Manus News Letter 2012
Content
J U L Y
1 2 – 1 4 ,
2 0 1 2
the
Manus Club
Volume 1, Issue 6
Letter from the President
Thanks to great attendance and participation, the Kiawah meeting was a resounding success! We filled three half days with a memorable academic program. Medartis generously sponsored the meeting and supplied us with a cadaver lab. The resort facilities were outstanding and provided more than enough activities for attending members and their families. Thanks again to all for making the trip a highlight of the summer! - Randy
Kiawah Island, South Carolina
Home of the 2012 PGA Championships, Kiawah Island served as a spectacular backdrop to this year’s Manus Club meeting. There to experience the event were President Randy, Jon, Rob, Steve, Lana, Becky, Sunjay, Milan, Subir, Phani, Kristen, and new member Adam Shafritz. In addition to the scintillating academic discussions and cadaver dissections, there was time for getting (re)acquainted with each other, swimming, biking, drinking (whoops – am I allowed to write that?) and eating. And in our usual selfless way, our members even previewed the Ocean Course for the PGA.
Inside
Club Notes
Page 2 Treasurer’s report, membership notes, talk bank and social media
tSunami Award
Page 3 As usual, a tough competition, but only one could claim the plaque
Academics
Page 4 Member presentations, Medartis, cases, cadaver dissections
THE LOREM IPSUMS
SUMMER 2016
Club Notes
Upcoming Events: ASSH meeting in Chicago – dinner AAOS meeting in Chicago – informal drinks
Treasurer’s Report – Steve Lee
Manus Club is a 503b tax exempt entity. Official papers available from Steve if anyone needs. We voted to reinstate annual dues at an amount of $150/year. To attend an annual meeting, you must be up to date on dues. Make checks payable to Manus Club, Inc (I hope that’s right, Steve!) This will help with meeting costs in the event we do not have corporate sponsorship.
Membership
A majority voted to loosen the attendance requirement, which had been to attend at least every other year. Now, once voted in, a member may continue to attend meetings so long as dues are paid up to date. No new nominations were made at this year’s meeting. Any nominations should now be made directly to Steve.
Talk Bank – Milan Patel
Many members have used each other as resources for images or talks for educational purposes. Milan has researched some possibilities for a collective talk bank to allow everyone to upload talks and store them in a place where anyone can access them. There is a cost to any of these storage sites, and this will be paid for by our dues. After discussing some options, we voted to try Google docs, and Milan will test this out. Credit will be given to the original creator, and any edits will be noted. Special note, even in his absence, web master Ray has created a Facebook page for Manus. Thanks, Ray!
Deep Thoughts – Dan Zlotolow
Congratulations to Dan and Marie on the arrival of their twins! Unfortunately for the rest of us, we had to do without Dan’s ever thought-provoking philosophizing this year. Until next year… Hey Dan – how ‘bout that new logo?
2
THE LOREM IPSUMS
SUMMER 2016
Family Fun on Kiawah
Kiawah Island proved to be an ideal place for our families to gather, get to know each other and have a great time. Activities included bicycling, running, hanging out at the pools (which had some pretty awesome slides!), playing golf, kayaking, surfing, visiting historic Charleston, and sampling the delicious southern fare. The kids were able to entertain themselves (under the watchful eye of at least on parent). And the littlest ones, Neeri and Keilani and Shaan, got to meet each other for the first time. We dined all together at
tSunami Award
As always, it was a epic battle for the coveted tSunami plaque. Front runners were Rob with an unstable elbow dislocation with ipsilateral DRF. Multiple procedures, persistent instability. Radial nerve injury at time of hinged ex-fix. Adam with a PHF in an arm with a Krukenburg, Fixed with long-stem hemi. 2 peri-prosthetic fractures over 3 3 years with weak radial nerve. But the winner was Milan, with a CTR and flexor tenosynovectomy who subsequently underwent I&D, a reversed radial forearm flap for an open wound and exposed tendons, hospital admission with PICC for IV ABX, who healed on POD 164. Congratulations Milan!
THE LOREM IPSUMS
SUMMER 2016
Cadaver Lab
Medartis
This year we were fortunate enough to have sponsorship for three mornings from Medartis, who introduced to us their line of upper extremity specific implants, which use the trilock locking system. We then had the opportunity to try them on cadaver arms.
Implants
We tested out the Aptus distal radius plate as well as the 4-corner fusion plate, both of which use the trilock system. The 4-corner fusion plate has 1 row of locking and 1 row of non-locking screws. Medartis will also be coming out with an elbow plating system.
Member recommendations
Some implant recommendations from members during the course of our discussions included the Tornier, uncemented distal humerus replacement for trauma, and the Wright radial head replacement which has a smooth stem.
Digression
During the talks described on the next page, there were often digressions from the topic for discussions regarding the ethics of practice, coding/overcoding, acting as an expert witness, and the way we each are trying to cope with the changes in health care. Editorial: while these digressions threw us off our schedule somewhat, this is part of what makes this meeting so fun and interesting. Let’s keep going off on those tangents!
4
THE LOREM IPSUMS
SUMMER 2016
Academics
A new format to the meeting was introduced this year that was well received by all. Each member gave a short presentation. Although we ran a bit late and the agenda had to be altered a few times, everyone was able to give his/her presentation and much was gained. Here is a brief recap: Rob started us off reviewing distal radius fracture management in the elderly. There is a higher risk of redisplacement, even after 10 days in a cast, and a longer healing time if age >60, >20˚ of dorsal angulation, and >5mm of shortening. ORIF is beneficial for more active elderly patients. Locking plate is better. Radiographic accuracy does indeed reflect outcomes. Adam discussed surgical approaches to distal radius fractures. In the volar approach the risk of injury to the palmar cutaneous branch of the median nerve was emphasized. It may even be within the FCR sheath. Therefore the FCR should be retracted ulnarly. Concomitant CTR is not routinely recommended as no true benefit has been shown. Randy reviewed the benefits of awake surgery using lidocaine with epi, debunking the age-old myth of not using epi in the hand. (History of the myth – acidic procaine had been used early on.) Pros include no tourniquet time pressure, no postop hematoma and therefore more predicatable recovery. Keys to success – volume and time (at least 15 minutes before cut). Maximum dosage 7mg/kg. It is reversible with phentolamine. Subir presented a case of AIN palsy and discussed true versus pseudo-AIN neuropathy (ie Parsonage Turner). Repeat studies (EMG, not just NCS) at 3 months , and intervene surgically at 4-6 months if there is no improvement. Check the OK sign and remember to examine the shoulder! Steve introduced us to the SLAM procedure, a SL reconstruction to restore the central axis between the scaphoid and lunate. A titanium anchor with a hole to receive a palmaris graft is inserted into the lunate through a drill hole from the scaphoid into the lunate. The leftover tendon is brought over the top to reconstruct the dorsal ligament. Potential pitfall: fracturing the scaphoid. Stay central! Arthrex – possible sponsor for next year? Sunjay discussed MCP collateral ligament reconstruction using the Arthrex mini-tightrope system. Endobuttons used on both sides of the tendon graft. The other side of the bone need not be exposed. No k-wires, minimal splinting, and early therapy. But beware of overtightening.
Jon reviewed the long term results of PRC from a 20 year follow-up study. (Eaton modification cases were excluded.) All had PIN neurectomy. 48 weeks of immobilization, 4 weeks of splinting, free at 3 months. 30 of 44 patients included. 6 failed and had fusion. If the PRC was a secondary procedure, it was more likely to fail. 21/30 good/excellent results.
Lana is rolling out a survey on expectations following basal joint arthroplasty. We reviewed a list of potential questions for the survey. There was a concern regarding reliability, and how to remedy that issue. Also raised was the question of geographical differences in expectations. Becky shared her experiences volunteering overseas in Bhutan, China, and Honduras. While many questioned the value of taking the time from practice and paying their own way while still incurring expenses, it is an experience that is encouraged.
5
NEXT YEAR
JULY 2012
Letter from the President
I suggested Banff, Canada as next year’s location and it was selected by 1 vote over Atlantis, Bahamas. Save the date now! July 25-27 was chosen to avoid conflict with the comprehensive review course. I am considering the venue to be the Fairmont at Banff. Check it out and let me know your thoughts! http://www.fairmont.com/banff-springs/ We opened the floor to new member nominations and no names were suggested. If anyone wants to nominate a new member, please let me know. Hope to see everyone at dinner in Chicago. Once again, a great meeting at Kiawah put on by Randy – thanks again for a great job! - Steve
Pres Steve Lee
PHONE: 917-843-1197
ADDRESS:
523 East 72nd Street, 4th Floor New York, NY 10021
E-MAIL:
steve.kichul.lee@gmail. com
1 2 – 1 4 ,
2 0 1 2
the
Manus Club
Volume 1, Issue 6
Letter from the President
Thanks to great attendance and participation, the Kiawah meeting was a resounding success! We filled three half days with a memorable academic program. Medartis generously sponsored the meeting and supplied us with a cadaver lab. The resort facilities were outstanding and provided more than enough activities for attending members and their families. Thanks again to all for making the trip a highlight of the summer! - Randy
Kiawah Island, South Carolina
Home of the 2012 PGA Championships, Kiawah Island served as a spectacular backdrop to this year’s Manus Club meeting. There to experience the event were President Randy, Jon, Rob, Steve, Lana, Becky, Sunjay, Milan, Subir, Phani, Kristen, and new member Adam Shafritz. In addition to the scintillating academic discussions and cadaver dissections, there was time for getting (re)acquainted with each other, swimming, biking, drinking (whoops – am I allowed to write that?) and eating. And in our usual selfless way, our members even previewed the Ocean Course for the PGA.
Inside
Club Notes
Page 2 Treasurer’s report, membership notes, talk bank and social media
tSunami Award
Page 3 As usual, a tough competition, but only one could claim the plaque
Academics
Page 4 Member presentations, Medartis, cases, cadaver dissections
THE LOREM IPSUMS
SUMMER 2016
Club Notes
Upcoming Events: ASSH meeting in Chicago – dinner AAOS meeting in Chicago – informal drinks
Treasurer’s Report – Steve Lee
Manus Club is a 503b tax exempt entity. Official papers available from Steve if anyone needs. We voted to reinstate annual dues at an amount of $150/year. To attend an annual meeting, you must be up to date on dues. Make checks payable to Manus Club, Inc (I hope that’s right, Steve!) This will help with meeting costs in the event we do not have corporate sponsorship.
Membership
A majority voted to loosen the attendance requirement, which had been to attend at least every other year. Now, once voted in, a member may continue to attend meetings so long as dues are paid up to date. No new nominations were made at this year’s meeting. Any nominations should now be made directly to Steve.
Talk Bank – Milan Patel
Many members have used each other as resources for images or talks for educational purposes. Milan has researched some possibilities for a collective talk bank to allow everyone to upload talks and store them in a place where anyone can access them. There is a cost to any of these storage sites, and this will be paid for by our dues. After discussing some options, we voted to try Google docs, and Milan will test this out. Credit will be given to the original creator, and any edits will be noted. Special note, even in his absence, web master Ray has created a Facebook page for Manus. Thanks, Ray!
Deep Thoughts – Dan Zlotolow
Congratulations to Dan and Marie on the arrival of their twins! Unfortunately for the rest of us, we had to do without Dan’s ever thought-provoking philosophizing this year. Until next year… Hey Dan – how ‘bout that new logo?
2
THE LOREM IPSUMS
SUMMER 2016
Family Fun on Kiawah
Kiawah Island proved to be an ideal place for our families to gather, get to know each other and have a great time. Activities included bicycling, running, hanging out at the pools (which had some pretty awesome slides!), playing golf, kayaking, surfing, visiting historic Charleston, and sampling the delicious southern fare. The kids were able to entertain themselves (under the watchful eye of at least on parent). And the littlest ones, Neeri and Keilani and Shaan, got to meet each other for the first time. We dined all together at
tSunami Award
As always, it was a epic battle for the coveted tSunami plaque. Front runners were Rob with an unstable elbow dislocation with ipsilateral DRF. Multiple procedures, persistent instability. Radial nerve injury at time of hinged ex-fix. Adam with a PHF in an arm with a Krukenburg, Fixed with long-stem hemi. 2 peri-prosthetic fractures over 3 3 years with weak radial nerve. But the winner was Milan, with a CTR and flexor tenosynovectomy who subsequently underwent I&D, a reversed radial forearm flap for an open wound and exposed tendons, hospital admission with PICC for IV ABX, who healed on POD 164. Congratulations Milan!
THE LOREM IPSUMS
SUMMER 2016
Cadaver Lab
Medartis
This year we were fortunate enough to have sponsorship for three mornings from Medartis, who introduced to us their line of upper extremity specific implants, which use the trilock locking system. We then had the opportunity to try them on cadaver arms.
Implants
We tested out the Aptus distal radius plate as well as the 4-corner fusion plate, both of which use the trilock system. The 4-corner fusion plate has 1 row of locking and 1 row of non-locking screws. Medartis will also be coming out with an elbow plating system.
Member recommendations
Some implant recommendations from members during the course of our discussions included the Tornier, uncemented distal humerus replacement for trauma, and the Wright radial head replacement which has a smooth stem.
Digression
During the talks described on the next page, there were often digressions from the topic for discussions regarding the ethics of practice, coding/overcoding, acting as an expert witness, and the way we each are trying to cope with the changes in health care. Editorial: while these digressions threw us off our schedule somewhat, this is part of what makes this meeting so fun and interesting. Let’s keep going off on those tangents!
4
THE LOREM IPSUMS
SUMMER 2016
Academics
A new format to the meeting was introduced this year that was well received by all. Each member gave a short presentation. Although we ran a bit late and the agenda had to be altered a few times, everyone was able to give his/her presentation and much was gained. Here is a brief recap: Rob started us off reviewing distal radius fracture management in the elderly. There is a higher risk of redisplacement, even after 10 days in a cast, and a longer healing time if age >60, >20˚ of dorsal angulation, and >5mm of shortening. ORIF is beneficial for more active elderly patients. Locking plate is better. Radiographic accuracy does indeed reflect outcomes. Adam discussed surgical approaches to distal radius fractures. In the volar approach the risk of injury to the palmar cutaneous branch of the median nerve was emphasized. It may even be within the FCR sheath. Therefore the FCR should be retracted ulnarly. Concomitant CTR is not routinely recommended as no true benefit has been shown. Randy reviewed the benefits of awake surgery using lidocaine with epi, debunking the age-old myth of not using epi in the hand. (History of the myth – acidic procaine had been used early on.) Pros include no tourniquet time pressure, no postop hematoma and therefore more predicatable recovery. Keys to success – volume and time (at least 15 minutes before cut). Maximum dosage 7mg/kg. It is reversible with phentolamine. Subir presented a case of AIN palsy and discussed true versus pseudo-AIN neuropathy (ie Parsonage Turner). Repeat studies (EMG, not just NCS) at 3 months , and intervene surgically at 4-6 months if there is no improvement. Check the OK sign and remember to examine the shoulder! Steve introduced us to the SLAM procedure, a SL reconstruction to restore the central axis between the scaphoid and lunate. A titanium anchor with a hole to receive a palmaris graft is inserted into the lunate through a drill hole from the scaphoid into the lunate. The leftover tendon is brought over the top to reconstruct the dorsal ligament. Potential pitfall: fracturing the scaphoid. Stay central! Arthrex – possible sponsor for next year? Sunjay discussed MCP collateral ligament reconstruction using the Arthrex mini-tightrope system. Endobuttons used on both sides of the tendon graft. The other side of the bone need not be exposed. No k-wires, minimal splinting, and early therapy. But beware of overtightening.
Jon reviewed the long term results of PRC from a 20 year follow-up study. (Eaton modification cases were excluded.) All had PIN neurectomy. 48 weeks of immobilization, 4 weeks of splinting, free at 3 months. 30 of 44 patients included. 6 failed and had fusion. If the PRC was a secondary procedure, it was more likely to fail. 21/30 good/excellent results.
Lana is rolling out a survey on expectations following basal joint arthroplasty. We reviewed a list of potential questions for the survey. There was a concern regarding reliability, and how to remedy that issue. Also raised was the question of geographical differences in expectations. Becky shared her experiences volunteering overseas in Bhutan, China, and Honduras. While many questioned the value of taking the time from practice and paying their own way while still incurring expenses, it is an experience that is encouraged.
5
NEXT YEAR
JULY 2012
Letter from the President
I suggested Banff, Canada as next year’s location and it was selected by 1 vote over Atlantis, Bahamas. Save the date now! July 25-27 was chosen to avoid conflict with the comprehensive review course. I am considering the venue to be the Fairmont at Banff. Check it out and let me know your thoughts! http://www.fairmont.com/banff-springs/ We opened the floor to new member nominations and no names were suggested. If anyone wants to nominate a new member, please let me know. Hope to see everyone at dinner in Chicago. Once again, a great meeting at Kiawah put on by Randy – thanks again for a great job! - Steve
Pres Steve Lee
PHONE: 917-843-1197
ADDRESS:
523 East 72nd Street, 4th Floor New York, NY 10021
E-MAIL:
steve.kichul.lee@gmail. com
