Jackson sits just south of Yellowstone and Grand Teton National Parks. The surroundings were spectacular!
A number of members arrived a little early to experience the town of Jackson, including the Cowboy bar where you can literally saddle up to the bar.
We were then treated to a brilliant, almost private, fireworks show right in the Teton Village for the 4th of July.
The following day, members took advantage of a full day off to head into Grand Teton National Park to hike at Jenny Lake and Leigh Lake, and to challenge their kids to boulder climbing and rock skipping. Congratulations, Don!
Later that night, Heather organized a chuck wagon dinner and show to experience the old west. Can you imagine crossing the Teton pass in one of these?!
The kids were thrilled.
On the first morning of meetings we were met with a breakfast to beat all breakfasts, with such offerings as elk sausages and local bacon. Thanks Betsy! As we all pulled out our computers, it became apparent that not everyone carries their own dongle. An exciting game of pass the dongle ensued. Once all those jokes were exhausted, the meeting commenced.
Ray reviewed the Treasurer's report. Manus is currently in a good position, in good standing with Uncle Sam, gaining traction with industry for stable sponsorships, and building a little cushion with member dues. Everyone expressed their gratitude to Ray for helping gain more financial stability. Ray reminded us that in order to keep companies interested in sponsoring our events, we have an obligation to stop by their booths at meetings, attend the cocktail hours and meet the reps. Do your part!
We then launched into member talks. Marc led us off with Elbow injuries in young baseball pitchers. We learned about Marc's love of the game and about his son's participation as well. (I will forgive him his Red Sox allegiance, though grudgingly.) He recommended reading the book "The Arm" by Jeff Passan. My copy just arrived from Amazon! The key to treating these injuries is Prevention! He encouraged multi-sport participation and less specialization. He talked about the myth of the Tommy John surgery, how some folks mistakenly believe that they will be better pitchers with the surgery. We looked at the geographical differences of players - warm weather versus cold weather kids. While most people think about the medial collateral ligament mostly with these athletes, the spectrum of injuries includes medial, lateral, and posterior injuries, all depending on the phase of the pitch. Some recommendations: Medial apophysitis: REST. Medial epicondyle fracture (usually in kids a little older): Consider EUA to evaluate stability; consider ORIF (Pearl: do in prone or lateral decubitus position with the hand behind the back - reduces the fracture). UCL: after skeletal maturity, usually. Direct repair may be possible.
Subir then discussed "Mega private practice groups" a way to maintain physician autonomy while taking advantage of the leverage that larger groups have over smaller ones. The process parallels the engineering industry of the past, where it was discovered that despite extensive training and expertise, there was not necessarily any increase in job stability. These groups increase revenue with better contracts, reduce expenses by decreasing malpractice, and derive new business through collaboration and investments that would be out of reach for smaller private practices. The difference between these groups and foundations or systems like Kaiser is that each group that joins the mega-group maintain their own individual rules and practices. Firewalls are built in so each group does not affect any of the others. There should be easy in and easy out procedures for joining or leaving the mega group. There needs to be a single tax ID, and there are some rules that need to be followed to avoid anti-trust violations. Those who are in small private practice groups who may be considering creating or joining a group like this should speak more with Subir, Sunjay, or Glenn.
Rob followed with a discussion on the Total Elbow, the "wobbly hinge". He reviewed the history of the joint, which started out as a constrained implant that all failed. The pendulum swung the other way with all unconstrained joints, that all failed due to instability. The compromise was the semi-constrained joint that allows varus, valgus, and axial motion, but even this is not a great solution. It was agreed that possible options for hemi-arthroplasty sounded attractive.
We then got an update from Glenn on the use of prosthetics for upper extremity amputees. Current practice is based on targeted muscle reinnervation, giving the nerve a new target to assist with powering a prosthesis. Only M1 function is required to make this work, as opposed to the M4 function required for a successful tendon transfer. The procedure can be done acutely, or can be delayed years and still be successful. The muscle is denervated before being reinnervated by a new nerve. An adipofascial flap is interposed between muscles to make sure each muscle receives a clean signal. While the prosthesis is being made, the patient trains using computer simulation, allowing the patient to have remarkably good control of the prosthesis even when it is first applied. Then my brain exploded and there was talk of myobands and blue tooth connections and pattern recognition using electrodes inside the prosthesis. There may have been smoke coming out of my ears by this time. You'll have to speak with Glenn directly to find out about the starfish procedure. I felt about as smart as an echinoderm by the time he was done!
The next day we would hear about the other side of the "arms race" (thank you, Jeff F.) between prosthetics and transplantation.
Dan Z. proceeded to review the club standings and club rules. All but 1 member now holds a status of 2 or 3. This means that almost everyone has come to either this meeting in Jackson, or to last year's meeting in Asheville. As a reminder, if your status falls to 0, you are at risk for losing your membership. If you reach 0, you would need to be renominated to keep your place in the club. So... come to the meetings! They're so fun!
2 new members were nominated. Aimee Schimizzi, whose name came up sometime last year. And Bauback Safa. Both will be invited to come to our happy hour on Thursday at the ASSH meeting in San Francisco, to meet everyone, and then we will vote. There are currently 29 members. approving both of these nominees would bring our total to 31, and no one at the meeting objected, although there was general agreement that we do not need to keep growing and adding members every year. At some point we may reach our steady state.
At this time a spontaneous discussion about the dates for next year's meeting erupted. As we know, there will always be conflicts during the summer months, between family obligations, kids' activities, academic meetings and courses, etc. There was a suggestion for alternating weekends each year: such as the 1st weekend of July this year, then maybe the 2nd weekend of July next year, or maybe the first weekend of August next year. Someone suggested the president send out a survey to find out what date will have the best turnout each year. Dan Z. has volunteered to collect black out dates that are constants for each member (constant, as far as we can tell at the moment, recognizing that things change all the time.) So if you have a black out date ie, unavoidable family reunion the 3rd weekend of July every year, send those to Dan Z. Given that next year July 4 is on a Wednesday, a decision was made to hold the meeting on the weekend following the 4th, as many people will easily be able to take the full week off and make a vacation out of it. For the future, it is still open for debate.
Warren and Jon had to leave before the usual Saturday morning vote on next year's location. This seems to be the case each year, that not everyone can stay until Saturday morning. Seeing as coming to the meeting allows you the privilege of nominating and voting on the following year's location, a move was made to do this piece of business on the first day of the meeting, and have a decision and a date by the last day of the meeting.
Whew. Day 1 done. I need a drink. Thankfully...
That evening, Integra sponsored a happy hour at the Teton Club for members. We enjoyed the gorgeous weather and some much needed libations. We met our generous reps who helped support this year's meeting.
We were joined by our families for a group dinner. The group keeps getting bigger and bigger! And the little people are so cute when they get together!
Oh OK - the big people are pretty darn cute too!
The Roosevelt contingent. Yes, I am absolutely inserting myself in here!
Some fun and games by the creek.
It is a mystery how we make this happen every year, but before things got too wild and crazy, we managed to get a group photo. If I'm not mistaken, Allison even came back from the pool to get in the shot.
The Manus kids.
Oh Jeff...
We are so ridiculous! I love it!
Day 2 of the meeting started with an update from Dan on Zion and his bilateral hand transplants. He seems to be doing remarkably well, and has integrated his hands into his life. Dan and Jaimie then reviewed for us what is going on in the world of upper extremity transplantation. There is, and likely will continue to be, ongoing debate regarding the indications for transplantation. We are usually tested on issues such as bilateral versus unilateral amputations, above or below elbow amputations, etc. They encouraged us to considered a broader picture of the patient in considering indications: body image, whole body function, and immunosuppression/immunoregulation. As he discussed last year, Jaimie reiterated the importance of the role of immunosuppression, or the consideration of immunosuppression, and the advances being made in immunoregulation instead. They now have patients on steroid free, single drug immunoregulation, and building tolerance to avoid life-long drug therapy. He showed us examples of some things that patients have been able to do with their transplants that they were not able to do with a prosthesis. All I can say is, Congratulations, to all our members who are doing such incredible work to advance our field, and to improve patients' lives. Well done. By this point, I was feeling about as small as an echinoderm.
Dan closed out our member talks with a plug for European car delivery. You order your car, go to Europe to pick it up, get a lot of freebies and perks while you're there, drive your new car around for 2 weeks, then ship it home. Bottom line: just do it.
In response to yesterday's discussion, we went about with the nominations for next year's location. And the nominees are...
Lake Placid/Lake George
Martha’s Vineyard
Hotel del Coronado San Diego
Amelia Island
Washington, DC
Costa Rica
Bar Harbor, ME
Mackinac Island, Lake Michigan
Bermuda/Caribbean
And the winner is...
Well, even though we chose the winner on this day, I'm going to wait until the end of this newsletter to reveal it. My prerogative!
We then proceeded over to the cadaver lab. Integra brought a number of toys for us to play with:
Total wrist
Total wrist
New volar plate – limited distribution
MCP/PIP pyrocarbon arthroplasty (silicone implants in set, same size as pyro)
Nitinol staples
Ulnar head hemiarthroplasty
Members took advantage of the time and the cadaver arms to do some of their own exploration. There were some anatomic dissections: the anterior approach to the radial head, identifying the exact location of the origin of the MCL in the elbow, etc. There were some demonstrations: the starfish procedure, ring ray resection followed by pushing the small finger metacarpal over on the hamate to close the gap, the dorsal approach to the PIP joint using an extensor splitting approach, etc.
Once again, a highlight of the meeting.
Once again, a highlight of the meeting.
Post-lab activities included checking out the town, fly-fishing, enjoying the amenities of Teton Village,
and floating down the Snake River.
Stopping for lunch, and more stone skipping.
After the fastest turnover ever seen, kids were dropped off in Ray's room for babysitting, and we were off to dinner at the Granary. The weather was perfect. The drinks were perfect. The company was the best there could be.
Like every year before, this was a great opportunity to get to know each other for the first time, or in greater depth. I don't know what it is, but it seems the more I get to know you guys, the more I like you!
Ray took the moment to give thanks to our presidents Lou and Betsy for the tremendous job they did in selecting the location, the venues, and putting together an amazing meeting. And apparently, if I understood correctly, for those who are organizing these meetings, 2 "reconnaissance" trips can be written off. I'll have to defer to Lou and Betsy to confirm that.
This is going to be a tough act to follow!
On the third and final day of our meeting, we had our Tsunami presentations.
Becky presented a psychological tsunami. 2 very similar distal radius fractures in 2 very similar patients. Both fractures were significantly comminuted and shortened. The first was done at Kaiser 5 years ago. The fracture settled placing the distal screws within the radiocarpal joint. The patient was minimally symptomatic, so the plan was to cast him, allow him to heal, remove the hardware, and consider a fusion in the future if he became symptomatic. His insurance changed and he saw a new hand surgeon who recommended revision. He underwent revision, did exceptionally well, then he sued Kaiser and his original surgeon - me, with the allegation that the screws were in the joint all along and therefore he was doomed to more surgery, more time lost, more pain etc etc. The case was found in my favor but it sucked. The second case came along just as the the lawsuit was concluding. His fracture also settled after ORIF. He too was minimally symptomatic. Had it not been for the first case, the plan probably would have been to cast him, allow him to heal, remove the hardware, and consider a fusion in the future if he became symptomatic. But because of the lawsuit, the decision was made to proceed with revision. During the second surgery, the bone fragmented more and more with every attempt to improve it. Final result was a dorsal and volar plate holding whatever they could. He is still in his cast, his xrays look awful, and he keeps bringing me presents (1966 Inglenook cabernet anyone?) and thanking me and telling me he loves me even though I did what I did to his wrist.
Rob presented a 24 yo male s/p uncomplicated, successful both bones ORIF. 1 year later he fell, fracturing the ulna proximal to plate. Healed with closed treatment. He then noted muscle herniation and pain at the ulnar plate (5 years later). Plan was for removal of hardware and closure of fascial defect. Under regional bock, hardware removed without incident, fascial closure had some tension initially but seemed to loosen as the case proceeded. For some reason Rob's Spidey sense failed him here. A "constellation of horribleness" ensued. There were multiple phone calls. The case was performed on a Friday, and the first call came that evening, fielded by Rob. It was felt the symptoms were normal for the given case, and the neurological symptoms were likely residual from the block. The next calls came over the weekend and were handled by residents. Again the patient was reassured and any neurological symptoms were again attributed to the block. The patient came to clinic on POD4 with a dead arm. He was taken immediately to the OR for fasciotomy but it was already too late. VAC, QOD washouts. He is seen daily. Rob and the patient have Taco Tuesdays. Talk about how outcomes can affect a physician's psyche. The patient has forearm rotation, some wrist flexion and extension, middle finger extension, moving Tinel’s over median and ulnar nerves. Since this case, new protocols have been put in place for phone calls, requiring residents to document the conversations and and bump up to the attending. Everyone felt for Rob, and gave him our reassurance that his continued care for this patient speaks volumes to his dedication as a doctor. Bad outcomes happen. Mistakes are made, but the worst thing that we can do is abandon our patients. Several members also had suggestions for how to proceed going forward, enlisting MR neurography or hi-resolution US or EMG to further evaluate any residual nerve function. A 2nd attending note on chart was suggested. Plans are for reconstruction for functional improvement.
This case led to discussions of pain management, chronic pain, and the use of blocks in these types of cases, and the incidence of rebound pain. One suggested protocol with regard to blocks: start taking narcotics every 4-6 hours as soon as they get home even if they don’t have pain in order to prevent rebound pain. When the block wears off, then take meds as needed. Setting patient expectations for pain and use of pain meds can greatly influence how much pain medication they actually use. Has anyone changed their practice in this regard since the meeting?
Jeff F. then presented a 17 year old boy who works in construction in Alaska in his dad's company. He sustained a crush injury to his wrist and forearm with soft tissue injury but no fracture. Multiple flaps and grafts were performed in Alaska that failed. 1 year out he is referred to Harborview with a persistent open wound on the radial forearm. Easy - a lateral arm free flap is performed without complication. He is discharged from the hospital but told to remain local. Same day as discharge (POD5), a phone call is received for bleeding. The flap is dead. At day 5??? No problem - a free gracilis flap is performed without complication. Again on POD 5, while still in the hospital, there is sudden bleeding, and then the flap “exploded”. Spidey sense is starting to act up. This is not what usually happens when flaps fail. After some investigation, it turns out the patient has factitious disorder, and had been manipulating the flap himself to bring his parents back together. He discovered that when he was in distress, in the hospital, that was the only time when the whole family was back together. Psych was consulted. Skin graft, cast, healed. When the cast came off, he cried, unfortunately, not tears of joy. He was placed in a new cast and sent back to Alaska.
(Biopsy for refractive crystals to check for drug use within granulation tissue - Jaimie's suggestion, for those facing unusual wound healing problems, and who live in Baltimore.)
Jaimie presented a 44 year old man who sustained a circular saw injury to non-domimant thumb and index finger. He is a 2.5 pack per day smoker, former IVDA 3 years sober. He was taken to the OR immediately for stabilization, tendon, nerve, and vessel repair. They returned to OR a day later for revision of an anastamosis. On POD 7 the thumb is dead. Next procedure: anterolateral thigh wrap around free flap. The presentation begins to suffer from small font sign. Multiple thromboses. Flap dies. Serial debridements. Positive cultures. PIA, skin graft (Not sure if the PIA here means "posterior interosseous artery" or "pain in the ass" I think one applies better than the other.) 13 surgeries total, 1 month as an inpatient. No insurance (of course). Multiple opioids now. As is usually the case with Tsunami cases, he probably should have done a revision amputation and been done with it - but this is what happens when a cool procedure worked once before.
Dan Z. presented a baby with a global plexus injury. At 4 months, the baby undergoes surgical exploration with a plan to repair, transfer, whatever is necessary. Lots of scar is found on the way in. For some reason, he didn’t follow the usual procedure of finding the phrenic nerve early on in the procedure. Buzzed through phrenic nerve while buzzing through scar. The phrenic nerve was clearly intact pre-op. C5 was ruptured, all else was avulsed. Now, they can’t use the contralateral C7 because of risk to other phrenic nerve. Can’t use the intercostals because the phrenic is out. Sural nerve graft is performed for the phrenic nerve. At 6 months, the baby gets RSV and is admitted to CHOP. He is intubated, and spends 1 month as an inpatient. Finally the treating physician calls Dan. They had no idea about the injury to the phrenic nerve and they almost operated on him because the diaphragm was not working and they can’t get him off oxygen. It took a while for them to understand how Dan knew that the phrenic nerve had been cut. Diaphragm recovered at a year.
Winner: Rob!
Congratulations?
Last year's winner Phani was not present to present the plaque, so President Lou stepped in.
The take home messages from this year's presentations: Follow your routine, do your best work, prepare - even for the routine cases, and always listen to your Spidey sense!
Congratulations?
Last year's winner Phani was not present to present the plaque, so President Lou stepped in.
The take home messages from this year's presentations: Follow your routine, do your best work, prepare - even for the routine cases, and always listen to your Spidey sense!
Then it was off to the pool!
A discussion started up about the difficulties of organizing this meeting in terms of locking in a good rate with a resort, in what will always likely be their high season. This is especially difficult if members will not commit early enough. Understandably, things come up all the time that require a change in plans. It seems everyone agreed that if a member has to cancel after a given date, that member will still be responsible for any committed rooms, and that the responsibility for those unused room nights should not fall on the club. It was suggested that future negotiations should set a lock in date for the discounted rates (something like June 1?). Louis smartly offered unused room nights to the Integra reps when members had to cancel after the deadline. He also reminded us that when negotiating rates, the president should speak with the business/meeting coordinator of the resort, not just the reservationist.
So here it is, the location of next year's meeting is...
Bermuda/Caribbean!!
And president for 2017-2018:
Tom Hughes
(and Lisa)
(and Lisa)
Date: July 5-7, 2018
To be put on the agenda for the 2018 meeting, the 2021 meeting location (our 15 year anniversary). First suggestion: Greece. Take over a boutique hotel on an island, or at one of the lakes in the north. Subir has volunteered to serve as President in 4 years to make this happen. We never took a formal vote on this. If anyone objects to this idea, please email your President Tom. And I do mean if you object to the idea itself, not necessarily the location. If you have other ideas for a different location, email the group and we should discuss. The other part of the idea was that at the 2021 meeting, in Greece or wherever it might be, we would vote not only on the location of the 2022 meeting, but also for the 2026 meeting, our 20 year anniversary, thus giving everyone 4-5 years to plan for a blow out meeting at a more exotic location. And so on and so on every 5 years.
And there you have it. Jackson, WY. Done.
We missed all of you who couldn't make it. Hope to see you next year!
Madam Secretary.
Out.
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