Stevenson, WA July 2019
From July 4-6, 2019 the Pacific Northwest played host to the Manus Club. We met at beautiful Skamania Lodge on the Columbia River Gorge. In attendance this year were President Jeff F., Adam, Marco, Jeff Y., Lana, Don, Jon, Rob, Milan, Randy, Ray, Lou, Becky, Kristin, Bauback, Marc, Sanj, Warren, Sunjay, Peter, Aimee, and Subir. 22! Remarkable turnout! A testament to the draw of Manus, the Pacific Northwest, and Jeff F.!
Some of us had the opportunity to explore the region a little before the serious work began, like hiking Multnomah Falls:
The Lodge was a beautiful setting for our meeting, with gorgeous grounds that allowed for some much needed R&R.
Some of us had the opportunity to explore the region a little before the serious work began, like hiking Multnomah Falls:
The Lodge was a beautiful setting for our meeting, with gorgeous grounds that allowed for some much needed R&R.
Day 1, July 4, 2019
First and foremost, Welcome Bauback! We hope Manus becomes the second family that is has become for many of us. For Bauback and for many other newer members, Ray gave a brief synopsis of the beginnings of the club, and our very first meeting in Scottsdale, AZ in 2007. Five members were present then, and look at us now!
Randy kicked off the meeting with a report on the reconnaissance trip to Cuba, to establish a base and a human connection for upcoming Manus mission work. The idea first came about at the Kiawah Island meeting in 2012. Becky gave a presentation on her volunteering experiences in Bhutan, China, and Honduras. While there wasn't overwhelming support for volunteerism at the time, it seems to have taken hold in enough people that in 2015 at Green Lake, inspired by the launching of the ASSH Touching Hands project, we decided that it would be a good thing for the club to give back in such a way. Cuba was selected as a possible site to start, given its relatively easy location to get to for most members, and a general interest among members to go to Cuba. Initially, we considered working as part of Touching Hands, but with the financial support of the Rotary Club (thanks to Dan's dad!) we decided to make this our own.
With the assistance of Altruvistas, the October 2018 trip was booked. They visited a medical school, 2 hospitals, a poly-clinic (usually the first stop if you are sick or injured), the French hospital and orthopaedics clinic. The group pitched our proposal for both clinical and didactic assistance, and they said Yes! In April of this year, Randy, Jeff F., Dan, and Marc returned to the island, gave six 20-minute talks on the requested topics, and listened to presentations of cases. The trip was a resounding success. Funding from the Rotary Club will be on-going, and at this time we would be traveling on a Humanitarian visa.
We were treated to a 10 minute video compiled by Randy's son Jackson, who had the unique opportunity of traveling with the group and witnessing the hopeful start of something great. Randy has shared that video on the google drive. I encourage everyone to watch it - you will be inspired!
The meeting continued with several presentations. Here is a brief summary of those discussions.
First and foremost, Welcome Bauback! We hope Manus becomes the second family that is has become for many of us. For Bauback and for many other newer members, Ray gave a brief synopsis of the beginnings of the club, and our very first meeting in Scottsdale, AZ in 2007. Five members were present then, and look at us now!
Randy kicked off the meeting with a report on the reconnaissance trip to Cuba, to establish a base and a human connection for upcoming Manus mission work. The idea first came about at the Kiawah Island meeting in 2012. Becky gave a presentation on her volunteering experiences in Bhutan, China, and Honduras. While there wasn't overwhelming support for volunteerism at the time, it seems to have taken hold in enough people that in 2015 at Green Lake, inspired by the launching of the ASSH Touching Hands project, we decided that it would be a good thing for the club to give back in such a way. Cuba was selected as a possible site to start, given its relatively easy location to get to for most members, and a general interest among members to go to Cuba. Initially, we considered working as part of Touching Hands, but with the financial support of the Rotary Club (thanks to Dan's dad!) we decided to make this our own.
With the assistance of Altruvistas, the October 2018 trip was booked. They visited a medical school, 2 hospitals, a poly-clinic (usually the first stop if you are sick or injured), the French hospital and orthopaedics clinic. The group pitched our proposal for both clinical and didactic assistance, and they said Yes! In April of this year, Randy, Jeff F., Dan, and Marc returned to the island, gave six 20-minute talks on the requested topics, and listened to presentations of cases. The trip was a resounding success. Funding from the Rotary Club will be on-going, and at this time we would be traveling on a Humanitarian visa.
We were treated to a 10 minute video compiled by Randy's son Jackson, who had the unique opportunity of traveling with the group and witnessing the hopeful start of something great. Randy has shared that video on the google drive. I encourage everyone to watch it - you will be inspired!
The meeting continued with several presentations. Here is a brief summary of those discussions.
Louis - Complications of Distal Radius Fractures
Nerve injury, such as the median nerve, or more likely, the palmar cutaneous branch of the median nerve. Injury can lead to painful neuroma or CRPS. If you see fat, stop and spread! The branch usually crosses from ulnar to radial in the distal part of the approach.
Volar escape. The Trimed hook plate can capture the volar lip fragment. A 0.062 k-wire can be used to transfix the lunate to the radius to maintain carpal alignment. Alternatively, a dorsal spanning plate for 3 months can work.
Dorsal escape. Options to prevent it: leave a k-wire in the dorsal fragment or inserting a single screw into the dorsal fragment. You can leave the volar screws longer than usual (length) in order to hold the dorsal fragment, and if they cause problems, they can always be removed later. The rule that the screws only need to cross 75% of the width of the distal radius can be ignored if there is a dorsal fragment that is misbehaving.
Nerve injury, such as the median nerve, or more likely, the palmar cutaneous branch of the median nerve. Injury can lead to painful neuroma or CRPS. If you see fat, stop and spread! The branch usually crosses from ulnar to radial in the distal part of the approach.
Volar escape. The Trimed hook plate can capture the volar lip fragment. A 0.062 k-wire can be used to transfix the lunate to the radius to maintain carpal alignment. Alternatively, a dorsal spanning plate for 3 months can work.
Dorsal escape. Options to prevent it: leave a k-wire in the dorsal fragment or inserting a single screw into the dorsal fragment. You can leave the volar screws longer than usual (length) in order to hold the dorsal fragment, and if they cause problems, they can always be removed later. The rule that the screws only need to cross 75% of the width of the distal radius can be ignored if there is a dorsal fragment that is misbehaving.
Tendon rupture. EPL rupture can be seen years out, usually due to a screw in the proximal row. FPL rupture is most commonly caused by the corner of the plate that is not appropriately seated on the bone.
Kristin - Distal radius malunions
Presented from her iPhone! We are so technologically advanced!
Intra-articular and extra-articular malunions were presented, and many members chimed in with techniques to help manage these difficult situations. Here are some:
Proximal ulna autograft - Acumed (4-6mm) reamer (1-time purchase) from tip of olecranon down the shaft (Marc)
Materialise - especially for osteotomy in more than 1 plane ($2800 - paid by hospital) (Ray, Jeff Y) Materialise great for both bone forearm osteotomies too
Femoral head allograft for structural support, add DBX
Newclip, osteomed - also doing 3D reconstructions and cutting jigs (Sunjay)
Check Vit D levels before osteotomies
Trimed magical screw driver to get length (Warren)
No need to treat reverse oblique DRUJ any differently - the articular cartilage is the same
Bauback
Fingertip Replantation - the more you do the better you are and the better your support staff is
Myths to be debunked:
1. Patient will be better off without replant.
Most patients want to made whole if given the option
2. Back to work sooner with a revision amputation
No data to support revision amp better than replant
FRANCHISE study - replant improved function, ADLs easier, better satisfaction
3. Too distal to replant
Just rongeur the bone down
Technical points:
Just rongeur the bone down
Technical points:
Central pulp artery - look for vessel more centrally
Veins are volar, - 0.3-0.4mm, so use 10-0, 11-0, 12-0 nylon suture
Can’t find vein? Artery only, fish mouth incision in pulp, heparinize and titrate to a slow ooze, starting in OR (based on weight); heparin scrubs qh; leeches as needed
5-7 days in hospital (5 if vein fixed, at least 7 if no vein)
Discharge on aspirin for a month
Outpatient replants? (Jeff F.) - home on aspirin
No vein? Use 1 artery as outflow, attach to vein
No target? Plug artery into subQ vein
Scope to 20-40X
Posterior wall technique - 1st stitch in center of posterior wall, work around. 4-5 stitches
0.1mm tips (rainbow micro instruments)
Discussion on regional replant centers - Becky will be sending these over the Bauback in SF.
Non-financial benefits of doing a lot of these: improve skills on low-stakes cases to be better prepared for high-stakes cases
Jeff Y.
Osteoporosis assessment using standard hand X-rays
Currently, the gold standard is a DEXA scan. Study done looking at using a standard hand xray to assess for osteoporosis, measuring the index metacarpal cortical percentage.
200 patients mean age 64, mostly women
Width of mc-medullary canal/width of mc (at the isthmus)
Results correlate with DEXA findings:
Threshold of 60% odds ratio 2.2x more likely (to be osteopenic)
<50% 11.6x more likely to be osteoporotic than normal
Gender specific across all ages?
They developed an app for iphone called BoneGuage. You input age and gender and uploads results. It creates data points for future evaluation and analysis. Once you have your results, send patient to PCP or endocrinologist to initiate treatment. Against a recent push at the ASSH, we collectively agreed that we should not be the ones coordinating the care of osteoporosis.
Warren
Add-on to Jeff's presentation. I think I got up to get food at this point, so I have skeletal notes. Something about how the measurement of the 2nd metacarpal cortical percentage (2MCP) risks human error, and about bringing in computer neural networks and AI to take that factor out of the equation and improve accuracy. Warren - please comment with corrections!
Presentations were followed by the annual business meeting
Ray - Financial report
Increasing dues to $500 made big difference - even the costs of travel to Cuba were reimbursed. If you have any leads on sponsors - get them in now! For Greece 2021 - Trimed is tentatively lined up. We need to get commitment on paper. Go to the booths at the society meetings and schmooze!!!!
President Jeff F. - Membership review
We had another discussion about when the club becomes stable. When do we stop inviting new members and stop monitoring attendance at meetings, with all agreeing that what we have is who we are? No conclusions. The discussion continues... 2 members go to 0 this year. Given their active participation on our listserv, we had volunteers who will speak with them each directly to assess their interest in continuing their membership. We also had interest from a former member who was unable to commit to the club at an earlier time. Do we take a vote on allowing him back in? We also revisited international members. Give them 5 slots? Guest slots? Fund it? Are they subject to the same rules? Further thought and discussion needed.
We also reviewed the veto rules on new members. In a nutshell, if one person says no, the answer is no. Regardless of the reason.
Nominations for a location for next year (2020)
Aimee - Los Cabos
Bar Harbor, ME
Grand Canyon
Mackinac Island, MI
Sunjay - Montreal/Quebec City
Marco - Lake Chautauqua
Adam - Fire Island/Block Island, NY
Marco - Grand Marais, MN
Greenbrier/Homestead, VA
Boulder, CO - Estes park? Durango, CO
Marc - Sea Island, GA
Dates for next year
2020 - explore 1st or second weekend of July - again
President - not necessarily the one who suggests the location
Child friendly - for small kids too!
Whew! What a first day! Time for a run to get some fresh air and recharge!
Whew! What a first day! Time for a run to get some fresh air and recharge!
We all took advantage of the amenities of the Lodge. The ropes course:
Axe throwing:
And golf:
And just happy to see each other again!
We can't even have just one kids' table anymore! There are so many and they are getting so BIG!
S'mores and sparklers to round out the 4th of July evening.
Look at the size (and beauty) of this group!
Day 2 - July 5
The meeting continued with more presentations and education.
The meeting continued with more presentations and education.
Marco
Marco gave us an update on small joint arthroplasty.
For index finger MCP joint DJD, there is still a debate on which is better: Silicone vs pyrocarbcn vs cemented (Stryker). Regardless of implant chosen, it is imperative to protect collaterals and avoid overstuffing. Intra-operatively - be able to get 10-15 degrees hyperextension (lag is frustrating for patients). If you are between sizes, opt down to avoid overstuffing. Sunjay recommended performing the shuck test intra-operatively to check for overstuffing.
As far as implant, Marco recommends starting with pyrocarbon and revising to silicone if needed. Soft tissue balance is paramount. Alloderm to reinforce soft tissue support, or a slip of FDS. Sunjay recommended using free PL graft to reconstruct collateral ligaments if needed. So if there are inadequate collaterals, not all is lost. Integra offers both silicone and pyrocarbon all in the set. Cuts are the same so you can decide intra-operatively.
Marco presented a case of non-silicone implants for the MCP joints in RA. Never again!
2-5 pyrocarbcn all dislocated.
Case: 32 yo gym teacher
Pre-op dx of RA
Dislocated left DRUJ, pinned, Darrach, after ulnar head stabilization, still painful
Darrach - invitation to catastrophe!
Option - BR to stabilize distal ulna post-Darrach
Jeff Y - BR - split in half, wrap one one way and the other the other - even more convergence?
Finally treated with a constrained arthroplasty.
Patient developed pain on the right side, treated with SK.
4y post-Schecker fx through ulnar shaft.
And it continues...
Rob
Total elbow arthroplasty failure
The talk began with a review of the primary and secondary stabilizers of the elbow. Also, the dynamic stabilizers - triceps, biceps, brachialis - these produce a compressive force across elbow.
Varying position of the arm changes forces - such as when arm is held out from body.
Rob also reviewed the history of TEA.
79% survival rate (compared with 95-96 THA/TKA). Not nearly the survival rate of the lower extremities.
20% complication rate. Why so high? Our experience has been with the large lower extremity arthroplasties, so in the design of the elbow, there has been disregard for elbow biomechanics and non-anatomic forces. Ligament de-emphasis, radial head resection, stress shielding, non-anatomic forces placed on the hinge. Examples of complications: aseptic loosening, periprosthetic fx, bushing and poly wear.
Worst case: Infection - remove implant, remove ALL the cement. Make bone windows to get it all out.
Recognize the possibility of doing more harm when considering TEA.
Revision options go down with time in terms of options and success rates.
Then we went off on a tangent, and had a discussion about doing the right thing vs making patients happy. How do we convince patients that doing what they want (what they think will make them happy) is actually the worse thing to do?
Then we went off on another absolutely unrelated tangent - cortisone injection for Dupuytren’s nodules.
Sanj
Hamate to scaphoid transfer for management of scaphoid proximal pole non-unions
Take the proximal half of hamate, osteotomize up to the hook (or less), with the CH ligament (volar).
Flip the graft so the ligament is dorsal - repair to SL ligament. The graft is non-vascularized.
Paper by Steve and Scott Wolfe re: scaphoid vascularity and healing: 70-90% correlation of morphology.
Carpal kinematics not changed significantly with removal of proximal hamate by cadaver tests.
Restored carpal kinematics after grafting to proximal pole of scaphoid. Compared to MFT and rib autograft results are comparable. Recommend CT scan first to determine if hamate morphology is a good match.
Questions/suggestions/recomendations:
Jeff Y/Lana - Accutrak screw - too much compression fractures the "proximal" fragment by hoop stresses?
Synthes headless screw instead - less compressive forces
Marco - Sotereanos capsular graft for revision
2.4mm screw - use smaller screw rather than larger (Micro)
Sunjay - Accumed - callus, calcium phosphate injectable
Jeff Y. - Medartis volar plate for scaphoid - 2-stage: need to remove the plate after healing?
Lou - the plate is better to hold in graft
Sanj - range wrist after plate is in to avoid impingement on radius
Steve - Modified Russe technique
Presentation from Endo Pharmaceuticals
Xiaflex
Ray - palmar fibrosis following injury, NOT Dupuytrens
Marco - Peter Stern article (link, anyone?)
Manus presentations continued...
Marc
DRF tendon complications - FPL most common; extensors less common now with more knowledge
Proper plate placement - tips and tricks
Place the plate as ULNAR as it can be and as DISTAL as it needs to be.
Randy - A little ulnar overhang is OK as long as screw is not in the notch
Watch the volar lunate facet - can displace if the plate is not ulnar enough or not distal enough.
(Peter - can bill for BR release. Tenotomy)
Debate - to repair or not to repair PQ. Not in Aunt Millie! Some still do, particularly to cover the distal part of the plate, to avoid irritation of FPL, but functionally not necessary.
Sigmoid notch view - collinear dorsal and volar lips
Sanj - What about the ski slope notches? - still able to use this view
In between sizes of plates - choose narrower one
Accumed plate - radial styloid target guide? Pin to see trajectory?
PL or slip of FCR as intercalary graft, or FDS ring transfer (Lou - hard to retrain) or allograft - do within 3 months. I'm not sure what this was referring to. Lou? A little help here please!
45 degree supination and pronation views to see if screws are out. The skyline view - 83% success determining if screws are as little as 1mm too long - need large C-arm. Can have false negatives. Screws only need to be 75% of the volar/dorsal width.
Business, Legal, financial Forum
WC
Reimbursement varies by state, and has changed
IME/impairment ratings - do your own?
Consent - not establishing doctor-patient relationship
Fee schedules - set your own, vary by state, WC determined
MedLegal
Factual witness - for your own patient?
Expert witness - adjust fee schedule. No one has ever been told their rates are too high. Bill what you think your time and experience are worth!
Sunjay - cases - cut median nerve from CTR, EPL rupture from DRF
Have to do both plaintiff and defense cases to be a credible expert witness.
Just stick to facts - no editorializing
Recommended podcast - Dr. Death. If you have not listened to this yet, you MUST! It brings up issues of self-policing among doctors. Is the state board effective in weeding out those who should not be practicing? Professional societies any better? Listen to the podcast!
All agreed that when we get advice from Manus or from former attendings, or any other professional colleague, “Discussed with colleagues” in official documentation. No naming names.
End of Day 2. We went out to enjoy nature some more. Hiking to Falls Creek Falls:
Jeff practicing for later...
Day 3 - July 6
Warren
MOC - "Continuous" Education
In a poll of hand surgeons, it was interesting that more preferred the high stakes once every 10 years test instead of the ongoing WLA
75 case limit for recert, min 35
Expanded CME options
WLA
Launched in Jan 2019. This format is open to all Diplomates. The testing is done on your own computer without having to go to a testing center.
There are 80-100 knowledge sources and you choose 15. 5 of the 15 have to be hand for specialty recertification. Between April and May, you have five weeks to answer 30 questions. It is completely open book but there is a time limit, 3 minutes per question. You must achieve 5 quality years (>24/30 correct 5 times during 10 year period) or 6 years with 120 questions correct.
For the every 10 year exam, there are 150 questions, or oral exam.
Patient reported outcomes
PROMIS - may be included in MOC process in the future
Guest lecturers to discuss Financial Planning - I am leaving this mostly in the bullet point form so it can jog your memory the way that it makes sense and matters to you, rather than me writing it out in the way that makes the most sense to me. I have such little knowledge of this stuff, that I'm afraid I might steer you wrong if I try to put this into complete sentences!
Ryan Price
- Investment
- Income tax plan
- Retirement
1. Tech/growth vs value stocks
Everything reverts back to the mean
Bonds - don’t bail on bonds!
Market volatility is normal - don’t bail on your portfolio
Behavioral biases
60/40 portfolio has never lost money over a 10 year period. 6-7% a year
Impossible to time markets, no matter what anyone claims
60% stocks, mix of S&P, emerging, international, etc, 40% bonds
Diversification wins even when it feels like its losing
2. Income Taxes
Tax control triangle
Don’t put all the money in tax deferred
Tax free - best bucket - only 5 strategies including Roth IRA, 529, municipal bonds, insurance policies, 1031 exchanges (if you own rental property)
Proactive advisor, maybe not your accountant!
Book - Power of Zero by David McKnight
White coat investor podcast
Consider VUL for kids - life insurance instead of 529 or in addition to 529
3. Retirement planning
Monte Carlo analysis - 25 year retirement
Include pension plan, annuities, etc not just stocks as you’re approaching retirement
Have Ryan review your portfolio
John Boylston
Estate planning, estate tax planning
State estate taxes - coming soon to California! And maybe federally. Great. Can't wait. Woohoo!
Community property states vs Common law states - it matters how it’s titled
Wills vs trusts
Wills and probate
Check beneficiary designations on life insurance, IRA, etc
Probate - approval process for a will. Public process. 1 year process, cost a percentage of assets (4% in CA)
Revocable living trust avoids probate
Trustor - owner (name is on trust)
Funding the trust - re-title accounts
How is practice aligned with trust - practice owned by trust?
Can keep assets under separate names even in joint trust
Trustee - president of the company. Can be the same as trustor but doesn’t have to be
Beneficiaries -
Divorce protection planning - protect your kids if they get divorced
Estate taxes
Irrevocable trust - cannot be changed after trustor’s death.
A/B tax planning with living trust - happens at the time of death
Division depends on how the assets are titled.
Repositioning Assets - protection and tax planning
Whole life policy - take it out of the estate if you have no plans to withdraw from it - keeps kids from having to pay taxes on it
Irrevocable life insurance trust
Look at state exemption rate
Spousal lifetime access trust - takes this out of estate, not subject to estate taxes - make sure it applies only while you are married!!! - money not available to creditors. Reasonable amount - roughly 1 third of assets acceptable
Qualified personal residence trust - personal residence and 1 vacation property. Reduces estate liability and protects house from creditors
Personal umbrella plans - max out. They’re cheap. Chubb or another robust company
Have John look at trust for free second opinion review
Where to go in 2020 - the votes are in!
Top 2
Bar Harbor
Sea Island
The winner is Sea Island! And president is… Phani (that's what happens when you're not here!) with help from Marc. Who says there can be only one president.
More exploring of the local scenery - rafting the Middle Gorge of the White Salmon River. Don't tell anyone but Becky fell out of the raft. In the calm part of the river.
And then the the adults only dinner.
A great night to catch up with each other while someone else watches the kids. Even better, while someone else's kids watches the kids!!! Built in babysitting!
tSUNAMi presentations
Adam
73 yo man
Feb 2013 Shoulder injury lifting 50lb cement bag resulting in a biceps rupture. Cortisone injection 2 months later with no improvement in symptoms. MRI revealed rupture of the subscap, supraspinatus, and biceps. Surgery Sept 2013- scope, biceps tenodesis, fix everything open. Huge post-op hematoma - drained, no infection. October 2014 (13 months post-op) while moving furniture patient feels pop. Treatment: PT with no improvement. Dec 2014 MRI - retear of supraspinatus, fatty atrophy, subscap healed. Cortisone injection. Aug 2016 (nearly 2 years post-re-injury) high riding humerus. Plan reverse TSA. Sept 2016. Happy patient! Yay!
Dec 2016 TKA and now has to bear weight through upper extremity. Usually you wait 6 months post-reverse before allowing weight bearing. Uh-oh. Jan 2017 acromion stress fx. Unhappy patient. Results in nonunion with conservative management. Miserable patient.
Jan 2018 - acute pain. No trauma. Dx: hemarthrosis. Scope, debride, cx negative. April 2018 - acromion plated with bone marrow aspirate, etc. Oct 2018 6 months later, not healing. Jan 2019 (2 years post-injury) revision ORIF with ICBG - no pain, healing? 80years old now, 6 operations in 7 years. Luckily all cultures have been negative. Healing? Who knows?!
Warren
35 yo man crush injury with laceration resulting. in zone 1 extensor tendon injury. 3 days later wash out, I&D, repair, pin. He goes on his honeymoon in Mexico. Strict instructions given. Pin is buried. to reduce risk of infection. When he comes back the finger is swollen with drainage. I&D, pin out, cultures of bone taken. ID consulted and patient is placed on Avelox, an oral MRSA med. On follow-up osteolysis, recurrent drainage. Add linezolid to Avelox. Less drainage and cultures grow gram neg bacilli. Infection cleared but there is angulation at the DIP joint, with no pain unless it is bumped. Fusion: pins or 3 months, consolidating. Healed, pins out, finger is straighter. Breathe sigh of relief.
3 years later, the patient bangs the finger, resulting in drainage, swelling, red/purple. Fractured through fusion site. I&D, cultures eventually come back positive. Finally, amputation at base of P2. Healed and doing well. Save FDS and central slip.
Becky
47 yo woman fell while hiking across a stream. Hit dominant hand on a rock underwater - open index finger PIP fracture. When she returned from vacation, finger swollen and red. Comorbidities: married to ED doc and friends with a Manus member. Cultures grew Aeromonas and Serratia. I&D x3, inpatient IV antibiotics. ID consult. Outpatient IV antibiotics for 10 weeks via PICC line. Intractable pain, developed PIP flexion contracture. MRI possible osteomyelitis - biopsy and cultures negative. Fusion at 4 months, hardware removal 4 months later. Stiff, small, still painful dominant index finger. Quit her job. Considering amputation...
47 yo woman fell while hiking across a stream. Hit dominant hand on a rock underwater - open index finger PIP fracture. When she returned from vacation, finger swollen and red. Comorbidities: married to ED doc and friends with a Manus member. Cultures grew Aeromonas and Serratia. I&D x3, inpatient IV antibiotics. ID consult. Outpatient IV antibiotics for 10 weeks via PICC line. Intractable pain, developed PIP flexion contracture. MRI possible osteomyelitis - biopsy and cultures negative. Fusion at 4 months, hardware removal 4 months later. Stiff, small, still painful dominant index finger. Quit her job. Considering amputation...
Jeff Y
Ulnar shaft fx treated elsewhere with plate. Went on to non-union, treated with IM rod which failed. Ulna re-plated, failed again. At this point the patient goes to Jeff. The ulna is re-plated with ICBG. 6 months s/p ROH IM nail. Cultures? (Jon) Non-union again! Pt refuses fibular graft. Another revision, resected more of non-union, fixed with vascularized ICBG. Even longer plate (Rob) Healed 7 months later confirmed by CT. Yay!.
Ulnar sided wrist pain now. DRUJ incongruency identified. Was the ulna shortened too much? Keep in mind location of where bone is taken from - level of ulna. 4 months later patient has elbow pain, loss of ROM, and the ulnar plate hurts. Plate removed. 4 weeks s/p ROH - fx through the ICBG just “picking up a pencil”. Treated non-operatively with cast, bone stim, and prayer. 4 months later, non-union again! Still refusing fibular graft. Another revision ORIF with new ICBG non-vascularized. CT scan 4 months later - still not healed.
9 months later healed. Yay!
5 months alter - wrist hurts again. Cut out consolidated bone from osteotomy site. 4 years later - all good!
The good news: he quit smoking and drinking, went back to school, is now a counselor for troubled teens, and still a mountain biker.
Tie! Warren and Becky
Tie breaker Jon - Warren wins! Unfortunately, Warren had already left by the time voting was completed. So Becky accepted the plaque on his behalf.
On the final night of the meeting all who were left gathered for dinner on the Hood River at Solstice Wood Fire Cafe and Bar. We sampled beer flights and enjoyed each other's company for one last night before heading back to the old grind.
And finally, first the demonstration:
We are definitely going to have to work on this...
See you all at Sea Island!!!!
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