A publication of the American Association for Hand Surgery Fall 2012

INSIDE THIS ISSUE

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○○○○○○○○○○○○○○ ○○○○○○○○○○○ From the Editor’s Desk 2 ○○○○○○○○○ MESSAGE FROM THE PRESIDENT Research Grants 2 Calendar 3 WHERE ARE WE NOW? Hand Therapist’s Corner 4 The American Associa- structured combined AAHS/

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AAHS Website 6 and energies of its many David Ring, MD. The one ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ volunteer members and day program entitled History Corner 7 leadership. The membership “Movement” will feature reflects a variety of individu- instructional courses; Jesse B. Jupiter, MD Practice Corner 8 als—all with a common surgical and rehabilitation courses; podium panels; Panel Discussion: purpose in providing panels, and several work- Hand Transplantation 9 outstanding care to patients shops—all featuring both two minute presentations; with problems involving the surgeon and therapist and featured surgical Hand Surgery upper limb. The member- expert speakers. This full videos. Our other guest Endowment 13 ship continues to grow with day program will run lecturers will be Dr. James 89% physicians almost simultaneously with the May Jr., former AAHS Leadership Profile: equally divided between first day of the AAHS President; Dr. Diego David Ring, MD 21 plastic surgery and ortho- meeting with both groups Fernandez from Berne paedic surgery training, as joining together for our Switzerland; and our Board of Directors 22 well as 11% health care guest lecturer Dr. Eduardo combined guest with the providers involved in the Zancolli Jr. of Buenos Aires, ASPN and ASRM will be evaluation and rehabilitation Argentina. He will be Carl Hiaasen, a well known of the upper limb. among a host of Argentine author of strange and funny While the activities of hand surgeons as our guest stories. the AAHS extend far beyond nation will be the Argentine We will have outstand- its annual meeting, I should Association of Hand Sur- ing social events including a . start with an overview of gery. 5K race; volleyball on the what we might expect at our Our academic program beach; golf and tennis meeting in Naples, Florida will continue to have tournaments; and a tremen- in January 2013. The meet- instructional courses; MOC dous banquet. ing will initiate a more (continued on page 6)

500 Cummings Center Suite 4550 Beverly, MA 01915 (978) 927-8330 www.handsurgery.org

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As the While this is typical for most, it sider this year to be the year “not to summer draws has not been true for Dave Ring, miss” the annual meeting. to a close and this year’s annual meeting program Finally, I would like to thank Dr my kids head chair. Dave and his committee have Danyo for his contribution for this back to school, reviewed hundreds of abstracts in edition of the Quarterly. Randy the beginning preparation for what will prove to Bindra had the idea to try to gather of another be an exciting and thought-provok- some information on the early “academic” ing meeting next January in Naples, formation of the AAHS and Dr. Thomas Hughes, season ap- Florida. The venue is a wonderful MD Danyo agreed to provide it. It does proaches. Just resort on the gulf coast, where there help to describe the foundation for as they are preparing for a new set is bound to be a tremendous the inclusiveness inherent in this of teachers and subjects, the medi- exchange of ideas between faculty group’s membership. If any other cal community also restarts their and participants; physicians and ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ members have interesting stories of academic pursuits. therapists. David, along with the earlier years, I would welcome ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Our department’s Grand President Jesse Jupiter, have plans their inclusion in future editions of Rounds and regular conference for an interesting collection of social this publication. schedule resumes after a break for events that will help to strengthen the ties that routinely form during Hope to see everyone in the summer. Conferences calls and Florida. CME events begin in full force after this meeting each year. Therefore, I what is typically a less hectic encourage every member to con- summer schedule. HAND SURGERY AAHS Research Grants Quarterly

The American Association for Hand Surgery is Now Accepting President Applications for its Annual AAHS Research Grant Jesse B. Jupiter, MD, FACS The American Association for Hand Surgery awards Annual Research Editor Grants to clinicians and therapists in private or academic practice for Thomas Hughes, MD small clinical studies focused in hand care, or for pilot studies leading Managing Editor to a more major hand care study. Grant applications are judged not Lorraine M. O’Grady only on scientific merit, but also on whether the project can realistically be completed in 1 year and on the quality and practicality of the budget. All AAHS members and applicants for membership are Hand Surgery Quarterly is a publi- eligible to apply. Non-member residents and fellows are also eligible cation of the American Association with confirmation of appropriate AAHS member sponsorship. for Hand Surgery and is published 1 award in the amount of $10,000 will be granted for a 1 year strictly for the members of AAHS. period. There may be up to 3 co-investigators; 1 of the investigators This publication is designed as a MUST be an Active or Affiliate AAHS member. forum for open discussion and Hand debate among the AAHS member- Surgery To view additional guidelines and to obtain an application, please visit ship. Opinions discussed are those

of the authors or speakers and are Quarterly http://handsurgery.org/grants/research.cgi. The deadline for all AAHS ○○○ Research Grant applications is November 1, 2012. Only electronic not necessarily the position, pos- submissions will be accepted. ture or stance of the Association. Fall Copyright ©2012, American Asso- 2012 ciation for Hand Surgery. All rights AAHS/PSF Combined Pilot Research Grant Opportunity: The reserved. No portion of this news- AAHS/Plastic Surgery Foundation (PSF) Combined Pilot Research letter may be printed without ex- Grant may be another funding opportunity of interest. All ASPS and press written permission from the 2 AAHS members and applicants for membership (including orthopedic publisher, 500 Cummings Center, surgeons and therapists) are eligible to apply. The application Suite 4550, Beverly, MA 01915, 978- deadline for the AAHS/PSF Combined Pilot Research Grant is 927-8330. December 3, 2012. To view instructions, visit http://www.thepsf.org/ research/grant-applications/combined-research-grant.

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ Calendar of Events 2012 March 4-8, 2013 2014 th October 18-21, 2012 12 Triennial Congress of January 8-11, 2014 th ASHT 35th Annual Meeting the IFSSH & and 9 Trien- AAHS 44th Annual Meeting San Diego, California nial Congress of the IFSHT Grand Hyatt Kauai The Ashok Hotel Resort & Spa November 15-17, 2012 New Delhi, India Kauai, Hawaii American Society for Recon- structive Transplantation April 25-27, 2013 May 18-21, 2014 th

3rd Biennial Meeting 14 South American Hand XIX FESSH Congress ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Chicago, Illinois Surgery Meeting in conjunc- Paris, France ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ tion with the 33rd National ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 2013 Meeting of the Brazilian 2015 Hand Surgery Society January 9-12, 2013 January 21-24, 2015 AAHS 43rd Annual Meeting Rio de Janeiro, Brazil AAHS 45th Annual Meeting Waldorf Astoria Naples Atlantis Resort Grande Hotel May 30 - June 1, 2013 Paradise Island, Bahamas Naples, Florida XVIII FESSH Congress Antalya, Turkey

Hand Surgery

Quarterly ○○○ Fall 2012

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1. You don’t need the latest and 5. There are many different ways greatest device to get the job done: to accomplish the same purpose. rocks can be used for traffic cones, Every time I visit Guatemala, I palm fronds for brooms, and learn about a different type of splint machetes for block cutting (I can or treatment technique from the split a block with 10 whacks!) other therapists on the mission. I was also astonished when I

2. Simple life = happy life. The watched a young boy with CP ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ stabilize himself in his chair with typical Mayan village family sleeps ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ in 1 bed in a 1 room mud walled his arms and put on his socks home. They are so happy and independently using just his feet. friendly. They would never pass you on the street and not say 6. Guatemalans do not possess a “Buenas tardes”. sense of “entitlement.” They do not believe they should be given 3. A mission trip is like adult services, money, or goods. They are summer camp. Wonderful people so grateful for anything that they volunteer for humanitarian trips, so receive. They wait patiently to be you meet the nicest people. My taken care of without questioning very best friends are people that I “how long will this take” or insist- met during the past 4 years of ing that “they were next.” participation in the Guatemala Healing Hands medical mission. 7. Probably the greatest gift that we bring to Guatemala is HOPE. 4. I have seen more complicated Parents want their children to have cases in one week in Guatemala a better life than they had. A than I do in years in the states. It is woman named “Suelema” sells a great learning experience to see a fabric scarves and weavings to variety of complicated cases: i.e. tourists. She told me that she didn’t gunshot wounds, stab wounds, have any education and has been severe electrical burns, nerve selling goods on the street since she traumas, etc. was 7 years old. She told me her daughter will graduate high school this year and attend the university next year. Parents of children with If you would like to volun- Hand congenital hand deformities want teer to be part of a future Surgery reassurance that their child will be mission or would like to Quarterly able to throw a ball or hold a cup. contribute money that will ○○○ Fall There is never enough money to be used to pay for a child’s 8. 2012 do all the things that you wish you surgery, please contact: could do to help those in need. Missions cost a lot of money and THE GUATEMALA even though volunteers pay their own way to go, surgical suites must HEALING HANDS 4 be rented, medications must be FOUNDATION paid for, and supplies to build latrines and stoves are costly. 290 6TH AVE BROOKLYN, NY 11215

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ CODING CORNER: E & M Office Visits

This edition of the Hand Surgery We are all aware that an E/M note— Quarterly gives us a unique oppor- at its most basic level—incorporates tunity to review coding guidelines three different sections. The first for Evaluation and Management (E/ section is typically the History. For M) office visits. The rules governing new patient notes, the History E/M codes are well defined for section should include a Chief primary care physicians and even Complaint, a History of Present for orthopaedic surgeons—look no Illness, a Review of Systems, and further than the American Acad- the Past Medical History. The emy of Orthopaedic Surgery Review of Systems is often ne- website for proof.1 However, glected but must be included to bill Eon K. Shin, MD coding guidelines for hand sur- for 99202/99242 or higher. Con-

geons are less concrete and deserve spicuously missing as a require- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ closer scrutiny. As always, the ment for the History is a section Consider listing the diagnosis for ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ purpose of this column is to help devoted to medications or allergies. every affected digit and/or hand. the practitioner avoid billing errors These details are routinely included For example, do not list multiple while maximizing his work units. in my notes for patient care reasons. trigger fingers as a single diagnosis; However, enumerating a patient’s consider listing each finger as a The definition of a “new” separate diagnosis. This practice is patient is important to clarify. From multiple medications will not alter the E/M code. substantiated by proposed ICD-10 an E/M standpoint, a patient that is changes, which will require that we new to the practice can be billed The second section is typically list a different code for each finger. with a new patient code (99201- the Physical Examination. Most As of now, right ring finger stenos- 99205) or a consult patient code hand surgeons will utilize the ing tenosynovitis will require a (99241-99245). A patient who has Musculoskeletal Single Specialty diagnosis code of M65.341, while not been evaluated for over three Examination, which includes a the left middle finger will require years can also be billed as a new general evaluation and details M65.332. Interpretation of radio- patient. Of course, the Centers for regarding the neck, back, and graphs, electrodiagnostic study Medicare and Medicaid Services extremities. Since most hand orders, and the utilization of other (CMS) stopped recognizing consult surgeons limit their practices to the diagnostic tools can elevate the codes 99241-99245 as of January 1, upper extremities only, the Physical coding level substantially. 2010. Examination will only describe The E/M level for new and CMS considers hand surgery to range of motion, stability, and strength of the neck and both upper consult visits is defined by the be a separate sub-specialty from lowest score of the three sections. orthopaedic surgery. A general extremities. From an E/M stand- point, this makes it extremely However, the coding level for orthopaedist could therefore refer a established visits is defined by the patient to a fellowship-trained hand difficult for a hand surgeon to code Medicare visits at a level higher lower component of the top two surgeon within the same sections. multispecialty orthopaedic practice than 99203. for a consultation. The hand Finally, the Decision Making Some final considerations to Hand surgeon could then bill the visit section usually constitutes the third consider: For new unrelated prob- using 99241-99245 for non-Medi- and final part of an E/M note. In lems that are treated within a Surgery care insured patients. this section, higher level codes can surgical global period, add modifier Quarterly

-24 to bill for the visit. For corticos- ○○○ A review of the basic anatomy be achieved by increasing the number of diagnoses reported. teroid injections that are unplanned, Fall of every E/M office note is needed. add modifier -25 so that the E/M visit is also reimbursed. This 2012 CMS considers hand surgery to be a separate modifier applies for initial and follow-up evaluations. An E/M visit sub-specialty from orthopaedic surgery. A gen- cannot be billed for planned injec- eral orthopaedist could therefore refer a patient tions. 5 to a fellowship-trained hand surgeon within the References same multispecialty orthopaedic practice for a 1. www.aaos.org/news/ consultation. aaosnow.jul10/managing2.asp

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ From the President (continued from page 1)

The AAHS has been exception- dollars. The Surgery”. ally active in extending its educa- Board is pleased 2013 will see any The AAHS tional activities and enhancing our with our will reciprocate national exposure reflecting our financial number of develop- with the Brazil- emphasis on education. Don management ments in our educa- ian Hand Lalonde, MD has been working in group especially tional activities. Society to serve concert with the ASSH in develop- during these at its annual ing Performance Improvement volatile eco- Among these include meeting in Rio Modules and he will also be the nomic times. an AAHS co-branded de Janeiro. A initial AAHS Visiting Lecturer at Within the pre-course has the annual ASHT national conven- past year, the Instructional Course been developed tion in San Diego. We hope that this Association at the AAOS Annual by Dr. LaLonde will continue on an annual basis. membership Meeting entitled○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ as an instruc-

The AAHS was featured by ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ and Hand tional program ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ VuMedi for a webinar entitled Surgery Endow- “Wide Awake Hand directed towards “AAHS presents—the ulnar nerve” ment contribu- Surgery”. surgeons This turned out to be one of the tors were working in most watched webinar with very surveyed as part underserved positive ratings. We are planning a of an analysis of the HSE. Using areas in Latin and South America. It second VuMedi webinar entitled this feedback and the vision of the is hoped that we will also work on “Job certainty in an uncertain AAHS and HSE leaderships, the similar programs coordinated with world.” Endowment will be working over the IFSSH. Our organization co-chairs the the coming year to strengthen its Dr. LaLonde is also negotiating Hand Specialty Day at the AAOS primary focus and initiatives. More to develop a reverse Fellowship in and will continue to do so annually. information on the Endowment’s Africa supported by this organiza- work should be available in January tion. Lastly, our journal, HAND, has 2013. become a well respected peer The AAHS has been exception- review journal under the guidance ally well managed by PRRI, which of Michael Neumeister, MD and is WHERE ARE WE GOING? has further enhanced our ability to seeing increasing submissions for 2013 will see any number of expand our activities successfully. publication. developments in our educational The AAHS is an inclusive On a different front, I am activities. Among these include an organization and we look forward pleased to report that the AAHS AAHS co-branded Instructional to your participation in our many financially performed well with net Course at the AAOS Annual committees or educational pro- assets exceeding one million Meeting entitled “Wide Awake Hand grams in the future.

Members Only Website Access: Hand Surgery

http://handsurgery.org/members/ Quarterly ○○○

AAHS Members have exclusive access to the Members Only area of the AAHS website. To access, Fall simply log-in with your individual Username and Password. Contact the AAHS Administrative Office 2012 if you need your login information.

 Access HAND, the official Journal of the AAHS. This is the best way to gain full access.  Go Green and receive electronic-only access to HAND. 6  Search the AAHS Membership database by name, geographic area, or specialty to find your colleagues.  Update and verify your Member Record for efficient and effective communication. Please be sure to note your specialty so your colleagues can find you!

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ HISTORY CORNER The Founding of AAHS J. Joseph Danyo, MD What began as an alumni ing Dr. Ray Curtis of Baltimore, a reached-those who did hand meeting turned into founding of the notable figure in the American surgery part time. This was a American Association for Hand Society for Surgery of the Hand historic meeting where both sides Surgery. Forty surgeons had been called. He asked the ‘why.’ The understood the position of each trained in Hand surgery at the reasons were stated. At this point other. Posch, Larsen practice in Detroit by Dr. Curtis invited the startup to a In the meantime, work pro- 1968. I finished a one-year fellow- meeting in Chicago. ceeded rapidly on the road to a ship there in 1967. We met at the airport over two national presence for AAHS.

Dr. Kim Lie, a Staff Hand days. Dr. Arthur Barsky of NYC ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Bylaws, legal matters, planning for surgeon in that practice, phoned me was the facilitator. Again was raised the 1970 meeting were consum- in 1968 to discuss the possibility of ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the question of why a second hand mated on time. ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ an alumni reunion. He received an surgery organization was needed. At the annual meeting drafts of affirmative. We settled on a place/ We stated: Most of our members documents were reviewed by the date for 1969. My task was to come practiced hand surgery on a partial Select Committee. Amendments up with details of a program and an basis. The Hand Society had a cap and deletions were made. The agenda for the discussion that was on membership-125. We had no general membership meeting to follow the presentations. cap. The Hand Society met just discussed the totality of the mate- rial. Here, too, amendments and deletions to the Bylaws took place. A different model would be employed with less Various committees were formed. formality and interactivity with presenters and Election of officers and Board positions, naming Chairs of com- leaders. Membership would be less restrictive. mittees emanated. I was asked to Occupational therapists would soon be capable continue as President until 1972. of membership. AAHS would not be a competitor. Development of the organiza- tion proceeded. A semi annual meeting of the Board was initiated.

In further communication with preceding the annual meeting of AAHS was in the air. Dr. Lie before the event, I indicated the Academy of Orthopedic Sur- the belief that a national organiza- geons. Many of our members were tion was needed. Three proposals plastic and general surgeons. A would be listed: no further re- different venue was required, such unions; another reunion in a few as preceding the annual meeting of years; form a national organization. Plastic and Reconstructive Surgery. AAHS Mission Hand The meeting took place in A different model would be Statement Detroit in 1969. It was well at- employed with less formality and Surgery interactivity with presenters and The mission of the Ameri- tended. An open discussion period Quarterly lasted a few hours and culminated leaders. Membership would be less can Association for Hand Sur- ○○○ with the vote supporting a national restrictive. Occupational therapists gery shall be to foster and to pro- Fall would soon be capable of member- mote the highest quality of hand body. I was selected president and 2012 tasked with development for a ship. AAHS would not be a com- care through the development national undertaking. A small petitor. and sponsorship of educational committee was formed to help in We anticipated cross-pollina- programs related to the hand the formation of the American tion as each organization had the and the upper extremity, 7 Association for Hand Surgery. In same mission. The Hand Society’s through communications with addition a place and date were set continuing education programs for the first annual meeting. It was were valuable and represented a health care professionals and the pegged for Montreal in 1970. stimulus to all hand surgeons. Yet public, and through the endow- ment of research. Shortly after the alumni meet- there was a populace that was not

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ PRACTICE CORNER What’s in a Name? “ICAM” versus “Relative Motion” Splints: What Should We Call These Immediate Active Motion Splints? Wyndell H. Merritt, MD, FACS, Richmond, Virginia Having first presented the emphasize “immediate” and repair (after verifying success “relative motion” splinting concept “active” to distinguish this from under local anesthesia with epi- some 30 years ago at the AAHS, dynamic splinting. Admittedly, nephrine) the proximal phalanx of I’ve been asked to address confu- “ah-cam” is easy for me to say! the injured digit is held at about 15 sion regarding its name. As this During the ten years of our study degrees greater flexion than its concept grows, we propose some only use of this splint for repair of neighbors, with only digits splinted clarification. long extensor zone 4-7 lacerations for six weeks, and otherwise full

When we first did cadaver was included in the published motion and use encouraged; ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ experimentation in the 1970s, and result. whereas a repaired long extensor of Maureen Hardy and Sandy ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Since that time, we’ve ex- the MP joint would be splinted in ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Robinson made the original alumi- panded the use of the relative 15 degrees greater extension than its num clunker splints, we believed motion concept to include acute neighbors for six weeks, including a the “relative motion” designation and chronic boutonniere manage- wrist component for the first 3-4 would clarify how this permits ment, which at first we called weeks to avoid passive tension on active motion by relative less ampli- “reverse relative motion” splinting the repair with full wrist and finger tude of motion and tension on (an even more confusing designa- flexion. As this concept becomes tendons with a common muscle, tion). Subsequently, combining Dr. accepted, I believe the ICAM such as the extensor communis, Lalonde’s “wide awake” local designation will be confusing lumbricals or flexor profundi. As anesthesia, epinephrine and no unless we have an ICAEM and an we encouraged full amplitude of tourniquet with relative motion ICAFM, which I believe will be interphalangeal flexion after long splinting has afforded opportunity even more difficult for me to extensor repairs1,2,3 and sagittal to expand the concept, albeit remember. I just pray we never band surgery4 our early publica- unpublished, to include complex confront “RMFS” and “RMES” tions named this the “relative repair and acute and chronic acronyms! motion splint.” However, it became boutonniere deformities, intrinsic I do believe that combining apparent to us that many surgeons tendon transfer to replace IP “wide awake” local anesthesia with and therapists did not comprehend extension, long extensor transfer for epinephrine and immediate active this splint provided active motion rheumatoid ruptures in concert “relative motion” splinting affords compared to the popular dynamic with synovectomies, joint replace- less morbidity and also provides splints, which do not require active ment with tendon repair or graft- continued new applications as this extensor gliding. Miguel Saldana, a ing, protection when mobilizing concept is recognized. It’s name pioneer in dynamic splinting, flexor tendon repair, digital nerve needs to include the concept. compared the two methods in his repair with early motion, etc., References series presented to AAHS in 1997 because this provides an excellent 1. Merritt WH: Complications of hand sur- and called it the “Merritt splint,” opportunity to verify the success of gery. Complications in Surgery Trauma, Hand (the least insightful name of all) and the procedure and the protection LJ Greenfield (Ed.), Lippincott, Philadelphia. pp 852-885, 1984. Surgery he concluded it to be preferable afforded by the splint in the operat- 2. Merritt WH: Written on behalf of the stiff

because of lesser morbidity. ing theatre. Any surgical or splint finger. J Hand Ther. 11: 74-79, 1998. Quarterly ○○○ When Julianne Howell accumu- adjustments needed can be made at 3. Merritt WH: Reflex Sympathetic Dystro- that time to ensure success. phy and management of the dystrophic hand. Fall lated our results, which she pub- The Hand and Upper Extremity Vol 7 & 8, Con- lished in 20055 she tried to solve this In discussing this with Dr. verse Textbook of Plastic Surgery WB Saunders 2012 confusion by choosing the acronym Lalonde, we agree that the least & Co., 1985. “ICAM” to clarify that it provided confusion might result if we call 4. Merritt WH, Howell J, Tune R, Saunders S, Hardy M: Achieving immediate active motion “I – immediate, C – controlled, A – these “relative motion extensor” or by using active and M – motion.” I person- “relative motion flexor” splints, relative motion splinting after long extensor 8 ally detest acronyms (because I can depending upon whether the tendon repair and sagittal band ruptures with never remember what the letters protected digit (or digits) is splinted tendon subluxation. Operative Techniques in Plastic and Reconstructive Surgery, Vol 7-1; 31- stand for) and “controlled” doesn’t in flexion or extension compared to 37, WB Saunders Co. February 2000 shed light on the mechanism of its neighboring tendons. For 5. Howell JW, Merritt WH, Robinson SJ: Im- how the splint works, but did example, in an acute boutonniere mediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. Vol 18(2); 182-190, 2005.

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ AROUND THE HAND TABLE Panel Discussion: The State of Hand Transplantation

Alex: This is Alex Spiess, I’m from tion from the transplant service at understand some of the unique the University of Pittsburgh. We your institution, the therapists, immunological features of these have an excellent panel gathered anesthesiology, pathology, psychol- particular types of transplants, that here today designed to provide our ogy, social work, nursing, pharma- an active research program should audience with an update on the cology, infectious disease, etc. is be the scientific foundation of any state of hand transplantation in essential. There’s literally about a clinical hand and face transplant 2012. Joining me tonight for this dozen different groups that you program. interactive discussion is Benjamin need to get on board before even Alex: Ben, can you walk us through Chang from the University of starting a program. I think the some of the anatomic and physi- Pennsylvania, Simon Talbot from daunting task is really trying to ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ologic considerations when you

Brigham and Women’s Hospital, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ coordinate all of these different evaluate a potential hand transplant ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Gerald Brandacher from John’s parts and identifying, what group candidate? Hopkins University, and Kimberly is going to be doing what when. Maguire, occupational therapist And then as you get closer to the Ben: Anatomically, the level of from the University of Pittsburgh clinical reality, you need to get the amputation has the greatest impact Medical Center. I just wanted to operating room staff and the on your likely functional outcome, thank all of you for participating in nursing staff - who’s going to be as well as designing the operation. this edition of Hand Surgery actually taking care of this patient - The operations are quite different at Roundtable, and with that, let’s get on board as well. So it really is a the distal forearm level as com- started. monumental effort. pared to the proximal forearm or above elbow level. I think we need Ben, can you briefly discuss the Alex: Gerald, what role do you feel to think about how likely it is that components that go in to the that research has in this process? patients will undergo the rehab creation of a viable and And do you feel that a program program and the nerve regenera- longstanding VCA Program? that’s offering VCA should have an tion required if you’re talking about Ben: Well I think there’s a lot of associated research program? a more proximal level amputation. operational work that needs to take Gerald: As with any novel and In terms of the actual procedure, I place. Number one is to enlist emerging field research is an think it’s important to simulate that institutional support and funding. integral component of VCA and I level transplantation as many times You also have to get all the team think as we’re about to begin to as you need to work out the actual members in place. Active participa- procedure, although it’s very (continued on next page) The Panel

Alexander Spiess, MD, Moderator Assistant Professor of Orthopaedics, Assistant Professor of Plastic Surgery, Division Chief of Hand Hand Surgery, Department of Plastic Surgery, University of Pittsburgh Surgery

Gerald Brandacher, MD Quarterly ○○○ Scientific Director, Composite Tissue Allotransplantation (Reconstructive Transplant) Program, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine Fall 2012 Benjamin Chang, MD, FACS Associate Professor of Clinical Surgery, Program Director and Associate Chief, Penn Plastic Surgery Kimberly A. Maguire, MS, OTR/L, CHT 9 Facility Director, Hand & Upper Extremity Rehab Clinic, Centers for Rehab Services, University of Pittsburgh Medical Center

Simon G. Talbot, MD Plastic Surgery, Hand Surgery and Microsurgery, Brigham and Women’s Hospital ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ appreciation of the involvement ○○○○○○○○○○○○○○○○○○○○○○○ Hand Table that they’re going to need to have (continued from previous page) through this whole process. There are certainly some psycho- similar to a replant I think all of us logical and some psychiatric factors who have done a hand transplanta- that may preclude a patient from tion have realized that it’s a very transplantation. In the early days different endeavor in trying to of this kind of work, the results of a organize the whole operation so number of different groups have you can get done in a reasonable shown that being very rigorous amount of time. In terms of the about this evaluation is a very physiologic aspects, through our important aspect because it cer- own screening we chose to exclude tainly can turn an otherwise people with primary malignancies. technically excellent result into a We have an excellent I think you also need to careful functionally very poor result. panel gathered here about diabetics. Patients, at least Making sure that patients who have ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ temporarily, are placed on steroids, today designed to ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ serious underlying conditions are ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ and steroids are also used for helped ahead of time or not offered provide our audience treating rejection episodes. So if transplantation is a very important with an update on the you start out with a diabetic it just thing. state of hand trans- makes one more thing that can Ben: May I just jump in and ask complicate recovery. I think, you, what are red flags for you? plantation in 2012. especially for a program that’s This is the most challenging part of - Alexander Spiess, MD starting out, you really want to pick picking a patient. What are the the best possible candidate in terms psychological aspects that you of overall health. would say that this patient is not a Alex: Simon, how important is the candidate? stresses and pressures that they’re pre-operative psychological evalua- Simon: I think that’s a very difficult under. Certainly getting a good tion? question because often it’s a very idea of how a patient may deal with Simon: I think it’s extremely grey area. And as surgeons we’re a very stressful situation is impor- important. I think all of us who much more comfortable dealing tant. have been involved in evaluating with level of amputation or cardiac Kim: I would have to agree with patients, meeting with patients, and disease, or something that we have that. The patient comes in for a talking to patients pretty quickly concrete variables and measure- screening and is seen by multiple realize that having a patient who ments for. Oftentimes the psycho- professionals. We must collaborate understands what the surgery logical evaluation is far less abso- and use our critical reasoning and involves, and understands what the lute. I think there are a few truly clinical judgment skills as little really extensive rehabilitation absolute psychiatric or psychologi- things will come out to each involves, is extremely important. cal contraindications. Obviously a different person that they see. We Making sure that underlying patient who cannot or who will not need to address their family problems that may become appar- reliably participate in the decision- struggles and issues. If they have ent after surgery are dealt with making or in the rehabilitation is a young children, how are they going Hand ahead of time; things like substance red flag. Any patients who have to deal with their childcare? If they Surgery abuse, underlying psychiatric active substance abuse issues, or are responsible for elderly parents, illness, or underlying physiological unresolved axis one psychiatric how are they going to be able to Quarterly trauma from the incident that may diagnoses, would certainly be suspend that responsibility while ○○○ have caused them to lose their absolute contraindications. they go through the transplant Fall arms, is very important. We have Many of the other things are a little process? There are additional 2012 all our candidates meet with a bit greyer and a little bit harder to stressors in their lives that we need psychologist and psychiatrist for a decipher. In the early days of to address as well as their medical baseline evaluation and to really evaluating a patient, part of our issues, so when they go through make sure that all these issues are goal is to meet them multiple times this procedure, they can handle it in 10 known and worked through. These so that we know that post-opera- addition to everything else that is specialists also to help us know that tively, when we’re having to see going on in their lives. our patients have a really good them many times a day for many Simon: I think that’s an excellent understanding of what they’ll be months into the future that they’re point and that’s where the multi- going through and a really good going to cope with all the kind of (continued on next page) ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ period, they need a stable social ○○○○○○○○○○○○○○○○○○○○○○○ said earlier, they think a hand is Hand Table situation in order to assume the life going to solve all of their problems. (continued from previous page) of a transplant patient. Transplant I think that’s one reason why it’s patients assume numerous respon- good to have the team talk to them disciplinary aspect of it comes in. sibilities such as taking care of the in various settings, both with their We’ve found that our occupational transplanted limb, medication family and without. That way you therapists are far more adept at adherence, and adherence to the get the full picture of where they’re identifying some of those addi- therapy regimine. The daily coming from. tional stressors and some of those stressors of such responsibility Alex: Ben, at this time, are there additional things that we’re not so require a stable support system to indications for unilateral below familiar with. Our psychiatry team manage. The costs of non adher- elbow transplants? In other words, is outstanding at meeting with the ence to the whole lifestyle can be does the risk versus reward ratio entire family and coming back with catatrophic to the transplanted lean in favor of being too risky at an evaluation of some of the things limb. Strong family support and a this point? to watch out for in the post-opera- good social situation is another tive period. So these are people Ben: I think that that’s going to be a aspect of the whole transplant ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ that are really specifically trained at process that goes understated. matter for debate. At Penn, our IRB dealing with these kinds of issues, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ actually only allows for bilaterals at ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Simon: I think the other point to and I think that’s the reason it’s very this point. I think the trade off...if make here is that these patients are important to have them on the team. somebody has a normal functioning potentially very vulnerable, and hand on one side, to have them Alex: I also think that PTSD is an having the support of a family who undergo a transplant and then be under reported psychological issue are part of the decision-making committed to immuno-suppression that most of our amputees deal process and able to discuss and the rest of their lives, the trade off with. We have seen it in our own reiterate with the patient, is very may still not be in the patients patients and we’re finding that it important. A lot of people see favor. But I think it’s definitely a may play a significant role in a receiving a hand transplant as the matter of personal opinion, cer- patient’s ability to make sound end to their problems, and I don’t tainly many unilateral hand trans- decisions with respect to medica- think that’s an accurate assessment. plants have been done around the tion and therapy adherence, Having a family who can perhaps world and have been successful. So potentially negatively impacting more clearly hear the risks, benefits, that’s another point that we’re going the overall long-term outcome of and alternatives is very important. to need more data to look at the transplant. Gerald: Along this line I think it is a outcomes to see how risky the Ben: How much family support do critical component of the pre-op operation is in the long run with you think is necessary? Would you evaluation and psychological chronic rejection and side effects of do a transplant on a patient who evaluation to ensure that both the the immunosuppression to see if has no family, but only a hired aid patient, as well as the family, have the tradeoff truly is worth it for a as the only help they have? realistic expectations of how a hand single limb. But whether you think Alex: So that’s a great question, and transplant is going to change their it’s worth it or not, the patient’s I think the answer right now is no. life and how it’s going to impact assessment may be quite different. I think that family support is a their overall well being. So I think it’s an issue that’s going critical part of the puzzle. I think Alex: That is a great point, Gerald. to be debated for a long time. that with these patients, not only I think that in time as we get a Alex: Along those lines, Gerald, Hand are they physically dependent on larger cohort of transplanted what are some of the more common Surgery somebody in the post-transplant patients and we really look back side effects, or common risks and study their outcomes and see associated with current Quarterly Our psychiatry team who’s thrived in this setting and immunomodulatory protocols, be it ○○○ who’s failed, we’ll be able to a triple or single agent therapy? Fall is outstanding at develop more refined instruments Gerald: Well in general the side 2012 meeting with the en- that will help us better predict the effects of conventionally immuno- tire family and coming patients that are more psychologi- suppressive agents are categorized cally stable moving forward. back with an evalua- in three major areas–infectious side Kim: Another thing to remember effects (viral, bacterial or fungal), so 11 tion of some of the when screening the patients is that called opportunistic infections, things to watch out they’re going to tell you whatever metabolic side effects and malig- they think you want to hear so that nant complications. for in the post-opera- you will recommend them for the tive period. transplant. I agree with what was (continued on page 14)

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○

Hand Surgery

Quarterly ○○○ Fall 2012

12

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ The mission of the Hand Surgery Endowment is to foster and promote the highest quality of hand care through development and sponsorship of educa- tional programs related to the hand and the upper extremity, through commu- nications with health care professionals and the public, and through the endowment of research.

The Hand Surgery Endowment depends greatly upon the generosity of AAHS members and affiliates for support. Contributions support current and future initiatives:

 Guatemala Healing Hands Foundation  Health Volunteers Overseas Missions  Partnerships with International Federation of Societies for Surgery of the Hand (IFSSH),

Orthopaedic Research & Education Foundation (OREF), and many○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ other organizations for international outreach and volunteer missions to improve global hand care ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○  Vargas International Hand Therapist Teaching Award*  Research Grants, including the AAHS Annual Research Grant and the HSE/AAHS/PSF Combined Pilot Research Grant

Thank you to those who have donated:

Jason M. Anane-Sefah, M.D. Degreef Ilse, MD, PhD William C. Pederson, M.D. Stephan Ariyan, MD, FACS Asif M. Ilyas, M.D. Linda G. Phillips, M.D. George W. Balfour, M.D. D. Marshall Jemison, M.D. Charles G. Polsen, M.D. Nabil A. Barakat, M.D. Curtis C. Johnson, M.D. Julian Pribaz, M.D. Mark E. Baratz, M.D. Gretchen Kaiser, OTD, OTR/L Gregory E. Rauscher, MD, FACS Rocco Barbieri, M.D. Martin A. Kassan, MD David F. Ruebeck, M.D., FACS Lynn Bassini, MT OTR CHT J. Daniel Labs, M.D. Todd K. Runyan, M.D. Robert R. Bell, M.D. JoAnne Levitan, M.D. A. Neil Salyapongse, MD Matthew Bernstein, M.D. Terry R. Light, M.D. James D. Schlenker, M.D. Michael E. Berry, M.D. John D. Lubahn, M.D. Grzegorz Sianos, M.D. Edward L. Birdsong, M.D. Joy MacDermid, BScPT, PhD Roger L. Simpson, MD,MBA, FA David Bozentka, M.D. John J. Mara, M.D. Jeffery M. Smith, M.D. Lance M. Brunton, M.D. Rosendo E Martinez, M.D. Elliot D. Sorene, M.D. Robert C. Buckley, M.D. Steven McCabe, M.D. Alexander M. Spiess, M.D. Linda C. Cendales, M.D. Patrick T. McCulloch, M.D. Chau Tai, M.D. Mark Cohen, M.D. Geoffrey S. Cook, M.D. Wyndell H. Merritt, M.D. Cary Tanner, M.D. Craig Alan Davis, M.D. Susan Michlovitz, PT PhD CHT Michael A. Thompson, M.D. Donald M. Ditmars, M.D. Jose J. Monsivais, M.D. David A. Toivonen, M.D. Hand Hiram B. Morgan, M.D. Douglas R. Trzcinski, M.D. Scott F. Duncan, MD, MPH Surgery Charles J. Eaton, M.D. L. Richard Morgan, M.D. Tsu-Min Tsai, M.D.

Keith D. Morrison, M.D. Thomas L. Von Gillern, M.D. Quarterly James F. Eckenrode, M.D. ○○○ Carlos H. Fernandes, M.D. Peter Murray, M.D. Renata V. Weber, M.D. John J. Fernandez, M.D. Daniel Nagle, M.D. Larry Weinstein, MD, FACS Fall Margaret J. Geringer, Toshiyasu Nakamura, M.D. Kirsten Westberg, M.D. 2012 Mark Gonzalez, M.D. Michael W. Neumeister, M.D. Michael J. White, MD, FACS Jeffrey Greenberg, M.D. Jose Ortiz, M.D. Todd Williams, M.D. Amit Gupta, M.D. A. Lee Osterman, M.D., FACS Barbara Winthrop Rose, MA, OTR, C Lon W. Howard, M.D. Srdjan A. Ostric, M.D. Aviva Wolff, OTR, CHT 13 Richard Howard, DO Patrick Owens, M.D. Levent Yalcin, M.D. Julianne Howell Eugenia Papadopoulos, OTR, CHT Karen Zaderej Ghalib A. Husseini, M.D. Mukund R. Patel Richard J Zienowicz, M.D. Click here to DONATE ONLINE ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ the US is that probably whenever ○○○○○○○○○○○○○○○○○○○○○○○ pression therapy due to some Hand Table possible a risk combination of a unique immunological features: (continued from page 9) CMV+ donor into a CMV- recipient A few of those unique aspects I should be avoided for these types think worth mentioning: 1) For the Probably one of the most common of transplants. of those side effects related to a first time in the history of trans- class of immunosuppressants Ultimately, prolonged suppression plantation it is possible to continu- referred to as calcineurin inhibitors of the immune system impairs the ously visually monitor the graft for or CNIs which currently represent ability of the body to prevent cell early clinical signs of acute rejection the backbone of any protocol for dedifferentiation and cancer by simply looking at the skin hand or face transplantation is development caused by carcino- component which is the main target nephrotoxicity. This is important to gens such as sunlight or oncogenic of rejection in these type of trans- keep in mind during screening and viruses. Hence, the overall risk for plants. This allows us to timely also follow up to have a very close malignancies in transplanted intervene with immunosuppression eye on renal function in those patients is higher when compared and to precisely adjust immuno- patients. to normal individuals. The risk of suppression, probably more so than developing certain cancers such as ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ in any other type of solid organ Other rather frequent side effects of

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ skin cancer, post-transplant transplant. This makes strategies ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ this type of agents include hyper- lymphoproliferative disorders for tolerance induction as well as tension, diabetes, hypercholester- (PTLD), or Kaposi’s sarcoma is attempts to minimize immunosup- olemia and neurological side effects increased by several-hundred-fold. pression particularly appealing. 2) such as tremors and paresthesias. The incidence of skin cancer within With the skin as the main target of Steroids are another frequently 5 years of transplantation in liver, rejection, transdermal (topical) used type of immunosuppressants kidney, and heart transplant drug application is a viable alterna- for both maintenance as well as recipients ranges for example from tive or adjunct to systemic immuno- treatment of acute rejection epi- 1.5% to 34%. suppression with fewer side effects sodes and have a variety of serious Alex: Thank you, Gerald. I heard in case of skin rejection. 3) VCAs side effects including but not you mention conventional therapy. are furthermore the only type of limited to hypertension, osteoporo- What is the future of immuno- grafts to include donor bone sis or osteonecrosis (observed in the modulation in hand transplanta- marrow and a vascularized bone very first US hand transplant tion? Is it going to continue to be marrow component as immuno- recipient, acne, baldness, anxiety or the ‘conventional triple’ therapy or competent elements. This not only depression and a slew of other are more programs going to move represents a constant source of metabolic problems. towards single agent therapies? Or donor antigen and donor-derived Mycophenolate mofetil or MMF is are programs going to move in a stem cells but also favors the ability associated with gastrointestinal completely different direction in the for chimerism induction and side effects such as diarrhea, future? maintenance. This has been shown in various experimental models, as nausea, abdominal pain or weak- Gerald: I believe that we will see a ness as well as leukopenia. well as in the clinical setting, to be a significant development and a lot of prerequisite to minimize or avoid According to the International different therapeutic avenues immunosuppression long-term. Registry for hand and face trans- pursued in these types of trans- plantation triple-drug regimens plants in the future. Upper extrem- Currently there are several promis- ing strategies to minimize or avoid used in upper extremity transplan- ity transplantation offers particular Hand tation have been predominantly advantages to implementing novel immunosuppression and to induce Surgery associated with diabetes mellitus, strategies to minimize immunosup- immunological tolerance for nephrotoxicity, osteonecrosis, transplantation on the horizon. The Quarterly leukopenia, hypertension and What is the future of most encouraging results have been ○○○ hyperlipidemia demonstrated for cell-based ap- Fall immuno-modulation in proaches for immune modulation A particularly serious side effect in 2012 hand transplantation? including donor bone marrow, VCA is CMV infection that can regulatory T cells, stems cells in trigger rejection episodes that are Is it going to continue particular mesenchymal stem cells challenging to treat/reverse. There- to be the ‘conventional and tolerogenic dendritic cells. fore CMV matching between donor These approaches have been shown 14 and recipient remains a very triple’ therapy or are to be successful in large animal important issue in this field. What more programs going studies for VCA and are also we have learned from more than a currently entering first clinical trials decade of experience with VCA to move towards single both initially in Europe and now in agent therapies? (continued on next page) ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ limited range, per the surgeon’s ○○○○○○○○○○○○○○○○○○○○○○○ days, and we got a positive Tinels Hand Table orders to limit the amount of scar signat the level of attachment (continued from previous page) adhesions. Additionally, active and between 28 and 35 days. Hypersen- active/assistive range of motion is sitivity began between 56 and 182 in both reconstructive and solid performed to the non-effected joints days. This actually impeded the organ transplantation. of the extremity, for example the therapeutic process and limited Also the use of biologic agents such shoulder and elbow. This also what we could do in therapy. We as monocloncal antibodies and assists with circulation and edema used desensitation techniques to costimulatory blocking agents that management. Cortical reintegra- help it to resolve. As far as lumbri- allow to very specifically and tion is started at 14-21 days so brain cal innervation, attachments at the targeted interference with T cell mapping can reestablish itself. It is wrist level showed signs of function activation during an alloimmune essential to have the neurological between 77-98 days. Obviously a response seem to be very promising connections in the brain begin to more proximal attachment would and will definitely be important in take over control of the hand. In take longer. At the University of future protocols for upper extrem- some cases, it has been many years Pittsburgh Medical Center the

ity transplantation. since the brain had a hand to ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ patients attended Occupational control, and we need to get that Therapy 5 days a week, 6 hours a

Other more conventional/tradi- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ tional approaches to improve the engaged again. The theoretical day, for the first six months. This is current clinical treatment protocols basis of Occupational Therapy is to in addition to their medical tests, for reconstructive transplantation get people to do things that are lab work, meetings with the psy- include steroid minimization/ very functional and meaningful to chologist, etc. So, it is very much avoidance and CNI sparing regi- them. This is encouraging to the like a full time job for them. That is men, switch from CNI to mTOR patient and increases their motiva- why it is extremely important to inhibitors long-term, mTOR and tion. Therefore, they participate in pick the right candidate who can MMF based maintenance protocols, the therapeutic activity longer and endure such a regimen. After 6 as well as alemtuzumab and other this leads to a quicker recovery. So, months, they get transferred to a non-myoablative induction regi- we get them to start self-feeding local therapist who takes over their men. with the transplanted hand using a care. These therapists are in contact universal cuff, an adaptive piece of with us on an as needed basis. We Alex: Kim, let me move the discus- equipment, within 7-35 days. (continued on next page) sion in a little different direction. Again, this is all dependent upon Can you take us through the first 12 the level of attachment of the months of the typical hand trans- extremity and the patient’s engage- plant patient from an occupational ment, motivation, and medical therapy standpoint? status. We also had our patients Kim: First, we receive a phone call beginning to write with adaptive either from one of the surgeons or equipment within the range of 7-49 the hand transplant coordinator days. Fine motor tasks began letting us know that the surgery has between 28-63 days. This includes taken place. We immediately begin small object manipulation, cutting to rearrange our schedules so that with spring loaded scissors, using we can have adequate coverage for chopsticks, and fingernail painting our other patients while we get with our female patients. This is Hand prepare for the hand transplant extremely important so they get a The theoretical basis of Surgery patient. The initial postoperative sense of “owning” their hand early splint is fabricated at 2-14 days in the process. Most activities are Occupational Therapy Quarterly depending on the patient’s surgery begun with a splint or a piece of is to get people to do ○○○ and the surgeon’s preference. The adaptive equipment. Then they are things that are very Fall splints vary depending upon the gradually weaned off until they are 2012 type of surgery that was done, the doing it independently with their functional and mean- level of attachment, and special new hand. As far as milestones they ingful to them. This is needs of the patient that brings typically start to have pain, espe- encouraging to the concern to the surgeon. We begin cially pain that requires some type 15 soft tissue mobilization for edema. of medication, between 14-105 patient and increases We try to control the edema early days. There was a wide range their motivation. because, as we know, circulation is between the group of patients we critical for healing. We also start treated. Hot and cold sensation passive range of motion, within a returned somewhere between 35-84 - Kimberly Maguire, MS ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ therapy did not recover function as ○○○○○○○○○○○○○○○○○○○○○○○ Hand Table well. This was independent of (continued from previous page) whether they had a positive or negative attitude towards the ask for monthly reports to record experience as a whole. It basically the patients’ progress and address comes down to their dedication to any issues that might arise. The therapy. I believe Gerald could patients come back every 3 months speak more about a bilateral patient so we can collect more data on in Austria who, even many years them which include functioning after formal therapy ended, contin- levels, strength, range of motion, ued his home exercise program and continued sensory return. daily as part of a physical fitness Alex: Kim, at what point do you routine. He did extremely well! Certainly if you had a feel that the typical compliant Alex: Simon, with the competition couple of national centers patient should be able to “wean for diminishing outside funding of excellence and had off” of the in-house occupational sources becoming stiffer, are ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ therapy and move into a home plenty of resources focused

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ individual hospital systems or ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ program? insurance companies or both going on those two or three Kim: Again, it would depend upon to agree to absorb the cost of hand areas, it would be an easier the level of attachment. Consider- transplantation, assuming that task to sustain. ation must also be given to the down the line, there are going to be amount of function they have and some reductions in the overall cost - Benjamin Chang, MD the compliance, engagement, and of the transplants as our techniques motivation exhibited. This will be evolve. Gerald: Along those lines, if you different for every patient. Typi- Simon: I think that’s a very good don’t mind if I just jump in and ask cally, it would be between 3-5 years, question. Obviously, right now we Kim if they have tabulated the cost if they are doing very well. Follow are in that phase where transplanta- of therapy for each of these trans- up with the team once a year would tion is still being either self-funded plant patients? The program de- be advised to determine if there are by individual institutions or funded scribed is quite expensive and you any issues or a decrease in the by grants, etc. I think that the future know, I think the different between functioning of their extremities. of VCA is going to have to depend a hand transplant and other trans- They could always go back into on broadening the available fund- plant patients is that this is going to outpatient Occupational Therapy ing sources and hopefully the go on for year and as you describe, for more intense therapy as needed. inclusion of private payer insurance it starts out into full time jobs. So, I Alex: In our experience, we have companies as a source of funding. would expect that the costs of the found that adherence to the pre- Our experience is that the cost of therapy portion would be much scribed therapy regimen is critical transplantation is not as high as higher than say on a kidney trans- to acceptable outcomes. Equally as many people had originally plant. important is the patient’s engage- thought. The immuno-suppression Kim: Yes, I would say so. I person- ment in therapy. Can you speak a that we are using on many of these ally haven’t calculated the full cost little bit more to this? patients, provided that it doesn’t get too complicated, is obviously no of it. However, Louisville did do a Kim: Yes. We had patients who presentation at the annual meeting Hand were compliant with their atten- more expensive than that which many kidney, heart, and lung of the American Society for Hand Surgery dance. However, they would be Therapists last year where they did very drowsy or sick from their transplant patients are already on. Quarterly

And the need for therapy is finite. a total cost breakdown. It becomes ○○○ medical issues and didn’t engage quite expensive. In addition to the in therapy as much as we would So, I think the key for us moving Fall forward is to show outcomes that therapists that you have to pay to have liked. They would take a lot of work with these patients one-on- 2012 breaks. We had other patients were are sufficient for private payers to agree to get involved with funding. one, there is also the cost of the distracted by their family members, splints, the adaptive equipment, cell phones, texting, conversing I think that is one of the key chal- lenges for those of us involved: to compression gloves, and a variety of with others in the clinic, etc. We other things that the patient may 16 have found that those who were not be able to measure our outcomes so that insurance companies can see need per their own specific case. So, as engaged as the patient who was it does get to be very expensive. very focused, worked extremely what our outcomes are and can see hard, and limited the amount of the patients that are benefitting interruptions in occupational from this effort. (continued on next page) ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ transplantation. You start to see just ○○○○○○○○○○○○○○○○○○○○○○○ Simon: So, I think it is very impor- Hand Table how expensive it can be to not have tant that we don’t standardize all (continued from previous page) a transplant if the alternative is a the protocols so much as to pre- functional transplantation. clude further innovation. However, Alex: Ben, if the insurance compa- Alex: So, it sounds like we need to I think it is very important for all of nies decide that hand transplanta- have uniformly collected national the different centers to share their tion is something they are not going outcome data to present to the data on the techniques that they are to fund in the future, where does insurance companies to really make using, the protocols that they are that leave us? Does it limit us to 1 a viable proposal as to why this is a using, the therapy that is being or 2 national centers of excellence justifiable cost for the insurance performed on these patients, and or is this something that is sustain- companies. obviously the outcomes. The last able within each individual trans- thing we would want to do is plant institution? Alex: Ben, is there a role for national reinvent the wheel each time and regulation of hand transplantation? Ben: I think it would severely limit we want to maximize any benefits how many centers could afford to Ben: I think we are going to get that are coming from new advance- there. As the number of centers do transplantation, and I think the ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ments. So, to that end, I think it is only other alternative is to get the increases, zones will overlap and I very important that we all contrib- funding from the military. I just ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ think just like the solid organ ute data to the pools such as The ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ can’t see, without eventually having transplantation programs, you International Registry on Hand and support from insurance companies really need to have a coordinated Composite Tissue Transplantation. how this could be a self sustaining program to identify donors and Of course, there are certain things model for institutions to try to come have a formal wait list and criteria that I think are very important to up with other sources of funding so that it doesn’t become a free for standardize. I think it is important aside from insurance and govern- all. Right now, with a very few to standardize many of the instru- ment. Certainly if you had a couple centers doing it and doing it ments that we use for outcome of national centers of excellence and sporadically, I think it is the time to measurements. We use many had plenty of resources focused on really think about setting some- outcome measurements because we those two or three areas, it would thing up like that before we get into don’t really have an ideal one and be an easier task to sustain. To have a situation where many centers are we don’t necessarily know which is a dozen different centers around doing it and then running into the most sensitive for the informa- the country all trying to get funding conflicts with each other. tion we want. At Brigham and to do one or two transplants a year I Gerald: I would agree. I think with Women’s Hospital we use the SF-36, don’t think is a workable model. the increasing numbers of trans- EQ5D, the DASH, and the Hand Alex: Simon or Gerald? What are plants that we are going to see over Transplant Score System, just to your thoughts on this? the next couple of years, it is critical name a few. I think we need to that we really get some regulation develop more specific and vali- Simon: I very much agree that and oversight. We also should think dated measures and we need to insurance companies are an essen- about how to best utilize the develop measures that are more tial part in the long-term manage- existing resources and systems that targeted towards hand transplanta- ment of this kind of funding. I think have been created very successfully tion and functional outcomes of even the Department of Defense for solid organ transplantation. hand transplantation. The goal of has an exhaustible supply of Also as the numbers increase, there transplantation is to help patients funding for this kind of thing. will be a need to be able to ex- Hand Ultimately we need to have enough (continued on next page) change a graft across the country. I patients and data to show the Surgery think to have multiple centers work

realistic results and the determi- Quarterly together, to have a shared and ○○○ nants of these results to determine nationwide waitlist for all these ...it sounds like we that it is worth funding. Fall types of transplants, to really need to have uniformly We have to remember that there are increase the chances of finding a collected national 2012 some very expensive sides to perfectly matching donor for every patients who are using prostheses recipient will become increasingly outcome data to and using around-the-clock nurse important. present to the insur- aides and the like. This flipside for Alex: Simon, assuming the indi- 17 patients who do not receive hand ance companies to vidual transplant centers personal- transplantations and require high- ize their immunomodulatory really make a viable cost ongoing care, is important to protocols, what aspects of trans- consider. I think that we often proposal.... plantation do you think can be forget that when look at the cost of standardized? ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ reviewed and presented, are we ○○○○○○○○○○○○○○○○○○○○○○○ barked on those procedures in the Hand Table going to find that hand transplants late 90s. Also, patient and graft (continued from previous page) are functionally superior to prosthe- survival rates are the highest of ses in all clinical situations, or is any type of transplant ever per- become integrated again and who there going to be a patient who just formed and in compliant patients are satisfied with their outcomes, does better with a prosthesis? are close to 100%. So, I think we and our measures need to reflect Simon: I think there are always were able to achieve a favorable this. Even if somebody has a great going to be patients who do better risk-benefit balance for this life objective outcome, if they don’t with one or the other option. This is changing procedures to those have personal satisfaction with the always going to be very patient- patients with amputations and surgery, we have seen the disas- specific. I think this is why we owe it devastating tissue defects. In trous results that can come from to our patients to have a really good addition, when we look at the that. So, to summarize, I think understanding of the options international registry data regard- obviously we don’t want to stan- available. This doesn’t just mean ing patient satisfaction, more than dardize everything, but standardiz- having a good understanding of 80% of all the transplant recipients ing our outcome measures is very what outcomes we are seeing in our ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ state that the transplant resulted in important. a great improvement and excellent

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ hand transplantations, but that also ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Gerald: I think that is a great point what prostheses are available out quality of life. and also ties into our prior discus- there and understanding what the Kim: I agree with Gerald with sion about funding. If we don’t advances are in the prosthetic world regards to the subjective reports have the data from standardized and what outcomes can be expected from the patients. Things we take outcome measures available to from prostheses. We owe it to those for granted, but they are now able justify to the government or the patients to be able to give them a full to do, thrills them. A young insurance companies that the range of options in the same way as mother stated early in her Occu- benefits of the surgery from a we do in other areas of surgery. So, pational Therapy that one of the patient’s perspective and from the do I think that one solution fits things she valued was to be able to healthcare dollars perspective every patient? Absolutely not. I have her hand to shake the for- justifies such an endeavor then we think there are certainly patients mula in her baby’s bottle without are in a very difficult position to that are poor candidates for trans- needing someone else to do it for argue for funding and coverage of plantation and therefore they fall by her. Another patient was very the costs of this type of surgery. default into a prosthetic side of happy that he was able to hold and Alex: Simon, when all of the data is things. Similarly, there are patients feel his girlfriend’s hand. A bilat- who do very poorly with prostheses eral recipient wanted to be able to because of levels of amputation, etc, simply brush his teeth and per- who certainly may do better with form toileting care without assis- transplantation. And there is tance. It is the simple humane everyone in between these extremes. things we take for granted that But, as physicians, really having a they miss so much. It means a lot good understanding of all the to them. They get these hand options is the key to informed transplants, and they get sensory consent on this issue. return, and are using their hands Alex: In 2012, do we have enough functionally every day. It’s not just Hand understanding of the outcomes of the objective data that we can use, hand transplantation to give our but the self reports from previous Surgery patients. They can talk to potential patients adequate information to Quarterly

make an informed decision regard- recipients to educate and advise ○○○ These are things that them as well. ing whether a transplant would Fall really enhance their lives? Simon: Kim, I totally agree with are very hard for us to 2012 measure, but function- Gerald: Well, I think that if we look you. There are so many of these at the world experience and all the things that are very hard to ally and in terms of outcome data available so far that measure. I had a patient the other quality of life and the answer is going to be clearly a day who said he finds it so much 18 patient satisfaction, “yes”. I think the immunological as easier when we goes to bed well as the functional outcomes that because he can pull the covers up these are absolutely we have seen by far exceeded over his neck and he doesn’t have critical. probably all of our initial expecta- to have someone put the covers to tions that we had when we em- - Simon Talbot, MD (continued on next page) ○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ Gerald: I agree that this is a diffi- ○○○○○○○○○○○○○○○○○○○○○○○ Hand Table cult question, but I think that this is (continued from previous page) also probably one of the most important questions that we have to where he wants them. He can swim ask. What we have learned in again and do things that he couldn’t clinical organ transplantation is that easily do before. These are things chronic rejection remains the main that are very hard for us to mea- reason for long-term graft loss. sure, but functionally and in terms However, if similar concerns are of quality of life and patient satis- warranted for hand transplantation faction, these are absolutely critical. still needs to be determined. Thus They are hard to measure, but they far only a few patients have a are very important. follow up beyond the 10-year mark This underscores the Ben: I agree with the point. I am and the incidence of chronic looking at the other slide where we rejection in hand transplantation as importance of close talked about informed consent. I compared to solid organ transplan- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ long-term surveillance think as with any complex opera- tation seems to be exceedingly low. tion, it is very hard to communicate ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ There is only one report in the and standardized fol- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ enough information to truly get world series of upper extremity low-up protocols in informed consent. I think once we transplantation of graft loss in a hand transplantation... have a population of patients who patient compliant with immuno- have gone through this and are suppression that showed vascular willing to speak to the prospective lesions such as intima - Gerald Brandacher, MD patients about the entire experi- hyperproliferation and luminal ence, we would be farther along the occlusion that are reminiscent of road to be able to get truly in- chronic rejection in solid organ two patients. Of concern, in four of formed consent. My impression is transplantation. However, in their patients standard techniques that many of the patients think that experimental rat hind limb trans- used for surveillance of rejection they are going to get the hand plantation models changes such as (protocol skin biopsies, DSA and transplant and everything is going intimal hyperproliferation and conventional vascular imaging to be back to normal, except they luminal narrowing/occlusion modalities) were obviously inad- have to take a few pills a day. That consistent with chronic rejection or equate for detecting early poten- is basically the bottom line for allograft vasculopathy have been tially reversible stages of allograft many of these patients. The other shown after repeated episodes of vasculopathy. stuff that you tell them about the acute skin rejection and frequent This underscores the importance of extent of the therapy and the lapses in maintenance immunosup- close long-term surveillance and complications and the risks and all pression. So, I think it would be standardized follow-up protocols in that stuff may just go in one ear and naive to believe that there is no hand transplantation in particular out the other. This is true for many such thing as chronic rejection in with more and more emerging of the other operations that we do VCA, but I think from what we experimental immunosuppression like breast reconstruction for have seen, it might be that the minimization and tolerance induc- example. I think even more so in incidents is significantly lower as in ing protocols. hand transplantation, there is an solid organ transplants at this Hand point, and it might be that we have Alex: Thank you all very much. On impression on the part of the Surgery patient that once this is over, I am to simply also learn that the mani- behalf of the AAHS, I just want to

going to be back to normal. As we festations might be very different as thank all of you for participating in Quarterly ○○○ know, it is not entirely the case. what we have seen in solid organ the call tonight. Hopefully we were able to better educate our readers Fall Alex: Those are all excellent points. transplantation. on the current state of this exciting Gerald, I am going to ask you a Most recently Christina Kaufman 2012 field. I know I definitely enjoyed difficult question, and that is on the from the University of Louisville this conversation. Again, thank you topic of chronic rejection. Do you reported some level of all for taking some time out tonight feel that chronic rejection exists in vasculopathy in all six of their hand to help to educate the readers of the VCA as we seen in solid organ transplant recipients with aggres- 19 Hand Surgery Quarterly on State of transplantation? If so, are hand sive and severe intimal hyperplasia Hand Transplantation in 2012. transplants only temporary? observed early post-transplant in

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Hand Surgery

Quarterly ○○○ Fall 2012

20

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ LEADERSHIP PROFILE: David Ring, MD

Dr. David Ring is the Program worked out in the end. Cinta ended he arrived at the Massachusetts Chair for the AASH Annual Meet- up in biotech consulting. General Hospital as an intern in ing in Naples, Florida. His mentor David had no idea that school 1993 hungry to do more research, and colleague, Dr. Jesse B. Jupiter, is was preparation for employment. the only attending he ever saw on the current President of the ASSH. Late to prepare for application to the ward early in the morning was David has been a member of the graduate school and medical Jesse Jupiter. After mustering up AAHS since 2010. school, he only had offers from a the courage to ask if he could do David was born, raised, and few places there was no way he some hand research, Dr. Jupiter schooled in San Diego, California. could afford. While preparing for a assigned him a small case series of He graduated from public high year of lab work and a better osteogenesis imperfect patients school in University City. He application to medical school the having Ilizarov tibial deformity started playing drums in ninth following year, a meeting with his correction. The paper got into JBJS- grade, but his neighbors told him to college Provost (Tom Bond I’m ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ A and Dr. Jupiter has been fueling David ever since. cut it out. He sulked for a few ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ forever in your debt) resulted in a ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ months and feared the guitar (only phone call, an interview, and Cinta and David planned to for gods like Eddie Van Halen) and acceptance at U.C.S.D. Medical have a child during the transition then took up the bass guitar. After School. from San Diego to Boston and buying the neighbor’s daughter’s When David arrived at medical surprisingly the plan worked. unused guitar, starting to play in a school, he figured he was the Their son Clinton, 18, was born protest punk band in high school, dumbest of the bunch, and he was during David’s intern year, made it and buying a set of drums when the probably right. But he loved the through Boston Latin High School band needed a drummer, he could healing arts and his enthusiasm led and is headed to UT Austin. fit in wherever needed—at least for to hard work and achievement. In Having travelled the world and the simple stuff. The closest he got the early days the idea was to learn inherited David’s love of music, he’s to stardom was drumming for a about infectious diseases and try to ready to spread his wings. David’s band named “All of Us” which got have an impact in the underdevel- Daughter, Laila, 13, also examed radio time in San Diego. oped countries that he and Cinta into Boston Latin High School and He couldn’t decide what not to were visiting on their school breaks. is just beginning to discover her study at the University of Califor- David’s first clinical rotation in interests, but is a natural talent on nia at San Diego so he switched medical school was neurosurgery. piano and guitar. from a Physics/Math—Computer He was the only one on the service David completed Dr. Jupiter’s Science double major to Physics that could take every other night fellowship and stayed on staff at and Biochemistry and Cell Biology call and round every day starting at MGH; met a psychologist-re- for double the B.S. He minored in 4:30am and not drink coffee. He searcher in 2000 and finally began Philosophy (which explains a lot). was heavily recruited to neurosur- to understand the human illness His wife, Cinta Burgos, was the gery. But the orthopaedic surgeons experience; and started the Dutch only woman in his freshman honors were having a lot more fun. And a fueled science factory in 2003. physics class. David was the only lot more impact. An open tibia Since the U.S. doesn’t have higher fracture was once a death sentence. degrees for clinical research he one that didn’t hit on her, but it Hand Now patients get to complain about defended a PhD in Amsterdam the their knee pain after nailing. same day his first Dutch PhD Surgery David’s love of research started student graduated, becoming the Quarterly

When he arrived at the ○○○ late in his third year when he first person to be awarded and then Massachusetts Gen- started a project on pediatric sponsor a PhD on the same day in Fall eral Hospital as an discitis with Dr. Dennis Wenger, Amsterdam. Since then it’s been 2012 lots of research, writing, and intern in 1993 hungry and learned to juggle multiple projects with Dr. Alex Vacarro (Dr. editing, in addition to a busy and to do more research, Steve Garfin’s fellow at the time rewarding clinical practice. the only attending he and now a Spine superstar at The music stopped in the third 21 Jefferson). One of the deans in year of medical school when life ever saw on the ward David’s medical school said, “You became too busy to make gigs. It early in the morning have to write a book to get into restarted again in 2001 when the was Jesse Jupiter. Harvard”. So he did. Well a book Harvard Orthopaedic Residency chapter. And a few papers. When (continued on next page)

○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○ Attention: Leadership Profile: Ring (continued from previous page) Budding Dupuytren had a drummer, guitarist, and and a fridge full of beer in the keyboard/vocalist all in one resi- dressing room. Researchers dent year and the band Rod the Having presented at several Long Bone was formed. A second AAHS meetings in the early 2000’s, The Dupuytren Foundation generation of residents, most of David’s friend Dr. Kevin Chung (nonprofit, no commercial ties) who ended up in the Boston area drew him back into the Association will award two $10,000 research keeps Rod alive to this day. David’s for the 2010 meeting. In addition to grants this year for work son, Clint, filled in on bass this year, being this year’s program chair, designed to advance under- the first time they’ve played David is the AAHS representative standing and/or treatment of together in a band—and hopefully to the Board of Specialty Societies Dupuytren’s Disease. not the last. Research Committee and was One grant will be awarded for Mark Baratz recruited Dr. Ring recently elected Vice Chair of that basic science research and one to help with the opening ceremo- committee. David loves the discus- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ grant for clinical research. nies at the ASSH meeting in San ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ sion and camaraderie that charac- Guidelines and application ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Antonio in 2007 and The Sagittal terize the AAHS meetings and information are available at Band was born. This led to benefit trying to build and inclusive and http://Dupuytrens.org/ gigs that are as close to being a rock interactive meeting for Naples. dfgrants.htm star as David will ever be: Hard Hope to see you there! Applications must be submitted Rock Chicago with a catered dinner via email prior to 12/12/2012 for consideration.

2012-2013 Board of Directors

PRESIDENT PAST PRESIDENT JUNIOR DIRECTOR AT LARGE Jesse B. Jupiter, M.D. Steven McCabe, M.D. Jeffrey B. Friedrich, M.D. Massachusetts General Hospital University of Louisville University of Washington Boston, Massachusetts Louisville, Kentucky Seattle, Washington

PENULTIMATE PAST PRESIDENT PRESIDENT-ELECT JUNIOR DIRECTOR AT LARGE A. Lee Osterman, M.D., FACS Donald H. Lalonde, M.D. Jeffrey Greenberg, M.D. Philadelphia Hand Center Dalhousie University King of Prussia, Pennsylvania Indiana Hand to Shoulder Center Saint John, New Brunswick Indianapolis, Indiana HISTORIAN VICE PRESIDENT Scott Steinmann, M.D. SENIOR AFFILIATE Mark E. Baratz, M.D. Mayo Clinic DIRECTOR AT LARGE Pittsburgh, Pennsylvania Rochester, Minnesota Sharon Andruskiwec, PT, CHT Hand Orthopaedic Specialty Group, P.C. Surgery PARLIAMENTARIAN SECRETARY Quarterly

Brian D. Adams, M.D. Julie E. Adams, M.D. PAST SENIOR ○○○ Mayo Clinic University of Iowa Hospital AFFILIATE DIRECTOR Fall Minneapolis, Minnesota Iowa City, Iowa Georgette A .Fogg, OTR/L CHT 2012 Keystone Rehabilitation SENIOR DIRECTOR AT LARGE TREASURER Randip R. Bindra, M.D., FRCS Sewickley, Pennsylvania Peter Murray, M.D. Loyola University Medical Center Mayo Clinic Maywood, Illinois JUNIOR AFFILIATE 22 Jacksonville, Florida DIRECTOR AT LARGE SENIOR DIRECTOR AT LARGE Joy MacDermid, BScPT, PhD William C. Pederson, M.D. McMaster University The Hand Center of San Antonio London, Ontario San Antonio, Texas

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Hand Surgery

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