The MANUScript: Colorado Springs 2025

It was a glorious day when we convened at the Broadmoor in Colorado Springs. The day was the 3rd of July, and we celebrated Steve's and Ray's birthdays in what Rob described as "the nicest place I've ever stayed". Present for this year's meeting were President Peter, Dan, Ray, Lou, Rob, Randy, Jon, Becky, Ruby, Kristin, Warren, Adam, Milan, Marc, Lana, and Sunjay.

Before the meeting officially got underway, some of us came early to enjoy the surrounding areas. Some started up in Boulder checking out the university for our upcoming launches. Some visited the Manitou Cliff dwellings to see how the natives of the area stayed cool using their natural resources.

Or the beautiful Cave of the Winds where we went on a haunted lantern tour. Tons of fun!

Or checked out Pike's Peak via the world's highest cog railway.

Once everyone arrived we gathered for a casual get together, and my how the Manus kids continue to grow!

Day 1: Thursday July 3, 2025

The academic meeting began with the Treasurer's report from Kristin. We received $40k from Acumed and Alafair this year. At the end of July 2025 we should have had $95k in the bank. A motion was made to make an amendment to the bylaws, to keep in savings the equivalent of one year's expenses, about $75k. The surplus would be used to defray the cost of the meeting for the attending members, at the discretion of the president. Dues will be maintained at $1000 per year. Tom will take over as Treasurer in 2029.

Ray then led us into the world of AI in healthcare. It all started with the Turing test in 1950. At the time it was predicted that physicians would be obsolete by the year 2000. Thankfully for us that turned out not to be true. But AI got better: AlexNet in 2012 beat humans in image recognition; AlphaGo in 2016 beat humans at chess; ChatGPT appeared in 2022 and is everywhere. (Make sure your prompts are as specific as possible to get the best possible result.) AI is here and here to stay. What can it do for us? In clinical research it can suggest hypotheses, summarize the literature (as long as it's not hallucinating!), draft an abstract and discussion. In practice it is streamlining note taking and generating appeals letters. And in the future? Surgical training? Smart ORs? Pretty sure we are still going to be needed, at the very least for ethical oversight. So we should embrace the changes that are coming, and be the ones to control them.

Marc then demonstratedcreative approaches to complex hand fractures. He is a big proponent of IM nails for metacarpal fractures. Even if it doesn't start out as a fracture that you could simply insert a nail, if you can get the reduction to loo like something you can nail, you can nail it. Open the fracture site and use clamps, cerclage, etc, then nail it! (A note on cerclage - cerclage using the Nice knot, a non-slip stable knot that can provie compression. Thanks, Lou!) Question: if you're going to open it, why not just plate it? The biomechanics are more favorable with an IM nail for early healing and return to activity. Also, the hole made in the articular cartilage of the metacarpal head is in consequential. A recent article in JHS supports this.

For phalangeal fractures, use coban to isolate the finger you're working on. Get the others out of your way! Again, Marc is a fan of the IM nail. Put 1 nail in, stress the finger immediately, and if needed add a second one in a lambda configuration. Can also use blocking screws to change the size of the canal to prevent movement of the nailAdd it after the nail is already in (0.045 k-wire for a 1.5 screw - is that right, Marc?? No need to drill.) And it is ok to put the nail through the central slip as shown below. Or, you can insert the guidewire retrograde exiting the corner of the phalanx, then insert the nail antegrade. So many options!

Jon updated us on what's new with distal radius fractures. He taught us about Montage, a polymer based putty from Acumed. It comes in 2 parts that have to be mixed together. They're called chiclets. Who remembers Chiclets gum? 😁 The mixed putty is malleable for 2 minutes - it gives structure to a comminuted fracture and you can drill through it. It is exothermic, but less than body temperature. It does expand slightly. MAke sure everything is dry, mix for at least 45 seconds, and press into the defect to allow the putty to interdigitate with the comminuted fragments. You can also split the chiclets in half and mix half and half at a time for smaller defects.

Rob then updated us on his elbow problem. Because he has a serious elbow problem. ARRCH orthopedics continues its saga with the FDA. Since the total/hemi was not making headway, he decided to separate out the ligament reconstruction part, for interposition arthroplasty.

But the FDA still didn't go for it. See his feelings about it below. It can be used, however, for compassionate use. He has done 3 cases so far with great results. Has the 4th one been done - it was coming up as of this meeting. Going to try again with the FDA. Fingers crossed!

Acumed then gave us an overview of their history (?) and then some new developments coming down the pike. New screws, nails, sutures, blah blah blah. Let's get to the fun stuff!

In several groups Manus hit the rivers for some fishing! What a gorgeous day, and we even had some success!

Others went for a hike to Seven Falls, right behind the property. The views were spectacular, and the zip-lining up there looked absolutely crazy!

After some brief rest following our afternoon adventures we gathered for the party bus to Mountain Clubhouse where we were treated to more stunning views out in the distance, and of each other! What can I say? We are a good looking crew!

The whole Manus family. I have to say - I love taking this picture every year.

And. I apologize - I was enjoying myself so much that evening that I was delinquent in taking more photos. So you will have to rely on your memories, which, if you are anything like me, may not be as robust as they once were. I hope you are not like me.

Day 2: Friday July 4, 2025:

The next day we reconvened in the Robert Trent Jones room for more lively discussions. Becky led us off with a comparison of Baseball versus Softball, and why softball is not just baseball on a smaller field with bigger balls. 😆 Moving on...

Adam discussed the challenges of being a hand surgeon at a Level I trauma center, responsible for replants but doing very little microsurgery. The burdens on each on-call surgeon are getting heavier while the success rates are dropping, because of lack of volume and continuous practice.

Lou then compared the several different types of practices he has been involved with since completing his fellowship in 2000. It was fascinating, so I'm just going to copy my notes in here for you to look at:

2000 Fellowship at Roosevelt

Feb 2001 started solo private practice - shared expenses, 3 separate practices - competing with each other. Divisive. Used Fairhealth website to determine cost of a procedure. Discounts and favors were divisive

Affiliated with Columbia until 2013

Bought by Mt. Sinai

Forced to move from RH, started OrthoManhattan 6 solo private practitioners

Became affiliated with NYU 2016-2022

Lou went to med school at NYU and had connections, became fellowship director. Glickel demoted. More friction

Moved to CU 2022, not UC Health

Private practice: total control, hire/fire, ancillary income, proud accomplishment

Enormous time and energy required - running a business, constant worry of overhead and staffing

COVID hit - applying for loans, paying rent, paying staff

Business took away the joy of being an MD

Salaried academic: part of a team, referrals get funneled

Free access to labs and statistician, funds for research; 2-1 matched 401K; extremely discounted health insurance compared to NYC private practice

Eliminates marketing (ZocDoc), no malpractice, max payout, 180-day statute of limitations (as opposed to 3 yrs in NY)

Can’t have an outside practice, all consultations have to go through CU

Less $, few personal relationships, difficult to get an appt, have to use an app, hard to actually talk to a person; no surgery center/OT/PT/MRI money

Legal/Consulting income taxed 10% by CU, no independent coding/billing, gave up shoulder and peds; so much admin, leads to errors, Epic - painful!

I hope you have found some life balance in your current practice despite the compromises you've had to make. It sounds like, at the very least, you're getting out to go fishing!

Dan gave us a talk about everything we've always wanted to (should) know about nerves and more. He reviewed the anatomy and normal physiology versus the physiology of injury. My take away was this: the timing and likelihood of recovery is tied to injury severity. Nerve injuries are surgical emergencies. Most people only think of vascular injuries this way. "Arterial injuries threaten the viability of the limb, but nerve injury threatens the utility of the limb. Viability is irrelevant if there is no utility." Early repairs do better than late, and primary coaptation is still better than grafting.

After Dan beat it into us the importance of early nerve repair, Warren talked to us about when to cut those nerves! He reviewed 3 papers including a 2018 paper by Lou on wrist denervation. Bottom line: it may or may not work. A diagnostic nerve block does not correlate with surgical results. Maybe it works better in the thumb and fingers? A 2019 paper by Tuffaha reviewed thumb CMC denervation vs suspensionplasty. Tuffaha wrote another paper in 2024 on finger denervation. The idea was generally well-supported among the attending members who have tried it. In the finger paper, 50% of patients did not require another procedure at 5 years. Go volar for PIP joint, dorsal at DIP joint, and gabapentin can be effective for post-op neurogenic pain. How to actually do the denervation? Cautery versus removing a segment of the nerve? Yeah - I didn't write down that answer. Anyone?

This was followed by an update from our friend Sarah Mayes of Alafair on Versawrap. Versawrap is composed of hyaluronic acid and alginate and is aimed at early stage healing to prevent post-op scarring. No animal or human tissue is used, it breaks down in 3-6 months, and becomes more permeable as it starts to break down. Reportedly it decreases the likelihood of needing a second surgery for tenolysis by 50%. Anyone with experience with it want to chime on on how you like it? I am unable to use it in my surgery center because of cost, though I'd like to try it!

After the morning session we gathered for a group hike at Garden of the Gods. The landscape was quite remarkable, with rock formations coming seemingly out of nowhere. It was a beautiful day and while there were many signs warning us not to climb on the rocks, some of us just couldn't help ourselves! (Some more than others!)

We returned to the Broadmoor with enough time to enjoy some of the amenities of the property. We even saw wildlife!

We were able to relax on paddle boats and in the infinity pool. And this slide was a favorite among many of the members and their families.

It was the 4th of July and we were afforded prime viewing of the fireworks from the deck off the Donald Ross Room. There were a few randos who tried to sneak into our private party but they were easily scared away. We were even treated to a rainbow before the fireworks started!

On our final day of the meeting we reviewed the bylaws. One amendment was made as noted above in the Treasurer's report. And again, dues will be kept at $1000/year.

We then nominated locations for next year, and the year after. As discussed last year, we will make plans for 2 years in advance, to give the president and other members enough time to secure sponsorships and to try to get as a good a deal as possible at the resorts. These were the nominees for 2026, and their scoring. Lowest score wins:

Nominations for 2026

Roatan 2 4 3 5 1 1 3 1 1 1 1 =23

Belize 3 2 4 1 4 2 4 4 2 4 2 =32

St. Thomas 5 5 1 2 2 5 2 3 4 5 4 =38

Baja oasis 1 1 2 4 3 4 5 2 5 2 3 =32

Little Cayman 4 3 5 3 5 3 1 5 3 3 5 =40

Winner is Roatan! And Aimee was named president for 2026. The resort chosen is the Klimpton Grand Roatan Resort and Spa

We then discussed options for 2027, and the group decided on Tofino, British Columbia. And this meeting will be helmed by Ruby! We will be at the Wickaninnish Inn.

And for 2028, perhaps the next big international trip? Members who have not yet served as president are Jeff Y, Sanj, and Warren. Did I miss anyone? We were supposed to send out a request for nominations for the international trip, giving that president even more time to organize, with help from the rest of us, of course! I will send out something soon.

It was time to present tSUNAMi cases. Peter, Jon, Lou, Rob, Dan, Milan all presented incredibly challenging cases. Remember, the definition of a tSUNAMi case is one where you wish you had just said no in the beginning. After a lot of cringing and "ooohs" and "oh nos", Dan Z took the prize. Fortunately, the tSUNAMi plaque is already in his possession! 😳

But the fun didn't stop there! Everyone gathered on the pickleball court for a lesson and a tournament. And what do you know, there are a lot of competitive people in the group!

I had to leave so didn't see the conclusion of the tournament. Is the the winner's photo? Looks like it to me! Congratulations! Glad Dan won something else too! 😁 I was very sorry to have had to miss this activity.

Final stop - the Golden Bee. And it looks like lots of people got lots of love from those little bees! Another fabulous, educational, heart-warming, fun and much too short meeting in the books. Thank you, Presidents Peter and Mary for hosting and organizing such a memorable event. I was truly sorry to leave you all.