in hand surgery who has been involved in running the whole transplant project.

“The knowledge that’s going to be collected can also be used for other conditions, like nerve damage in the hands, which is what considerably more people suffer from. It feels very exciting and rewarding to work in such an active and forward-thinking team.”

Keen interest in small scaphoid bone
Another focus of his research is on treating fractures and ligament injuries in the metacarpus of the hand. The focus is on injuries in and around the scaphoid, the bone connecting the forearm and hand. This is the most commonly fractured carpal bone, and scaphoid factures affect several thousand people annually in Sweden. Initially, the injury is often difficult to detect on X-rays. This can be problematic if it is not treated, since a fracture that has not healed may give rise to a “pseudoarthrosis” or false joint.

“In this area, much of my research has been about diagnostics and treatment with keyhole techniques, or what’s known as arthroscopy. This has culminated in two completed theses and two ongoing doctoral projects. And there are international collaborations going on here too, with Denmark and research groups in Boston, Massachusetts, and Houston, Texas.”

Sequel to book on hand surgery: on hand rehabilitation
Apart from his research and clinical work, Björkman has also devoted himself to writing educational works on hand surgery. As he has written, the human hand may be seen as a sensory organ — an extension of the brain towards the surrounding world. The hands’ capacity for both fine-motor skills and a powerful grip plays a crucial role, and a hand injury can create major problems in people’s working life and for their prospects of engaging in meaningful leisure pursuits.

With these statements, Björkman and his colleague Göran Lundborg open the preface to their book Handkirurgi (“Hand Surgery”). Lundborg, who was Sweden’s first professor of hand surgery, is the man who introduced Björkman to hand surgery. The book is published by Studentlitteratur.

“Hand surgery is bigger than you think. Every year, cutting and pinching accidents happen to lots of people, and they have major difficulties in everyday life and in returning to work. We thought a textbook in Swedish in this field would fill a gap. Writing a textbook was a fun and instructive experience, I must say.”

For more than a decade, Björkman has been in charge of the specialist training course in hand surgery for aspiring orthopedists, where the book is included on the course reading list. He now has a new book underway on hand rehabilitation, aimed primarily at occupational therapists and physical therapists — two very important occupational groups in the rehabilitation process.

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“Hand rehabilitation involves a very unusual team effort, with close collaboration among patient, surgeon, occupational therapist, and physical therapist. Surgery is often the first stage of treatment, and a perfect surgical outcome can be ruined if rehabilitation is neglected or not done properly.”

He therefore thinks it is important for advanced hand surgery to be performed only at university hospitals, because this is where the most experienced hand therapists work.

“It’s an exciting book project that we hope will be completed in the fall. This time, my coauthors will be Senior Lecturer Birgitta Rosén, who’s an occupational therapist, and Stefan Johansson, a physical therapist at Sahlgrenska University Hospital.”

Björkman’s production of teaching materials reflects his interest in education. At Lund University, he used to handle parts of the anatomy teaching about the arm, and he hopes that in the long run he can do so here as well. He will, naturally, be involved in teaching the course on hand surgery, too, but that is a fairly small part of the medical training.

Challenges ahead — getting injured nerves to regenerate properly
“All nerve injuries pose big challenges. One is how to guide nerves to grow back right. For instance, if you sever a nerve at the wrist, the cut-off part of the nerve and its axons (fibers or branches), which extend into in the hand, degenerate. Then the cut nerve has to grow back again so that the axons join up properly, which they can’t do unaided, because the nerve fibers that used to go to the thumb maybe grow into the index finger or vice versa. The result’s a great big mess. So it would be wonderful if something could be found to make nerves regrow correctly.”

He also sees another major challenge in using brain plasticity for rehabilitation: tricking the brain into making the hand work better. If this is achieved, many patients can be helped, he believes.

“Over half of our clinic patients have hand injuries from accidents, and the average age of these patients is below 30. The damage happens either at work or in their free time, when it’s easy for the knife to slip when you’re dividing frozen bread or splitting an avocado. Many people have just entered the labor market, and too many may never return, at least not to the work they had first. That’s terribly tragic, and it would of course be a financial gain for both society and the individual if our treatment succeeded.”

What are you looking forward to as a new professor?
As a professor, Björkman is aiming to strengthen academic activities in hand surgery with sustainable lines of research that cover various areas of clinical activities. There also need to be clear translational connections with orthopedics, plastic surgery, radiology, rehabilitation medicine, medical technology, and preclinical nerve research, and also ties with Chalmers University of Technology.

“I look forward to developing and advancing the research here at the clinic, which has great potential with extremely talented staff. We’ll develop the resources available and broaden the work. I also look forward to getting started on teaching the students. I appreciate the teaching part a lot, and that’ll be at basic and advanced [first- and second-cycle] level as well as in continuing professional development. For me, as a doctor and professor at a university hospital, the goal is to give a boost to all three of our missions: patient care, training, and research. I look forward to sharing my passion for hand surgery with the staff and hope I can inspire many people.”