Pour yourselves a glass of wine and settle in to your favorite sofa or armchair, because this is a long one!
This year's meeting took place on the beautiful island of Roatan, off the northern coast of Honduras. It was, in a word, spectacular. The resort, the Kimpton Grand Roatan, was beautiful, with comfortable rooms, delicious foods, and access to all kinds of island activities. A huge thanks to Aimee, Lou, and Kristin for all the work they put in to making this meeting happen, and making it the huge success that it was. Really, all I want to do is just show you pictures, but there was actually a meeting to recount! I'll do both! Present this year were Lou, Becky, Marc, the Jeffs, Rob, and Dan. While the larger meetings where almost everyone is there are so fun and educational, these smaller, more intimate meetings are possibly even more so. Even though we missed everyone who couldn't be there, the seven of us and our families truly basked in the glory of each other's company.
Roatan is really an off-the-beaten-path Caribbean island. Our hotel sits at the far west end of the island.
A few of us arrived a little early to take advantage of the idyllic setting. We met for happy hour and a beach front dinner.
Caribbean reef octopus
Caribbean king crab
Not 100% sure but I think a Whiptail stingray
Not to be outdone by the nightlife, the diurnal creatures put on a show for our SCUBA divers. We were taken to Danny's Drop Off and the Blue Channel.
No idea what these are but they were everywhere! We've nicknamed them LTPs: Little Tiny Puffers.
For our first official evening we met for Happy Hour then dinner on the beach at The Drop Off, where Lou and Betsy went above and beyond and got a huge screen for us to watch World Cup soccer.
Day 1 - Thursday July 2
Breakfast each morning was generously sponsored by Axogen.
The meeting started off with a presentation by Field Orthopedics, who gives us the NX nail, used by many of us for intramedullary fixation of metacarpal and phalangeal fractures. They also introduced us to a new thumb CMC arthroplasty device called Griplasty, which uses a suture anchor and a V-shaped suspension under the thumb metacarpal. It seems to me like another variation on what a lot of us already do. What I'd like to see (maybe a Manus lab?) is the Touch prosthesis!
Jeff F. then gave us some lessons on the multidisciplinary management of the mangled hand.
Key points:
Marc followed with OCD lesions in the adolescent elbow
Look for these in gymnasts and baseball players. Introduced us to fresh osteochondral allograft transplantation to the capitellum. Get a CT scan, choose a properly sized allograft. OCA is evolving in favor over OATS. Generally more successful in baseball players than in gymnasts.
It is so exciting to see/hear these new techniques being developed and showing success. Keep it coming!
Lou then discussed scaphoid plating.
Medartis scaphoid plate now available in 3 sizes. Make sure with your rep that all three sizes are there. Get pre-op CT to assess for humpback deformity. Get MRI if worried about AVN, though AVN is not a contraindication to plating. Approach with a z-plasty incision over hockey stick - better access. Stay radial to the FCR for easier access to the scaphoid. Consider radiolunate k-wire to stabilize the lunate - flex the wrist all the way down to get the lunate in the proper position. The key is to correct the humpback - bone graft either from the hip or radius. Trim the volar lip of the radius if needed to prevent impingement. Follow with a bone stimulator. Why not? What's your favorite bone stimulator? Confirm healing with post-op CT. When? 12 weeks?
Rob gave us an update on elbow instability.
Notes: you can take 50% of the olecranon without loss of function. The elbow is most unstable at 30° of flexion. We reviewed the Horii Circle - sequential disruption from lateral to medial. But is that really how it happens? Maybe the injury starts on the medial side - a reverse Horii Circle? We were then introduced to the Injury ladder as a new way of thinking about these injuries. More thought-provoking things to think about!
Dan then discussed global health and how we can contribute.
Choose a place that you would want to go back to again and again. Maybe a place that has a prominent pathology that you are an expert in? Maybe you know the language (always helps). A place you can get to via a direct flight would be ideal. Need to choose fertile ground - a place that is compatible and willing to have us and learn from us. The goal is to go someplace, and then make ourselves obsolete. Just like many organizations like Orthopedics Overseas, the goal is to teach the local providers to become independent, so that they don't need us to go anymore. Learn to work with and improvise with the local equipment. You won't always have what you're used to. And learn from them too. In my experience, that has always been the most rewarding part of these trips. Make sure you go back for follow-up - reinforce the bonds you made and get follow-up on your patients. Learn and adapt and adapt and adapt. Invite your colleagues, create even more meaningful bonds.
The group then met down the beach for a catamaran cruise. It was a beautiful day to be out on the water!
We even saw leaping dolphins! OK this was cheating - this was the Roatan Institute for Marine Sciences and the dolphins were in an enclosure with caretakers and trainers.
We dropped anchor to do some snorkeling.
The endangered filefish! Before we left for the boat that morning I pointed to this fish on the fish ID poster and said "I want to see this fish!" I didn't even know it was endangered! How lucky we were!
Day 2 - Friday July 3
Sarah Mayes from Alafair started us off on Friday. She gave us an update on their development of Hydrogel, a flowable gel in place of a sheet. The gel gets absorbed and disappears as the tissue heals. Full resorption by 6 months. They also have a Hydrogel pellet, where 1 pellet = 1 sheet of Versawrap.
Rob then gave us a history lesson about polymethylmethacrylate.
PMMA = Plexiglas = Lucite. I for one never really gave it much thought that this is the same stuff we use as cement in our arthroplasties. In WWI and WWII, plexiglas was used for aircraft windshields, periscopes, and gun turrets. It's the same stuff we put in bone! I am still trying to wrap my head around it.
But, when surgeons started to use PMMA as cement in hip arthroplasties, they started seeing complications, such as BCIS (bone cement implantation syndrome) which could lead to cardiopulmonary collapse and death. Enter the FDA. (Ah! Now we see where this talk is going!!)
In 1969 the FDA became involved in medical implants because everything was unregulated, and in 1969 there were over 700 deaths from medical devices. In 1976 a medical device amendment was added to the Food, Drug, and Cosmetics Act. It introduced a risk stratification method that consisted of 3 classes (Class 1 - minimal risk, Class 2 - 510(k) pathway for devices that are substantially equivalent to already approved devices, and Class 3 - something new and a multi-million dollar process). Almost everything from that point tried to prove what they were introducing was a Class 2 device, to avoid the long and expensive process for a Class 3 device.
Then metal on metal implants happened. And this changed the FDA process to become more stringent, requiring pre-market approval and post-market surveillance, and a much stricter approval process. This started in 2016, and let's see, when did we first hear about Rob's elbow problem? According to my notes - 2017.
Interestingly, the Touch implant has received pre-market approval already, without going through the rigorous process because of how well it is already doing in Europe. So again - when do we get to use it??
Lou gave us an update on the Touch prosthesis. But when are we going to be able to use it??
Indications for Touch: The trapezium has to be at least 8mm thick. There can be no (or mild) STT arthritis. The MCP joint must be stable: no collateral ligament instability, no significant hyperextension.
Contraindications: Tender 1cm proximal to the basal joint - which would indicate symptomatic STT arthritis. Pain with wrist flexion and radial deviation, which could mean the same. But what if there is radiographic STT arthritis but no symptoms? Can you still use the Touch?
Early failure is most often seen in young, active patients. Is there an age (physiological age?) cut off? The surgery seems to be harder in male patients. According to therapists, it appears those with the most pain and who take longest to recover are those with partial trapezoid resection. Leave it alone even if there is some loss of cartilage? So many questions!
Lou reviewed the surgical technique with us. Excellent results can be seen even on post-op day #3. 5% failure rate at 10 years. If revision is needed, put in a larger cup or revise to suspensionplasty. Share techniques slides with us, Lou? On Google drive?
Marc discussed short term outcomes of retrograde screw fixation of distal ulna fractures
Nail over screw bc compression not needed. Flex and radially deviate the wrist to access the starting point at the ulnar fovea. Yes, you are drilling through the articular disc of the TFCC! Getting an accurate starting point is the hardest part.
Becky gave an update on her patient with the cement burns to the fingertips.
Then I got cocky, and decided to do the back of the bench using spare slate tiles so I wouldn't have to spend any money. Unlike my wiser younger self, I did not do any research or take any classes on mosaic-ing (is that a word?) with natural stone. Nor did I invest in proper safety equipment. So not only did I burn my fingers, but I ruined the bench because unlike glazed ceramic tile, natural stone like slate clings to grout and doesn't just wipe off.
My family, fortunately, convinced me not to take a sledge hammer to the whole thing, and with much effort I managed to clean the tile.
Here it is! 16 years after I started. And now, because I am a glutton for punishment, I am working on the seat of the bench. Oh - my fingers? They healed. No debridement needed. But I still can't feel the tips. Not sure if I am comfortable going back to calling myself an artist yet, but I think I am getting there. Maybe another 10 years! So tell me, who were you before you became Dr. Hand Surgeon? I really want to know! Thank you all for indulging my story.
Dan came back to tell us what every hand surgeon should know about pediatric hands.
Kids have active periosteum, with tremendous remodeling potential on the compression side of a fracture. They need less immobilization than adults.
It was back to the reef for our SCUBA divers. This time at a site called Butcher's Block. Sounded a little ominous, but it turns out the site was home to some cute little critters.
And I don't just mean Jeff and Jenn!
Arrow crab
Seahorse!!!
Day 3 - Saturday July 4
Becky led us off with a review of the bylaws.
The big news with regard to the membership, is that Marco Rizzo has made the difficult decision to step away from the club. He is unable to commit the time needed to be a meaningful contributor, in his mind. In my mind, just knowing he is part of this club gives it meaning! But we respect his decision and look forward to seeing him at other meetings. What that does to our bylaws, however, is that Marco is no longer able to hold the position of having to declare that he loves you in order for you to continue to be a member . Fortunately, Jeff F. has volunteered for this very challenging job. Thanks, Jeff!
Some other changes: previously dues were to be paid by the end of the calendar year. But because of some members' institutional fiscal calendar, we have changed this rule, so dues need to be paid by the start of our annual meeting. Failure to pay results in automatic expulsion from the club (except when we are sitting at the meeting and people at the meeting who haven't paid pay immediately, and we call/text those who are not at the meeting and make them pay). Don't make us do extra work! Pay your dues! Dues are remaining stable at $1000 per year.
We are also no longer requiring members to attend the annual meeting every 3 years. As long as dues are paid, active membership is maintained. But, if you have not been to a meeting in the last 3 years, you no longer have veto power for any new member nominations. Speaking of new members, those present discussed (again) whether or not we have reached a steady state. Do we need to add more members? Most of those present were in agreement that there is no need to add new members, even if we drop below 30 active members (which we have). But we do not want to make it a hard stop - if someone extraordinary is interested in joining (and committing), then they can be considered. For me, I am happy with where we are. This is us! But that's just me.
A reminder that Kristin's 5-year term as Treasurer is at its midway point. Starting at the 2028 meeting, Tom will start working with Kristin on a year-long transition. Tom's term will officially be 2029-2034. At our meeting in 2028, we will nominate a successor for Tom. This is a vote that will go out to the whole membership, not just those present at the 2028 meeting. The treasurer will still receive a $2000 housing subsidy for the annual meeting.
Now that we are getting to the point where only a few remaining members have not yet planned a meeting, the process has changed. Jeff Y. has volunteered to helm the 2028 meeting. It will be up to him and Jenn to choose a location. After all these years, I think it is pretty clear what kind of place we like, and what kind of budget we can work with. So the President will choose a site and put it out to the membership, not so much for approval, but I think if anyone has any serious objections, they should let the President know. Warren and Sanj, I'm looking at you for 2029 and 2030! It's never too early to start thinking of where you might want to go and which year you want to claim as yours. The president will likewise receive a $2000 housing subsidy for the annual meeting.
Then we got into Tsunami cases
Dan: Baby born with a flail left upper extremity. At age 4-5 months, the plexus was reconstructed (using glue!) for C7 and C8 avulsion. At extubation, atonal breathing and no expansion of the left chest. CXR showed no PTX but high diaphragm. Reintubated, re-extubated, reintubated. Eventually weaned from the vent after 3 months, but is now in a long term care facility.
Note: a history of a prior shoulder dystocia is an indication for a C-section, as there is a 20% higher rate of repeat dystocia.
Jeff Y: A 57-year old mail carrier dislocated his thumb CMC joint. Treated with trapeziectomy AND trapezoidectomy (somewhere else). It is unclear if this was 100% intentional? He presents with pain and a completely unstable thumb metacarpal, and settling of the index metacarpal. Treated with fusion of the index MC to the long MC, tightrope revision of the thumb MC, fusion of the thumb MCP joint.
Rob
40 yo Wrestler and bricklayer
Bil distal triceps ruptures
Failed left, recurrent left elbow infection
Meth, anabolic steroids, MJ, EtOH, Cocaine, Opioids - Geez!
Right - minimal function
Left - rerupture, on function
Recon with Achilles allograft, olecranon ORIF, ulnar n neurolysis, radial neurolysis, Plate over the insertion at the olecranon. Woven into remaining triceps
Casted - LAC!
Speed bridge? Arthrex swivelok?
Complication - fell onto left elbow, infection.
I&D, wound vac, IV abx
Left AMA to get his cocaine
Back to OR again - draining distally - removed plate, VAC
Strength returned!
A new addition to our agenda: Jeff Y. presented a series of challenging cases contributed by anyone who wanted. Different from the Tsunami, this was not a series of disasters where you wish you had done nothing to start with. It was more a quick look at cases that were difficult, didn't turn out exactly as we had hoped, what we would have done differently if we had to do it again, etc. I thought it was interesting and educational and would vote to keep something like this in our schedule for the future. Thanks, Jeff!
1. 50 yo man had undergone scaphoid excision and 4-corner fusion, but now the screw is in the radius. What would you do? Answers ranged from revising the 4-corner fusion, total wrist fusion, just remove the screw. Oh, and discuss with the patient. Marc summarized the thought process: do the last operation first, or make our way there one step at a time. What was done? PRC with partial capitate resection and capsular interposition.
More pearls: For midshaft or distal P1 fracture, go retrograde with IMN. Base of P1, put in one IMN, stress. the fracture under fluoro in OR. If unstable, add a second from the other corner for a lambda configuration. Thumb MC fracture? Use 2 IMNs to fill the canal, like in a 21 yo offensive lineman that was also presented.
4. Then I have a random note: after pulp reconstruction with kite graft, if you have hair growing on the pulp, send to derm to laser off!
On our final afternoon the Friedrichs went fishing...
Pufferfish
Aliens! (OK, cuttlefish. But they could be aliens!)
I knew it was the 4th of July, but we were also in Honduras. So... But of course, the resort community caters to American tourists, so there were fireworks! Right off the beach. And we got to see them from the water. It was a really fun and unusual perspective!
And a munching turtle. It was right in front of us, chomping away. It eventually swam away and waved goodbye to us. I think it was sad to see us go. Adios and gracias, Roatan!
And now, introducing for the first time in Manus history: The Manus Book Club! In preparation for our meeting in Tofino, I have, with the help of the Friedrich clan, assembled a reading list for the membership. You have a rich variety of genres to choose from - something for everyone!
Remarkably Bright Creatures by Shelby Van Pelt - This story is set in an aquarium in the Pacific Northwest, and is narrated by a Giant Pacific Octopus. While the setting is not quite Canada, and the Giant Pacific Octopus not quite the same as a Caribbean Reef Octopus, I thought it was the closest thing to a transition book from Roatan to Tofino. And it's a great book. But if you don't like to read, Netflix did a pretty good job adapting it to a movie, starring my new favorite actor, Lewis Pullman! Fun fact, Marcellus the Giant Pacific Octopus is voiced by Alfred Molina, who played Doc Oc in Spiderman. I guess he likes cephalopods!
The Curve of Time by M. Wylie Blanchet - the chronicle of a widow and her five children exploring the waterways between Vancouver Island and mainland British Columbia over 15 summers in a 25-foot boat. And Passage to Juneau by Jonathan Raban - a non-fiction travel journal that takes us on a sailboat from Seattle to Juneau along the famed Inside Passage. I think it would be interesting to read these two accounts side by side, to see the difference between a man's and a woman's approach to a similar theme, though she had her 5 kids with her and wrote her story 30 years earlier. Also, his journey is undertaken in one continuous stretch and takes us all the way up to Juneau (duh), while hers takes place over many summers and is limited to a smaller area around Vancouver Island. Still, I think it would be interesting.
The Starship and the Canoe by Kenneth Brower - one of few memorable books I read as a Freshman in college. I don't even know what class I read it for, but it left a lasting impression. It is about the contrasts and similarities between a brilliant astrophysicist dad who wants to explore the heavens, and his dropout counterculture son who lived in a treehouse in British Columbia building kayaks and exploring the waterways and wilderness. All based on the true story of real life father and son, Freeman and George Dyson. I am going to have to reread this one! Disclosure: James did not enjoy this book.
The Glass Hotel by Emily St. John Mandel - James recommends this one instead. It is a suspense novel that starts out in a luxury hotel on Vancouver Island. It centers around an international Ponzi scheme and the fallout when it collapses. Its core themes are greed and guilt: basically rich people making poor decisions, and unwitting people getting caught up in the deception. You might be more familiar with her better known novel (and later TV show) Station Eleven.
Snow Falling on Cedars by David Guterson - a novel following the murder trial of a Japanese-American fisherman accused of murdering a local fisherman in post-war Pacific Northwest. The trial unearths deep seated systemic racism in the small community, where memories of wartime Japanese internment run strong. NB: for mature audiences only! While I have not read the book, the 1999 film adaptation was well-done. Ethan Hawke plays emotionally traumatized characters very well!
Twilight series by Stephanie Meyer - From serial killers to vampires and werewolves. This young adult romantasy series follows a human teenage girl as her life becomes entwined with mystical creatures, and, of course, she falls in love with one (two?) of them. The popular and award-winning books have been adapted into films that I am sure many of you have seen, even if you won't admit it.
Our Perfect Storm by Carley Fortune - In a classic Friends to Lovers trope, this romance finds itself unfolding to a large extent on Tofino! It mentions many of the places where we will be and has me looking forward to our meeting even more than before. NB: if you are thinking of sharing this list with your younger kids, know that this is not a closed door romance!
For those of you who don't have time to read, or read too slowly to make it enjoyable (me), I highly recommend listening to them instead. You can get many of these titles for free on Libby, and if you listen to them at 1.25 or 1.5 speed, you get through them pretty quickly. Instead of listening to music on my commute or when I run (read: walk) I prefer to listen to stories. In any case, I hope some of you check out these books. They are definitely getting me excited for Tofino!
The Long Beach Lodge: https://www.longbeachlodgeresort.com/
And while we're here, Presidents-elect Jeff and Jenn have chosen. It looks like we might finally make it to a dude ranch in 2028! Alisal Ranch (https://www.alisalranch.com/) in Southern California along one of the most beautiful stretches of the coast. (For those who don't want to ride horses, they have pickleball!) Can't wait!
