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Timeline of Hand Surgery in Singapore
< 1952: Hand conditions were treated under general surgery and leprosariums
1952: Foundation of Orthopaedic Department (Singapore General Hospital)
1960: Increased interest in hand trauma and leprosy treatment amongst Orthopaedic surgeons
1967: Professor Pesi Chacha joined the department of Orthopaedic Surgery
1968: Outpatient Hand Clinic started at Singapore General Hospital
1971: Dr Kanwaljit Soin visited Dr John Hueston under Colombo plan
1974: Professor Robert Pho joined the department of Orthopaedic Surgery
1974: First operating microscope and microvascular surgery laboratory
1975: First macroreplantation of an amputated arm
1977: First thumb replantation
1978: First free fibula transfer
1980: First toe transfer
1982: Foundation of Singapore Society of Hand Surgery
1985: Establishment of Singapore General Hospital Hand Surgery
1990: Establishment of National University Hospital Hand & Reconstructive Microsurgery
1996: Hand Surgery gazetted as a specialty with independent advanced specialist training program
2005: Foundation of Chapter of Hand Surgeons (Academy of Medicine, Singapore)
2009: Establishment of Tan Tock Seng Hospital Hand & Microsurgery Section
2011: Establishment of Hand Surgery Residency
1952: Foundation of Orthopaedic Department (Singapore General Hospital)
1960: Increased interest in hand trauma and leprosy treatment amongst Orthopaedic surgeons
1967: Professor Pesi Chacha joined the department of Orthopaedic Surgery
1968: Outpatient Hand Clinic started at Singapore General Hospital
1971: Dr Kanwaljit Soin visited Dr John Hueston under Colombo plan
1974: Professor Robert Pho joined the department of Orthopaedic Surgery
1974: First operating microscope and microvascular surgery laboratory
1975: First macroreplantation of an amputated arm
1977: First thumb replantation
1978: First free fibula transfer
1980: First toe transfer
1982: Foundation of Singapore Society of Hand Surgery
1985: Establishment of Singapore General Hospital Hand Surgery
1990: Establishment of National University Hospital Hand & Reconstructive Microsurgery
1996: Hand Surgery gazetted as a specialty with independent advanced specialist training program
2005: Foundation of Chapter of Hand Surgeons (Academy of Medicine, Singapore)
2009: Establishment of Tan Tock Seng Hospital Hand & Microsurgery Section
2011: Establishment of Hand Surgery Residency
Hand Surgery in Singapore evolved over four decades in three main stages, the pre-microsurgical era (pre-1975), the microsurgical era (post-1975), and the era of specialisation and sub specialisation (mid 1990s).
The Early Days
Prior to the foundation of the Orthopaedic Department at Singapore General Hospital (SGH) in 1952, orthopaedic and hand conditions were treated by general surgeons. This changed with the establishment of the Orthopaedic Department in 1952 under the leadership of Professor Cameron (Chief, 1952-1955), and later Professor Karlen (Chief, 1956-1961). The department managed orthopaedic and burns cases while general and neuro surgical cases were managed by the department of General Surgery, forming the early basis of specialization.
Unlike the American and European scenario where hand and reconstructive surgery were born of necessity during the world wars, the specialty owed its beginning to leprosy and industrialization in Singapore. In the 1950s, leprosy was rampant amidst the deprived and squalid conditions in which many lived in Malaya and Singapore. Lepers were confined to colonies such as Sungei Buloh Leprosarium (Malaysia) and Trafalgar Home (Singapore). Professor Donald Gunn (Chief, 1961-1967), an accomplished surgeon practicing at Sungei Buloh prior to joining the Department of Orthopaedic Surgery at SGH in 1956, and Dr Raja Ayathurai were the early surgeons who performed nerve decompression and tendon transfers for lepers. They were later joined by Dr Yeoh Kean Hong, who spent some time with Paul Brand (Vellore, 1961) on his way back from completion of his orthopaedic examination in United Kingdom.
Meanwhile, the rapid pace of industrialisation in Singapore led to numerous machine related hand injuries, overwhelming the medical services available. Recognizing the need for dedicated care for hand injuries, Professor VK Pillay (Chief, 1967-1972) recruited Professor Pesi Chacha, whom he met in 1964 in Liverpool to join the department as clinical lecturer in 1967. Chacha was tasked with development of spine and hand surgery services at SGH. The early Hand Surgery clinic was manned by Chacha, Yeoh, and Dr Kanwaljit Soin, who joined SGH in 1972 after her fellowship with Dr John Hueston (Melbourne).
The outpatient clinic consisted of a small partitioned area for consultation rooms on the ground floor of Norris Block (later demolished to make way for the current Health Promotion Board) while the dressing and treatment area was situated at the basement landing, not far from the doctors' changing room for operating theatre. The Occupational Therapy department was situated nearby. The Burns Unit was located in an adjacent annex, and remained under Orthopaedic Surgery until the establishment of specialized burns care by the department of Plastic Surgery in 1972.
Dawn of Microsurgery
Early successes in extremity replantations in China and Japan cultivated interest in microsurgery in a few centers in America, Europe, China, and Japan. Locally, the interest to develop microsurgery was keen but resource was scarce. Furthermore, the local medical fraternity was skeptical despite early successes of Japanese and Chinese colleagues. The development of orthopaedic micro and reconstructive surgery for orthopaedic conditions was catalyzed by Professor Pesi Chacha and Professor Robert Pho, who joined the department in 1974. Early in his career, Pho developed his interest in microsurgery while assisting in paediatric tracheo-esophageal fistula surgery during his rotation at the Royal Victoria Infirmary.
The enthusiasm of Pho and Chacha in developing microsurgery was faced with difficulty in securing funds and convincing colleagues of their cause. A fortuitous acquaintance at a Trafalgar Home charity event saw their plight answered by Mr Robin Loh, an industrial magnate and well known philanthropist. Loh donated $40,000 through Lions Club East of Singapore to secure the first operating microscope (Zeiss OPMI-1) and some instruments from Professor Yoshikazu Ikuta (Hiroshima). Apart from providing instruments, Ikuta advised Pho and Chacha on establishing microsurgical training. Over the next few years, Pho and Chacha spent much time tinkering with microsurgical techniques in the attic adjacent to the operating theatres in Norris block. Early experimental protocols on static and rodent models were established. They were supported by the late Mr Moorthy, the trusty technician who laboured day and night with them, keeping detailed logs of experimental and clinical cases. Another pivotal figure was the late Professor of Anatomy, Ragunathar Kanagasuntheram, who provided the rats, animal holding facility and histology support.
To support their clinical application of microsurgery, rodent angiogram and histological examination of vascular anastomoses were routinely performed. Up to this point (circa 1976), there was no major breakthrough in clinical microsurgical cases in Singapore. The first successful replantation of a trans-elbow amputation was undertaken at Alexandra Hospital by Leong Hin Seng (General Surgery) and team. The patient, a 17-year-old factoey worker, sustained an elbow amputsaation injury on her first day at work. The procedure was undertaken in two stages: the initial bone fixation and brachial vessel anastomoses, was followed by staged nerve repair three months later.
The first microsurgical breakthrough was a thumb replantation by Robert Pho, Tay Chong Kam, and Yeoh Khee Quan in 1977. The following year, the first free fibula transfer for distal radius reconstruction post giant cell tumor resection was performed by Pho, Chacha, and Yeoh. Around this time the first great toe to thumb transfer was performed by Pho, Tong G On, Jimmy Daruwalla, and Tay Boon Keng, while Professor Tan Ser Kiat performed a second toe transfer. These early clinical successes set the stage for Singapore to host various microsurgical meetings in the following years. The inaugural World Convention on Microsurgery and Workshop on Microsurgery took place in Singapore on 5 December 1979. These early meetings provided the platform for networking between local and international microsurgeons, paving the way for numerous clinical fellowships.
Era of Specialization
The need for specialized care of the hand has always been recognized by orthopaedic surgeons and occupational health physicians. As early as 1970, there were proposals to form specialized surgery units to care for hand injuries. This was further driven by the successes of microsurgery applied to care of the hand and extremities.
With the support of the Ministry of Health and Dr Kwa Soon Bee (Permanent Secretary of Health, 1984-1996), the department of Hand Surgery was established on 1 January 1985. (Chief: Robert Pho, Consultant: Tan Ser Kiat, Registrar: Tan Kok Chai). Lacking a formal training curriculum and specialty trainees, the department was supported by registrars and medical officers on rotation from the departments of Plastic and Orthopaedic Surgery, and a clinical fellow.
A track record of success and increasing workload of the department compelled the ministry to form another unit with specialized surgical care for the hand. In 1989, Robert Pho joined Orthopaedic 'C' (University) unit at National University Hospital in 1989 while Teoh Lam Chuan succeeded him at Singapore General Hospital (Chief, 1989-2003). The department of Hand and Reconstructive Microsurgery (HRM) was founded on 1 December 1990 at NUH with Robert Pho (Chief 1990-2000), K Satku (Consultant), VP Kumar (Consultant), and AK Kour (Senior Lecturer).
Both departments pushed the envelope of reconstructive and hand surgery. In SGH, nursing staff were induced into the microsurgical unit to provide specialized post surgical care. This culminated in visits to Louisville, Baltimore, and Minesota by Miss Quek Ai Huan, Tay Kim Neo and Lim Peng Muay. Hand therapists, led by Ho Ming Jiang continued to develop and further integrate into the workings of the department at SGH. Therapists with keen interest visited Louisville, Indianapolis, and Raleigh. By the early 1990s, Agnes Tan, Yong Fok Chuan, David Khoo, and Lim Beng Hai joined the ranks of the department.
Surgeons at NUH pioneered reconstructive techniques in oncology limb salvage, limb lengthening, basic science investigations and prosthesis. By now, both units were well established regional centres at the forefront of academic and clinical practice. Fellows from the region and further afield visited Singapore to gain exposure in micro reconstructive surgery, many of whom returned home to lead their institutions in the field of hand surgery.
The spectrum and depth of hand and reconstructive surgery continued to grow, heralding the dawn of the era of sub-specialization in Hand Surgery. Globally, surgeons recognize that best outcomes in hand surgery could only be achieved with integrating concepts from both orthopaedic and plastic surgery, prompting the development of training curriculum for hand and reconstructive surgery. In both institutions (SGH and NUH), training curriculaum were structure to provide trainees with capabilities from microsurgery to skeletal fixation in order to handle the full spectrum of conditions affecting the upper limb from brachial plexus to fingertip.
Hand Surgery as a Specialty
Renewed calls for further specialization in 1990s paved the way to foundation of Hand Surgery as an independent specialty. With the encouragement from Professor Chee Yam Cheng, then Chairman of the Joint Committee on Specialty Training, a training syllabus was drafted. Professor Lee Seng Teik, then Master of the Academy of Medicine, ran an editorial in the Annals of the academy on training of hand surgeons. With further encouragement from Professor Raj Nambiar, the specialty was formed in 1996 with Teoh Lam Chuan, Yong Fok Chuan, Agnes Tan, Kour Anam Kueh, and Lim Beng as the founding surgeons.
In addition to the two Hand Surgery departments, a team consisting of Associate Professor Low Yin Peng, Dr Toh Choon Lai, and (the late) Dr Low Chee Kwang was formed in Tan Tock Seng Hospital to provide dedicated care for hand conditions. This was the early part of the evolution that eventually led to the formation of the Hand and Microsurgery Section (HMS) in 2009. HMS formed the third national training centre for Hand Surgery after its accreditation by the Joint Committee in Specialist Training in 2009. 2011 marked the transition of a basic and advanced specialty training system (BST-AST) to a through train ACGME (Accreditation Council for Graduate Medical Education) styled six year residency program. Trainees rotate through several medical and surgical specialties in the first two years of training, followed by four years of Hand Surgery training. An exit certification is provided by the Specialist Accreditation Board (SAB). By 2014, there were 30 SAB certified specialists and 21 residents in the specialty.
A publication on the History of Hand Surgery in Singapore by the Society is available through the secretariat.
The Early Days
Prior to the foundation of the Orthopaedic Department at Singapore General Hospital (SGH) in 1952, orthopaedic and hand conditions were treated by general surgeons. This changed with the establishment of the Orthopaedic Department in 1952 under the leadership of Professor Cameron (Chief, 1952-1955), and later Professor Karlen (Chief, 1956-1961). The department managed orthopaedic and burns cases while general and neuro surgical cases were managed by the department of General Surgery, forming the early basis of specialization.
Unlike the American and European scenario where hand and reconstructive surgery were born of necessity during the world wars, the specialty owed its beginning to leprosy and industrialization in Singapore. In the 1950s, leprosy was rampant amidst the deprived and squalid conditions in which many lived in Malaya and Singapore. Lepers were confined to colonies such as Sungei Buloh Leprosarium (Malaysia) and Trafalgar Home (Singapore). Professor Donald Gunn (Chief, 1961-1967), an accomplished surgeon practicing at Sungei Buloh prior to joining the Department of Orthopaedic Surgery at SGH in 1956, and Dr Raja Ayathurai were the early surgeons who performed nerve decompression and tendon transfers for lepers. They were later joined by Dr Yeoh Kean Hong, who spent some time with Paul Brand (Vellore, 1961) on his way back from completion of his orthopaedic examination in United Kingdom.
Meanwhile, the rapid pace of industrialisation in Singapore led to numerous machine related hand injuries, overwhelming the medical services available. Recognizing the need for dedicated care for hand injuries, Professor VK Pillay (Chief, 1967-1972) recruited Professor Pesi Chacha, whom he met in 1964 in Liverpool to join the department as clinical lecturer in 1967. Chacha was tasked with development of spine and hand surgery services at SGH. The early Hand Surgery clinic was manned by Chacha, Yeoh, and Dr Kanwaljit Soin, who joined SGH in 1972 after her fellowship with Dr John Hueston (Melbourne).
The outpatient clinic consisted of a small partitioned area for consultation rooms on the ground floor of Norris Block (later demolished to make way for the current Health Promotion Board) while the dressing and treatment area was situated at the basement landing, not far from the doctors' changing room for operating theatre. The Occupational Therapy department was situated nearby. The Burns Unit was located in an adjacent annex, and remained under Orthopaedic Surgery until the establishment of specialized burns care by the department of Plastic Surgery in 1972.
Dawn of Microsurgery
Early successes in extremity replantations in China and Japan cultivated interest in microsurgery in a few centers in America, Europe, China, and Japan. Locally, the interest to develop microsurgery was keen but resource was scarce. Furthermore, the local medical fraternity was skeptical despite early successes of Japanese and Chinese colleagues. The development of orthopaedic micro and reconstructive surgery for orthopaedic conditions was catalyzed by Professor Pesi Chacha and Professor Robert Pho, who joined the department in 1974. Early in his career, Pho developed his interest in microsurgery while assisting in paediatric tracheo-esophageal fistula surgery during his rotation at the Royal Victoria Infirmary.
The enthusiasm of Pho and Chacha in developing microsurgery was faced with difficulty in securing funds and convincing colleagues of their cause. A fortuitous acquaintance at a Trafalgar Home charity event saw their plight answered by Mr Robin Loh, an industrial magnate and well known philanthropist. Loh donated $40,000 through Lions Club East of Singapore to secure the first operating microscope (Zeiss OPMI-1) and some instruments from Professor Yoshikazu Ikuta (Hiroshima). Apart from providing instruments, Ikuta advised Pho and Chacha on establishing microsurgical training. Over the next few years, Pho and Chacha spent much time tinkering with microsurgical techniques in the attic adjacent to the operating theatres in Norris block. Early experimental protocols on static and rodent models were established. They were supported by the late Mr Moorthy, the trusty technician who laboured day and night with them, keeping detailed logs of experimental and clinical cases. Another pivotal figure was the late Professor of Anatomy, Ragunathar Kanagasuntheram, who provided the rats, animal holding facility and histology support.
To support their clinical application of microsurgery, rodent angiogram and histological examination of vascular anastomoses were routinely performed. Up to this point (circa 1976), there was no major breakthrough in clinical microsurgical cases in Singapore. The first successful replantation of a trans-elbow amputation was undertaken at Alexandra Hospital by Leong Hin Seng (General Surgery) and team. The patient, a 17-year-old factoey worker, sustained an elbow amputsaation injury on her first day at work. The procedure was undertaken in two stages: the initial bone fixation and brachial vessel anastomoses, was followed by staged nerve repair three months later.
The first microsurgical breakthrough was a thumb replantation by Robert Pho, Tay Chong Kam, and Yeoh Khee Quan in 1977. The following year, the first free fibula transfer for distal radius reconstruction post giant cell tumor resection was performed by Pho, Chacha, and Yeoh. Around this time the first great toe to thumb transfer was performed by Pho, Tong G On, Jimmy Daruwalla, and Tay Boon Keng, while Professor Tan Ser Kiat performed a second toe transfer. These early clinical successes set the stage for Singapore to host various microsurgical meetings in the following years. The inaugural World Convention on Microsurgery and Workshop on Microsurgery took place in Singapore on 5 December 1979. These early meetings provided the platform for networking between local and international microsurgeons, paving the way for numerous clinical fellowships.
Era of Specialization
The need for specialized care of the hand has always been recognized by orthopaedic surgeons and occupational health physicians. As early as 1970, there were proposals to form specialized surgery units to care for hand injuries. This was further driven by the successes of microsurgery applied to care of the hand and extremities.
With the support of the Ministry of Health and Dr Kwa Soon Bee (Permanent Secretary of Health, 1984-1996), the department of Hand Surgery was established on 1 January 1985. (Chief: Robert Pho, Consultant: Tan Ser Kiat, Registrar: Tan Kok Chai). Lacking a formal training curriculum and specialty trainees, the department was supported by registrars and medical officers on rotation from the departments of Plastic and Orthopaedic Surgery, and a clinical fellow.
A track record of success and increasing workload of the department compelled the ministry to form another unit with specialized surgical care for the hand. In 1989, Robert Pho joined Orthopaedic 'C' (University) unit at National University Hospital in 1989 while Teoh Lam Chuan succeeded him at Singapore General Hospital (Chief, 1989-2003). The department of Hand and Reconstructive Microsurgery (HRM) was founded on 1 December 1990 at NUH with Robert Pho (Chief 1990-2000), K Satku (Consultant), VP Kumar (Consultant), and AK Kour (Senior Lecturer).
Both departments pushed the envelope of reconstructive and hand surgery. In SGH, nursing staff were induced into the microsurgical unit to provide specialized post surgical care. This culminated in visits to Louisville, Baltimore, and Minesota by Miss Quek Ai Huan, Tay Kim Neo and Lim Peng Muay. Hand therapists, led by Ho Ming Jiang continued to develop and further integrate into the workings of the department at SGH. Therapists with keen interest visited Louisville, Indianapolis, and Raleigh. By the early 1990s, Agnes Tan, Yong Fok Chuan, David Khoo, and Lim Beng Hai joined the ranks of the department.
Surgeons at NUH pioneered reconstructive techniques in oncology limb salvage, limb lengthening, basic science investigations and prosthesis. By now, both units were well established regional centres at the forefront of academic and clinical practice. Fellows from the region and further afield visited Singapore to gain exposure in micro reconstructive surgery, many of whom returned home to lead their institutions in the field of hand surgery.
The spectrum and depth of hand and reconstructive surgery continued to grow, heralding the dawn of the era of sub-specialization in Hand Surgery. Globally, surgeons recognize that best outcomes in hand surgery could only be achieved with integrating concepts from both orthopaedic and plastic surgery, prompting the development of training curriculum for hand and reconstructive surgery. In both institutions (SGH and NUH), training curriculaum were structure to provide trainees with capabilities from microsurgery to skeletal fixation in order to handle the full spectrum of conditions affecting the upper limb from brachial plexus to fingertip.
Hand Surgery as a Specialty
Renewed calls for further specialization in 1990s paved the way to foundation of Hand Surgery as an independent specialty. With the encouragement from Professor Chee Yam Cheng, then Chairman of the Joint Committee on Specialty Training, a training syllabus was drafted. Professor Lee Seng Teik, then Master of the Academy of Medicine, ran an editorial in the Annals of the academy on training of hand surgeons. With further encouragement from Professor Raj Nambiar, the specialty was formed in 1996 with Teoh Lam Chuan, Yong Fok Chuan, Agnes Tan, Kour Anam Kueh, and Lim Beng as the founding surgeons.
In addition to the two Hand Surgery departments, a team consisting of Associate Professor Low Yin Peng, Dr Toh Choon Lai, and (the late) Dr Low Chee Kwang was formed in Tan Tock Seng Hospital to provide dedicated care for hand conditions. This was the early part of the evolution that eventually led to the formation of the Hand and Microsurgery Section (HMS) in 2009. HMS formed the third national training centre for Hand Surgery after its accreditation by the Joint Committee in Specialist Training in 2009. 2011 marked the transition of a basic and advanced specialty training system (BST-AST) to a through train ACGME (Accreditation Council for Graduate Medical Education) styled six year residency program. Trainees rotate through several medical and surgical specialties in the first two years of training, followed by four years of Hand Surgery training. An exit certification is provided by the Specialist Accreditation Board (SAB). By 2014, there were 30 SAB certified specialists and 21 residents in the specialty.
A publication on the History of Hand Surgery in Singapore by the Society is available through the secretariat.
