Celebrating 10 Years - Asheville, NC

Volume 2, No. 2
7/7/16 - 7/9/16

Our Tenth Annual Manus Club meeting was held in beautiful Asheville, NC, presided over by Milan, who (with Kanan!) managed to organize not one, but two meetings! In attendance at this year's meeting were: Milan, Ray, Rob, Becky, Steve, Randy, Jon, Dan Z, Lana, Kristin, Sanj, Bassem, Marco, Louis, Phani, Warren, Glenn, Marc, Jaimie, Peter, Don, Adam, Ryan, and Sunjay. I feel like I'm leaving someone out - if it's you, I apologize!!! But this was, far and away, the largest turn out we've ever had, perfect for a milestone meeting.

We were based on the Biltmore estate, the largest attraction being the mansion, built by George Washington Vanderbilt II, completed in 1895. The house itself and the surrounding gardens were amazing. The gardens were designed by Central Park and Golden Gate Park designer, Frederick Law Olmstead.

Everyone had a chance to visit the famed mansion and take a tour.

We considered having our group dinner here, but thought maybe it might be too formal for the likes of us.



And maybe followed by a game of bowling downstairs. But who would stand at the end to reset the pins after each roll?! The kids!

There was no shortage of scenic sites on the property.

Back inside, Milan led off our meeting on Thursday morning. The morning was filled with stimulating presentations and discussion. Adam discussed the changing landscape of medicine, and it's impact on hand surgery practices. Concepts brought up included clinical and payment integration, outcomes measures, and pay for performance. The direction appears to be heading toward doctor driven care, coordinated by the PCP. The counterargument was that in larger metropolitan areas, patients will still want choices, and will pay for those choices. Areas with more diverse patient population may not be able to adapt to such an arrangement. It does appear that ortho groups across the board are being absorbed by hospitals or foundations. The recommendation was to try to get bigger before you get absorbed, and there may be a bigger payout when it happens. As always, a lively discussion took place.

[nb: I do my best to take accurate notes during our conversations and to summarize them here. If I get something wrong, please feel free the correct me, and the easiest way to do so is through the comments that you can leave at the end of the post. Thanks!)



Ray followed with an out-of-the-box discussion of the use of virtual reality medicine. He gave a short history of virtual reality and it's potential uses in medicine: PTSD, anxiety, rehab, pain management. In his own practice he is experimenting with it as it can apply to post-operative pain and anxiety. He has found that it enhances the patient experience, and also increases overall patient satisfaction. Questions arose as to its necessity, applicability, cost-effectiveness, and availability. Who pays for it? Does it reduce the amount of post-op pain medication required? We were all eager to see how this technology may play out in clinical practice.

Ray then gave us an update on Manus's financial state. It seems we allowed our non-profit status to lapse (oops!) but it has since been reinstated, and the back taxes have been paid. Thanks, Ray! We voted to increase annual dues to $200/year. Please send your payments in if you have not already. We also voted to make a donation to the AFSH in Manus's name for $1500. Lastly, in recognition of the amount of time and effort involved in being President and Treasurer of Manus, we voted to cover the hotel expenses for these 2 members at the annual meeting.

Another bit of good news came in bits and pieces during the meeting. As you all know, our original choice for location for this meeting was at the Wyndham Grand Rio Mar in Puerto Rico. When we cancelled our meeting due to the Zika outbreak, they refused to refund our deposit. Ray went ballistic on them, calling in the big guns and sending them letters from attorneys that gave them no choice but to refund our money. We got that bit of news during one of our academic sessions.



Steve then gave us an account of his experience in Operation Enduring Freedom in 2001, in "The Adventures of SKL". We were reminded to thank our brothers and sisters in the armed forces for their service.

Dan and Jaimie gave us an update on hand transplantation. They discussed the need to offer a full spectrum of treatment for limb loss, which may or may not include transplantation. We talked about immunoregulation versus immunosuppression, possibly using a single drug protocol, which may make the process less risky and more tolerable. What are the current indications, and what protocol is to be followed? These are changing constantly, many factors are taken into consideration and decisions are made on a case by case basis. We were given an update on Zion, who is doing well 1 year out from his bilateral hand transplantation.

After the first day's meeting, we explored more of the beauty of our surroundings, and eventually made it down to the Antler Hill Barn for drinks and dinner with everyone and their families.

The grounds were the perfect place for the kids to run around while the grown-ups enjoyed drinks and conversation inside. Except that the weather had other ideas. It seems everyone had a great time anyway!

During dessert Becky gave a presentation on the history of Manus, and battled the wind and rain for attention. It was fun for me to put together the talk, to see the club develop and watch as families grew and changed. The powerpoint presentation is uploaded on the google drive if anyone wants to get a longer look at the photos. Afterward, the winds quieted down, and we boarded the party bus back to the Inn.

Day 2 brought 2 presentations by Glenn. The first, a fascinating account of upper extremity injuries in NASCAR. And we're not talking about just the driver. The pit crew, 7 guys consisting mainly of college football players who didn't make it to the pros, are specifically susceptible to certain injuries depending on their specific role in the pit. It really is like the movie Cars! Injuries range from lateral epicondylitis to TFCC injuries to fractures.

We then learned more about a novel muscle transfer for independent digital control with a myoelectric prosthesis at the transmetacarpal level. The interossei are transferred dorsally, a more intuitive procedure for powering the prosthesis. I don't even know if those last 2 sentences made any sense. You'll have to talk to Glenn directly to get more detail. At this point, I was still thinking about Lightning McQueen!

Last year at Green Lake the possibility of Manus starting and running a Touching Hands site was brought up, with Cuba as a possible site. Is it still a possibility? Dan, Randy, and Becky had originally volunteered to look into the logistics. Despite the fact that Cuba is now opening up to tourists, the regulations regarding a medical "mission" and the logistics involved are still quite formidable, but not insurmountable. More on this to come...

The bylaws were once again reviewed by Dan Z. No big changes were made. The bylaws cap the membership at 30, but many felt that this should not be a hard cap, and if there are people who would enhance our club but would bring our total over 30, then we should not limit ourselves. Our total is 29 right now, but this includes some members who have missed more than 3 consecutive meetings and technically are no longer members, and a few who are on the brink. In that vain, we discussed the creation of a new inactive level of membership, The Jennifer Wolf membership, for those who are clearly dedicated to the club but because of other obligations, like, say, the Bunnell fellowship, have not been able to make it to the annual meetings as required in the bylaws. Jeff Yao, welcome to the Jen Wolf membership! Inactive members do not vote on issues such as new member ratification.

Two people were nominated for membership during the meeting, and their acceptance would bring our total to 31. Strangely, I didn't write their names down, so if anyone remembers who those 2 nominees were, please let us all know! Again, using the comments section at the end of the post would be a good way to do so.

Following the meeting, Aimee Schimizzi (Eaton-Littler fellowship alum) was also nominated. Hopefully, all three of these folks will be meeting you guys this Thursday in Austin for drinks. The reception will be  held at Swifts' Attic: 315 Congress Ave. Austin, TX 78701 from 5pm - 7pm CST. Someone please fill me in on how that goes!

Day 2 ended with our annual cadaver lab, a highlight of our meeting, sponsored this year by Integra. Security was tight - we even had our own security guard outside the lab!

Highlights included an ulnar head replacement (hemi or whole), and a CMC pyrocarbon prosthesis. Tips and tricks were shared by many, notably Bassem, Warren, Lou, Steve, and Adam.

The meetings ended, as usual, at lunchtime, when we joined our families at the pool, down in the village, or out and about in Asheville.

There was a round of golf, which included first-timer Jon. Apparently, he didn't do too badly!

For dinner on Friday night, the children had pizza and movies with babysitters, while the grown-ups went out. But before we left for the restaurant, we gathered for a group photo, which is getting more and more difficult every year with our numbers growing the way they are!

Here we go...

...like herding cats...

But we got one!

Then we let Adam's daughter loose with the camera!

The First Five.

We don't look a day older, do we??

We boarded a bus, finally, and headed into town to Posana, where we enjoyed a fine meal, and even finer company.

On our third and final day of the meeting, we heard from Louis about how hand surgery is like fishing. It was a realization that came to him while in surgery. The similarities were quite obvious once pointed out, and the photos of the fish that Lou has caught were rather impressive!

We then launched into case presentations for the (not so) coveted tSunami award. I'll spare you the details of all the entrants, but our winner, with a nearly unaimous vote, was Phani! Normally I summarize my notes into a neat little paragraph, but it just doesn't seem possible! So here are my complete notes!

39 yo man

Congenital analgesia

h/o left humerus fracture, osteo, flail arm, unusable left arm

Right elbow dislocation

Closed reduction in ER and cast by someone else

4-5 weeks later, still out, huge amount of HO

4 weeks later, still in cast, worse position, more HO

Open reduction, resection of HO, ligament repair, static ex fix x 4 weeks

Hinged elbow brace at 6weeks

12 weeks post-op, no brace on, dislocated again, more HO, anchor pulled out, medial trochlea eroded away – Charcot?

Plan – reconstruct bony defect, interposition arthroplasty, reconstruct ligaments

Open – foul odor. Wash out, abx beads, outside facility, wound care, IV abx

3 weeks later, no splint, open wound

Close, huge ex fix

5 months later, wrist looks weird – ex fix pin cut through radial shaft, distal ulna  coming out of skin

Dr. Morrey: :I don’t know what to do”

ORIF radial shaft, healed, DRUJ incongruent but stable and no pain. Elbow is in and stable

9 months post-op, 30-130 through pseudo-joint

Peter seemed perfectly happy to hand the tSUNAMi plaque over!

On the last day, for anyone still present, Milan and Kanan arranged a tour of a local brewery, a special interest of his, since he likes to brew his own. Hey Milan - I'd like to offer a suggestion for the name of your next beer: Dos Beckys!

Afterward, everyone and their families met for drinks and snacks at a great place with an outdoor patio whose name I cannot recall - have you noticed how my powers of note-taking deteriorate as the weekend progresses???

And finally sprinkles, and a cherry on top. No better way to end a meeting.

Thanks, Milan and Kanan!! It was absolutely superb!

Louis Catalano will serve as our next President, as his nomination of Jackson, WY won over several variations on a theme: a dude ranch, runner up for the second year in a row. The meeting will be held at Hotel Terra, and the dates are

July 6 - 8, 2017

Mark your calendars and make your reservations now!