27th Annual Smith Day; April 29, 2016
3rd Annual Jesse B. Jupiter International Hand Forum; April 30 – May 1, 2016
Royal Sonesta Hotel, Cambridge
Hosted by: Hand & Arm Center, Massachusetts General Hospital, Boston, MA
Course Director: David Ring, MD, PhD & Kyle R. Eberlin, MD
Honored Sage: Jesse B. Jupiter, MD
27th Annual Richard J. Smith Day Orator: Joseph Upton, III, MD
3nd Annual Jesse B. Jupiter International Hand Forum Orator: Milan Stevanovic, MD
Program and Highlights:
Reported by Suzanne Wilkens, MD,PhD student, The Netherlands
Friday, April 29, 2016: Smith Day
A variety of talks were planned for Smith Day, from surgical techniques to the psychosocial aspects of hand and upper extremity conditions. These are a few random thoughts based off comments made by speakers, moderators and my own personal observations and musings throughout the day.
With a comprehensive breakfast and coffee to start with, all heads were turned to the front with high expectations. During the 43 talks, 5 minutes per presenter, Dr. Mudgal luckily was not forced to open the trap door underneath the presenters to move on to the next one !! There was absolutely no chance to doze off! The pointer was our biggest friend today and kept Dr. Mudgal in great physical condition, just like a few jumping jacks in between the talks.
Special thanks to orator Dr. Joseph Upton, III from Boston and other visiting Drs: Morrone from Argentina, Lin and Qui from China. In addition, a warm welcome to Dr. Ring, who joined us from Austin, Texas and was as enthusiastic with the wandering microphone as ever, overwhelmed by it all so much that he forgot part of his ‘script’.
The discussions led to flapping ears, amazing new insights and things to learn from. A brief overview of some of the interesting topics, but nowhere near covering all topics: A very intriguing case of a hand allotransplantation caught our attention, accompanied by a personal story. These presentations inspire us as young researchers. Unbelievable that as much as 95% of the world’s opioids are prescribed in the US, while other countries prescribe only NSAID’s or no pain medication: ‘they did well but might have been traumatized,’ commented one moderator in regards to femur fracture fixation in India.
Presenting as an ‘avatar’, Dr. Eberlin represented Dr. Winograd in the ongoing discussions and reminded us several times to please not forget to visit and thank the sponsors of the event. Our after lunch session turned into some time to relax by watching a 60 seconds mindfulness video exercise with our “most talented and handsome” moderator Dr. Lee, after which we had to think of our exit strategy from suboptimal patient interactions!
Dr. Jupiter in paraphrasing Dr. Mankin, talked about ‘our finest flower’ as a memory of Dr. Smith, we must remember that it is important that we learned and enjoyed doing it.
Dr. Joseph Upton shared some fascinating ‘one time only’ microsurgical cases with all of us. A great conclusion of the day from bloodsucking leeches to a preserved leg kept in his locker, just in case the patient would live after a multi trauma; play dumb like a fox and live up to your curiosity, imagination and persistence….great advice from Dr. Upton !!
Time for drinks and more profound discussions regarding all the inspiring talks of today. More to follow tomorrow at the inaugural International Jesse Jupiter Hand Forum, hope to see you all there!
Saturday, April 30, 2016– Day 1
3rd Annual Jesse B. Jupiter International Hand Forum
This first day of the Inaugural Jesse Jupiter International Forum – ‘casual Saturday’ brought a bunch of great hand surgeons together. Short talks with several patient cases were presented and since it is a forum, exchange of discussion was the main goal. I felt privileged to be part of this amazing forum.
We started the day off with soft tissue defects in the hand and how to best close these defects with talks by Drs. Jason Ko, Amir Taghinia, Alex Spiess, Matt Iorio, Allen Bishop, Kyle Eberlin, and Jon Winograd. Secondary intention healing, use of Integra, vaccum assisted closure therapy, skin grafts and all kinds of different flaps passed during the talks and the discussions. Everyone shared their thoughts without the actual need of a moderator. Patient cases from personal experiences were used to create discussion on the different approaches and for us young researches, provided a clear overview on the topics.
A lot of comments were made worthwhile to remember. Here are some examples that stuck with me. A new ratio was introduced by one of the hand surgeons who has treated patients with multiple tattoos – the T (teeth) / T (tattoo) ratio – which defines an unreliable patient with a score of less than 1. We also learned that we better not hold a bottle rocket bomb in our hand the upcoming 4th of July and most importantly that every patient is different and needs an individual approach.
Dr. Milan Stevanovic shared his thoughts on upper extremity reconstruction related to soft tissue and long bone defects. Ending his talk with excellent words regarding Dr. Jesse Jupiter paraphrasing Ben Franklin: ‘If you will not be forgotten when you are dead and rotten, either write things worth doing or do things worth writing’ – Jesse meets both criteria !!
The working lunch resembled an actual Dutch lunch as we know it, including ‘build your own sandwich’, which for some fellows was quite an experience. Dr. Jesse Jupiter talked about mangled extremities and the question on whether to salvage or amputate after sustaining such an injury. He introduced us to a patient from Maine whose hand was salvaged and was left with two fingers and his thumb….could that be called a ‘lobster claw’ ?
After enjoying a few sunbeams, Dr. Chai Mudgal took us through the pearls in his provocative talk on un-united scaphoid fractures. Followed by Dr. Allen Bishop on pedicle and free bone flaps and even more opportunities to discuss several patient cases.
Next were the talks on non-union, with first of all, Dr. David Ring who raised the question on no graft or autogeneous cancellous graft for humeral fractures. Dr. Jason Ko talked about free vascularized bone and paraphrased Dr. Gregory Dumanian given the thought of options: be aggressive… ‘You must attack big problems with overwhelming force’. We also learned how to get your patient to follow up with you; just keep the external fixator in place.
We ended the day with the Third Annual Jesse B. Jupiter Lecture on functional muscle transfer for upper extremity reconstruction by Dr. Milan Stevanovic. A variety of free functional muscle transfers were explained in his presentation and immediately showed us how incredibly successful their outcomes can be by showing us truly inspiring videos of amazing patient’s outcomes. We were reminded that our fingers are golden and most of all; that an actual great teacher inspires !!
As a young researcher the more I learned about all these exciting and interesting topics, the more I realized there’s a lot to learn. It was amazing to be part of all this wisdom of so many great accomplished hand surgeons. Being here definitely encourages me even more to pursue a career in hand surgery, and certainly looks promising for tomorrow!
Saturday, May 1, 2016– Day 2
3rd Annual Jesse B. Jupiter International Hand Forum
It was time to enjoy the last few hours on this second day of the 3rd Jesse Jupiter International Forum. After a short review of prior day’s discussion by Dr. David Ring, our focus shifted towards non-traumatic aspects of hand and upper extremity surgery and nerve injuries.
An introduction regarding carpal and cubital tunnel syndrome was made by Dr. David Ring, who triggered all surgeons to think about recurrent versus persistent symptoms after release.
This still proves to be difficult and the comment: ‘No surgeon leaves the room with the thought that he has just performed an incomplete release’, underlines the thought of many surgeons. One amusing comment on persisting pain stuck with me: surgeon to patient: “if it stops ringing, you know the pain is gone, since the patient referred to carpal tunnel as ‘Cow bell tunnel’”.
The foundation was laid by Dr. Bauback Safa for a more detailed talk on the decision for revision surgery in compressive neuropathy. With reference to revision cubital tunnel surgery and the merits and demerits of various operations, Dr. Mudgal pointed out that it’s important to not shoot the messenger (the operation), without looking at the message (the state of the ulnar nerve) – in other words, before deciding the treatment, what does the nerve itself look like on the electrical study and on clinical exam?
A hot topic at the moment – shared decision making – led to further increase of the discussion. Comments like “health is getting from ‘how things seem’ to ‘how things are’”, “treat the human, not the disease”, and “you’re the doctor, doctor, tell me what to do”, made us realize this all depends on what kind of patient sits across from you. No patient is the same, a scripted conversation can be good, but sometimes you can’t get through. An analysis on data found on Google by an educated patient could drag you off of your feet for example, but the most important thing is to not debate with the patient, try to emphasize and validate what the patient says and build on this with further options, and remember to think of your exit strategy… great advice!!
Dr. David Ring shared a video with us on the carbonaro effect; in this video a piece of wood, sand and kale were magically turned into a delicious cannoli. This demonstrates how we use our system 1 or automatic thinking and our system 2 or analytical thinking.
The subsequent talks on nerve injuries; the timing of surgery by Dr. Jon Winograd and immobilization after nerve repair by Dr. Alex Spiess, continued the conversation on this topic.
The day was concluded by talks on nerve reconstruction. Dr. Bauback Safa presented several cases of patients with nerve gaps and shared his thoughts on options for graft and conduit. We learned to think twice before we decide to take the slide at Slide SF, as you could unintentionally amputate your small finger. He was followed by Dr. Allen Bishop, who addressed nerve transfers and showed us some really great outcomes. Last, but certainly not least, Dr. Chai Mudgal ended the forum with his talk on tendon transfer. He pointed out that is is okay to think big, but it is already amazing to be able to help a patient regain the ability to do what he likes best, for example play golf again.
I can speak on behalf of all researchers who attended the last couple of days, that we felt privileged attending this year’s Jesse Jupiter International Forum and experiencing the interesting exchanges of discussion. Great speakers who really inspired us, thank you!