Abstract
The beginning
The history of hand surgery in Bulgaria dates back to the 1940s and 1950s, with the names of Professors Yanaki Holevich and Elena Paneva, and Ivan Matev in the later decades. Their techniques are published in today’s popular hand surgery textbooks, such as Green’s Operative Hand Surgery and Hand Surgery by Berger and Weiss. Methods such as the first dorsal metacarpal artery flap, two-stage technique for flexor tendon reconstruction, reconstruction of Boutonnière deformity, surgical technique for the treatment of the spastic hand and median nerve entrapment in the elbow joint as a radiological sign were described by Matev.
Professor Ivan Matev was awarded the highest civilian state honour in the order of Stara Planina. He was the founder and president of the Bulgarian Society for Surgery of the Hand (BSSH) in 1984 (Figure 1) and a Member of Parliament in the 38th National Assembly for a short time (2000–2001). On his resignation he said, ‘The Parliament was going to kill the doctor in me’. He died in 2012 (Figure 2).
The logo of the Bulgarian Society for Surgery of the Hand (BSSH).
Professor Ivan Matev.
The BSSH has been a member of the International Federation of Societies for Surgery of the Hand (IFSSH) since 1986. In 1988, a big international hand surgery symposium was held in Albena (a popular Black Sea resort), where 30 leading hand surgeons from all over the world took part. More than 40 hand surgeons from the United States also attended. In 1989 in Taranto, Italy, the Federation of European Societies for the Surgery of the Hand (FESSH) was founded. The BSSH was represented by Professor Pavka Trichkova. In 1994, Giorgio Brunelli, Hanno Millesi, Warren C. Breidenbach and Isidor Kessler took part in a symposium in Druzhba (another Black Sea resort). Professor Isidor Kessler was born in Russe, an old Bulgarian city located on the Danube River. In 1996, Isidor Kessler and Robert Malcolm McFarlane (President at that time) visited the city of Pleven in Bulgaria in another meeting. In 1998 at a IFSSH congress in Vancouver, Canada, Professor Matev was acknowledged as one of the ‘pioneers of hand surgery’. The BSSH was accepted as a member of FESSH in 2002 at a FESSH congress in Amsterdam, even though Bulgaria was not yet a member of the European Union. This exception of the FESSH rules was supported by Professors Alain Gilbert, P. Borelli, Simo Vilkki, Ann Nachemson, Thierry Dubert and Daniel-V. Egloff.
Subsequent presidents of the BSSH include Professor Kamburov (2003), Professor Pavka Trichkova (2007) and Professor M. Kateva (2012 to date).
Training of hand surgeons
Hand surgery in Bulgaria is not a separate speciality. Committed hand surgeons are usually those that started their work experience in a hand surgery clinic and have been involved in hand surgery since the very beginning. There are two hand surgery centres in Bulgaria: one in Sofiamed Hospital and the other in Pirogov Emergency Hospital. Both of them are located in Sofia.
After finishing medical school, young doctors choose a clinic to start their specialized career and to evolve as professionals. They become residents – usually on a competitive basis, because of the lack of positions in the most desired specialities and subspecialities (hand surgery being one of them). After receiving interview-based approval from the head of the department, they start their residency in orthopaedic surgery but deal with hand surgery most of the time. Their 5-year residency programme requires them to spend 1 month in another orthopaedic clinic, 1 month in another trauma clinic and 1 month in a general surgery clinic. They take 12 colloquiums and finally go to a speciality examination to acquire an orthopaedics and traumatology certification. They continue working in the hand surgery clinic after the speciality examination, where they eventually receive a hand surgery certificate and are then required to apply for a microsurgery certification. During their residency, they all have working contracts and get payment for their work.
Hand surgery certificate
In an attempt to improve diagnostics and treatment approaches in hand surgery across the country, BSSH established a certification procedure for ‘Highly specialized activities – Hand surgery’. The certificate is acquired after training and an examination in the hand surgery centre in Sofiamed Hospital, which is approved by the Medical University in Sofia. In order to undergo this course, one has to be an orthopaedic surgeon in speciality. The course lasts 6 weeks and is usually conducted once a year: 1 week per month until 6 weeks are completed. The course includes a practical and a theoretical part. The course does not claim to create a fully capable hand surgeon, but it gives the main directions for surgical professionalism and delivers knowledge to recognize hand pathology and undertake the first and adequate treatment steps. It is mostly aimed at colleagues who do not work in the two major hand surgery clinics, but at those working in trauma orthopaedic centres across the country. In addition, this is another way to involve more young colleagues in hand surgery and encourage them to select this path after specializing as an orthopaedic surgeon. Our desire to make hand surgery a separate speciality has not yet been accepted by the government.
Microsurgical course
In addition to the hand surgery course, there is an annual microsurgery course, organized by BSSH, focused on microvascular and nerve repair. Professors Edgar Biemer and Margarita Kateva have been the main supervisors of these courses since 2013.
Practice
The current practice of hand surgery in Bulgaria covers the entire spectrum of hand pathology, including replantations, congenital malformations, arthritis, occupational diseases, tumours, paralysis, nerve, injuries, spasticity, infections, reconstruction of tissue defects with flaps and free transfers. There has been a leap in the success rate regarding the treatment of complex nerve injuries in the last decade, thanks to Professor Kateva, who acquired profound knowledge and techniques through numerous collaborative visits in Munich, Germany and Vienna, Austria. She elevated the standards in treatment of congenital extremity anomalies, spastic paralysis, obstetric brachial plexopathy, brachial plexus trauma in adults, reconstructive surgery on both soft tissue and bone complex defects.
There are two Hand Trauma Committee (HTC) certified centres in Bulgaria recognized as hand trauma units (HTU) and providing service 24/7; one is located in a private hospital, University Hospital Sofiamed, and the other in a public hospital, Pirogov Emergency Hospital. Both units are located in Sofia. Every month, there are more than 100 hand surgery trauma cases in each of them, including fractures, tendon and nerve lesions, soft tissue and bone defects, crushing injuries and amputations. Both units equipped with microsurgical sets and microscopes, and offer access to facilities required to manage complex hand trauma. Each unit has more than three certified hand surgeons and one certified hand therapist. These centres still lack a hand surgeon with a diploma from the European Board of Hand Surgery (EBHS) but there are candidates preparing to take the examination in the next few years. This would allow the units to acquire hand trauma and replantation (HTRC) accreditation.
State health insurance in Bulgaria is obligatory and the National Health Fund covers most of the treatment. There are voluntary private funds that cover additional expenses, such as implants, and voluntary extra services, such as surgical team selection, private room and so on, that can be self-funded. Both private and state hospitals have accreditation levels, which allows them to sign contracts with the National Health Fund for particular clinical paths. For instance, for a microsurgical clinical path for a replantation, the hospital is required to be at accreditation level 3 (highest), with at least four surgeons with a microsurgery certificate in the unit, resuscitation unit, clinical laboratory, X-ray department, transfusion haematology department, cardiology department, operating theatre with microscope and so on.
The obligatory health insurance tax for the National Health Fund is 8% of income. The voluntary funds are for the patient to decide for the level of insurance or if this additional insurance is desired at all. In case of emergency, citizens from the EU are admitted to a hospital with their European Health Insurance Card (EHIC).
Scientific activity and the future
There is one major journal in Bulgaria where hand surgeons can publish their scientific work: Bulgarian Journal of Orthopaedics and Traumatology (Figure 3). There is no journal devoted to hand surgery but that might change in the future. The board of the BSSH takes efforts to establish a better national hand surgery network and to improve the basic knowledge required for proper assessments and initial treatments in traumatic hand cases. That remains a mission still not fully accomplished. However, there are very encouraging results: in the city of Rousse (where Isidor Kessler was born), there are several young and ambitious hand surgeons who have taken the challenge, and after their hand surgery training, started performing operations such as nerve transfers and reconstruction procedures with vascularized flaps. Their centre is not yet certified by the FESSH HTC criteria, but we expect these to be certified soon. Every year, Bulgarian hand surgeons take part in the FESSH congresses or triennial IFSSH congresses. In addition, our hand surgery society has annual meetings, where all kinds of hand surgery topics are discussed. Every 4 years, an international congress for hand surgery is organized where there is rich participation from all around the world, including Germany, Italy, Hong Kong and Israel.
Bulgarian Journal of Orthopaedics and Traumatology.
We work closely with hand therapists across the country, but this speciality still lacks personnel. The newly established (2022) Bulgarian Society for Hand Therapy (BSHT) is led by Georgi Petrov. The BSHT started its own training programme, and we believe this will create a better network of national hand therapists in the near future. The BSSH annual meetings (Figure 4) are combined with the BSHT, which is a member of The International Federation of Societies for Hand Therapy (IFSHT).
The 2022 Bulgarian Society for Surgery of the Hand (BSSH) annual meeting.