And as we get the program back underway, I want to invite up Etan Melamed to tell us a little bit about the SSH's traveling fellowships. Thank you. Thank you, Steve. My name is Etan Melamed. I work, I'm in my seventh year of practice now. And I work in a city hospital, public hospital. So for those of you who are familiar, that's like going on a mission trip every day. So I'm going to talk to you about probably the most amazing experience I had as a physician, as a person this year, which is the International Traveling Fellowship by the SSH. And so why should someone consider going away for three months to a country like India or China during a pandemic? And I think you would do if you had an unsatisfied need. And it's not just the need to survive. We're talking about need to really be capable of becoming everything you can become and be a more versatile provider, more versatile surgeon for your patients. And you as fellows, I think you're in the best time of your career to start planning such a trip. And as you know, hand surgery is so diverse. You heard that the entire day. And that's an excellent educational day that shows you the breadth of hand surgery and how much it requires expertise in so different anatomic locations. And it's not just knowledge, it's technical skills. And some of you can teach yourself, but most of us need to follow some form, some education. So if you choose to take care of complex hand, brachial plexus in adults and children and congenital hand, acquisition of those skills to get there is really tough if you only train in the U.S. because the opportunities are fewer. And this is where the ACSH Traveling Fellowship really comes in and bolsters your skill. So it's a structured three-month fellowship, either in India or in China. It was started by Dr. Neil Jones for UCLA a few years ago. And it really exposes you to intense pathologies that you don't often see in the U.S. And if you do, the numbers and the frequency is not as much. And I will show you slides. So you join as a formal fellow, which is nice, because you usually assist as a first assistant surgery. Some of the procedures, you will be the primary together with a resident. I was fortunate to match to the Ganga Hospital in Coimbatore, and it was really hard to say no to that opportunity, even in a COVID year, because the ACSH provides you with the funds, with the mentors, with a place to go, and they take care of you there. And there are more good news. So unlike any other traveling fellowships or visitorship, you're part of the team, and you're focusing on mangled extremities, both lower and upper, so something that comes more naturally to plastic surgeons among us, replantation, both the digital major replants, brachial plexus adults and kids, and pediatric hand surgery. You also interact with the hand fellows in that location, and they are eager to learn from you, because you're superbly educated, and they really want to learn from you about your experience. And they probably can teach you a lot, too, from their experience in India or China. So this is Coimbatore. It's a city in South India on the map here, and this is the home of Ganga Hospital where I traveled. It's a 600-bed specialty hospital, and they see trauma, orthopedics, and plastic combined. They have special expertise in reconstructive surgery and microsurgery. And one of the best things that you can do there is the local microcourse, and each of these hospitals have some type of microcourse, because it really can up your game, even if you're doing microsurgery regularly. These are the statistics for the first month I visited, and that's during COVID. So 21 free flaps, eight replants, and they have six free flaps trays that are ready to go at every given time, so that speaks volume about what you're going to be exposed to. And they have observers all around the year, so they have visitors from India itself, and they all take pictures. So here you can see the line for picture taking. That's a case of a bilobed groin flap, which is commonly practiced there. And here's a patient I saw. He had an injury for an industrial machine, because all the manufacturing in that part of the country. And the patient had a block on arrival, and here you can see the patient relatively comfortably positioned for x-rays, getting the consent, talking to the family, and also washing out some debris before he enters the operating room. And in this hospital, one incredible thing was that the ED is completely bypassed. It's only for registration. So instead of having resuscitated twice in the ED and the OR, they only get it once in the anteroom of the OR. So the block is given there. The patient is resuscitated. There's a senior anesthesiologist that does it, and there's a surgeon. And I recommend everyone to read this paper, because it will make you think about the things we do here compared to other places. So the experiment was positioned for x-rays, and here you can see that segmental radius and an ulnar fracture. Then they positioned that over a draining pan, and we washed it out really thoroughly before the patient gets into the OR. So in the same time, the scrub techs are preparing the room, and we wash out the gross contamination with sterilized tap water. They don't use saline. And this is pre-debridement. So we found a lot of devitalized muscles, segmental radius fracture. It was a large area of degloving. Both arteries were cut. The only structure that was in continuity was median nerve in this case. And this is just post-aggressive debridement with preservation of the median nerve. And one thing I learned at that trip was to debride much more aggressively. So since I came back, I probably debrided once or twice, not more than that usually. And that's a huge lesson. Then we moved to skeletal shortening and stabilization, which really dictates, gives you the platform for nerve work, tendon work, and anastomosis later. And in this regard, if you shorten the skeleton, that's a really powerful tool because the nerves can be brought end-to-end, the arteries and veins can be brought end-to-end most of the times. Whereas if you choose to do a graft, that may expose the patient to complications. And this can be done in the forearm, in the forearm shortening, and even a one-bone forearm. And that really pushes the envelope for extremity reconstruction in a patient where the limb would otherwise be amputated. So although this is not always looking great or necessarily has excellent function, it's better than an amputation, as you can see in this patient. So keep shortening, skeletal shortening in one-bone forearm in your armamentarium. That's a really powerful tool for reconstructive microsurgery. And this is what we attempted to do in our patient. That's a standard DC plate stainless steel, relatively straightforward. And then we moved to vascular repair. And in this particular case, we did radial to ulnar crossover anastomosis after it was really heavily shortened. And we did three veins. And we also took an artery that was intact and wasn't used, the radial artery, and interposed it to get some venous outflow to overcome a segmental defect in the veins. And we did the ulnar nerve end-to-end as well. And this is what we chose to do for stage one. That's local coverage with the remaining skin and leaving the other areas open. And in the mangle extremity, it's very useful because many times the skin will survive on perforators. So we try not to discard the skin on day one. And the portion that didn't survive, we went for a second debridement and skin grafting. And we still needed that flap to cover dorsally. Notice how much the arm is supinated with a one-bone forearm. This is a more useful position for people who live in India. But I guess in the Western country, mite pronation would be more useful. And we eventually acquired soft tissue reconstruction. This is a superiorly based pedicle parambilical flap, really a workhorse flap in the hospital and really something I took with me. And this is the final outcome, better than an amputation. And since you're an integral part of the team, you get to see those patients. You get to interact with them, connect with them in the clinic, and manage them post-operatively. But not everything is about medical skills. So there are other few things that we took from the trip. So they encouraged me as the visitor, as the fellow, to write my vision. So I asked, what is the vision? Is that a dream? So they said, no, no, really, you have to get into it. So it's finding a larger purpose than yourself. So I told them, well, I want to become the best hand surgeon in the world. And they said, no, no, that's not a vision. That's not about yourself. That's beyond yourself. So for example, solving all hand problems in your community of patients who don't have health insurance, for example, that's a vision. So that's a vision that's actually never ending. But I have great people on my team that can help me. And once you have a vision, you will find people that will help you go to that journey. And in that process, you will become great. But that's really a side effect of the vision. Another thing that I learned there, and I really brought to our program in Mount Sinai and in Elmhurst, is to expect your trainees and to expect from yourself to do more than what you're expected to do. So there are a lot of examples to that. And it can be simple things like taking the patient to the radiology, showing the tech how to position the patient properly, instead of just complaining about the x-rays that are bad quality. Or another example that we have is just calling the clinic supervisor when equipment fails, instead of reaching in the morning and improvising with our things. And finally, to be the person that people choose when they have a choice. And in India, believe it or not, it's a very competitive country. And they have a lot of providers there. And this is something they really take into heart. And the way to do that is really to emphasize quality. The only way to get there. So from incision to the well-molded splint. And they really drill it to the brain of their trainees. Doing the small things well really gets you a long way. Especially if you have a clinic without insured patients, like I do. I have 40% of my patients have no insurance. And they have a choice. Their choice is not to come and get treatment, which is not what we want. And I would leave with that. Strive for progress, not for perfection. It's really a prime opportunity to get progress in your career. Your host will be your lifelong friends. They will be your mentors. Today with WhatsApp, you can consult them for anything. They even fed me cake on my birthday, which was nice. I'm very, very grateful to that. So I would like to thank Dr. Raja Sepapati, Dr. Hari Vankatramani, and Dr. Jones for starting this program. This is my contact details, so if you want to get in touch. And I can answer any questions about the program. All right, moving on to the next item in the program, which is nightmare cases, lessons from early practice. So we have Dr. Rhea and Dr. Sears, come on down. All right, hello everyone, thanks for getting that started, Steve, awesome. So thanks to Paige and Steve for the opportunity to present and share some disasters with you all. But no, in reality it's really good to get used to normalizing when things don't go the way that you hope. So this is me doing that, it does require some vulnerability. But I love the previous quote that the previous speaker ended with, it's about the progress. So as you all will be thinking about your transition from trainee to new attending surgeon, this is often like how you feel as a senior resident. I'm just curious, how many in the room has worked with a first year attending? Wow, that's much higher than I would have thought. So it's very eye opening experience, if you probably all recall. So the resident usually tells that person like, hey, it's going to be great, no worries. And then this is usually how you're feeling during that time. Often losing sleep, it needs to be perfect, I'm not sure if it's going to be okay. So just a few reminders, as you are transitioning to independence, complications are a part of surgery. And one of my senior partners who also trained me said, if you don't have complications, you aren't operating enough. And I would just encourage you to make sure you go to clinic as a senior resident. We love being in the operating room, but going to clinic, particularly as you're transitioning to independence, is really where you're going to learn how to have those difficult conversations and deal with complications. And then when things don't go as well as you like, whether it's something small, you're just struggling in the OR to get the maneuver that you want, or a bigger thing like a complication, it's really important to reflect as an opportunity for improvement. And of course, don't be afraid to ask for help or advice. Not just people who are around you with peers and your partners, but rely and lean on your mentors and people who trained you, even if you aren't with them every day. So onto the topic of this talk, which is my nightmare cases, lessons from early in practice. I will share with you two cases that I had in my first year of practice. I'm now six years later, and they definitely still are cemented in my mind. The first patient was a loss of reduction of a distal radius fracture, which was a failure on my part. And then the second patient was really just helping me going through and helping a patient with a very difficult problem of severe multidigit ischemia and our long course together. Both of these patients were selected for my ABPS oral board examinations, so that helped to cement them in my mind, as well as prepare for this talk, because I had their cases laid out very nicely. And then, of course, we'll reflect on some valuable lessons that I learned for each patient. So the first patient, this is a 49-year-old woman who had a history of RA, who presented with a volarly displaced left distal radius fracture and ulnar styloid fracture after a fall. And she underwent attempted reduction, but this is unstable fracture pattern, so we planned that she would need an ORIF three days later, and you can probably see what my feel is going to be with not adequately supporting the ulnar column and lack of a full appreciation for the amount of comminution that was there, but you can see here 12 days later what she looked like, and you can see a little bit of loss of height there. And then this is her 26 days later, and clearly more loss of height and apparent problem here. So this is when I started to panic, and I, like the previous advice, got a CT scan. Didn't get a CT scan the first time, but bought some time to try to figure out what was happening with her fracture, and you can clearly see a lack of support of her ulnar column there and multiple fragments. And so at this point I'm feeling panicked and some shame. This was about probably two or three months into practice, and then so I sought opinions from my senior partner. Steve was one of them, and you can probably guess who said, they always talk about this at complication at national meetings, I've never seen it. So that made me feel better, and then I planned to take the patient to the OR for revision. I did get multiple differing opinions on what to do in terms of fixation and stabilization with the revision. And so ultimately we went back to the operating room, took off the volar plate, and then I distracted her out to length with the bridge plate, and then you can see some loss of her volar cortex and bone there, so I supported her subchondral bone and articular surface with cancellous allograft, and opted not to put the volar plate back on. And this is her three months after her plate removal, which was left in place for five months, a little bit longer than I typically would do given her history of RA and her medications. And you can see not perfect articular surface, but this is her motion overall pretty good, slightly decreased compared to the other side. And overall the patient had no pain, no limitations, and so she did relatively well, despite the appearance of her retocarpal degeneration. And so one lesson that I learned here amongst multiple is that whenever you have a patient with complications, and you particularly, I mean this lady was super nice and didn't want to avoid her, but sometimes you have people that are like, oh, I don't want to see them. You need to see them more often if they're having complications, because they need to have an understanding that, or make it very clear that you will see them through the bad situation and it shouldn't even be a question. And so see them more often. And clearly recognize fracture patterns that are at risk for a loss of reduction, which I did not appreciate here as much as I should have. And then when you're anticipating them, then you devise a plan to minimize risk of collapse. And then lastly ensure that critical structures, clearly here in this case the ulnar column, are well supported with fracture fixation. And don't hesitate to take more time than you need to on the first operation to say adjust your plate until it's absolutely perfect, because it's better obviously to take more time during that first operation than to have to go back for another operation. And so second patient, this is a 35-year-old woman with history of Crest syndrome, had diffuse left-hand digital ulcers, as you can see here, that progressed over the previous two months. And she was initially admitted to the inpatient medicine service for Flolan. And I think this hit me hard a little bit, because I was literally the exact same age as when I was treating her, and to see somebody go through something and have it imagined going through something similar yourself, which I couldn't, is a bit challenging. And so we obtained non-invasive vascular studies that showed absent digital pressures in all the digits of her hand, and subsequently got an arteriogram that showed occlusion of her ulnar artery, proximal, or distal rather, and then occlusion of her radial artery at the wrist as well, but reconstituted flow in her deep arch. And then you can see even further distally, really absent flow in her superficial arch and digital arteries. And so we had a long discussion with her about potential options, and ultimately recommended periarterial sympathectomies of her superficial arch, common digitals, and radial and ulnar arteries at the wrist, and to perform a radial artery bypass. And so at this time, she was very adamant about not touching her fingers, was not agreeing to any amputations or debridement. So we did those procedures to try to improve her flow. And this just shows here, proximally after laying the tourniquet down, her radial artery, and then further distally, her occlusion before it reconstitutes at her deep arch. And then this is the reverse vein graft into side, approximately here, and then end-to-end into the deep arch. And so this is her two weeks post-op. We thought, okay, we'll give her some time. Most likely she'll need some amputations, but she really didn't want to entertain the conversation about that. And so given the lack of infection, we said, okay, we'll just keep watching this, but if things progress in the wrong direction, we'll have to move toward debridement and potential amputations of some of her fingers. And so we just had a plan to recheck her every couple of weeks. And she did come back at the four-week mark, and then disappeared until four months post-op. And surprisingly, much better than I would have thought. And still at this point, we thought, okay, well, we recommend amputations of index and middle finger for this irreversible gangrene, and she still wanted to continue with dressings. And then finally, at about seven and a half months, she was playing with her nephew and hit her finger and had some exposed bone of her middle finger. And at this point, she really only wanted to excise clearly necrotic tissue and nothing more, not even to try to get full closure. And so I agreed to that, and just covered her exposed bone after excising the clearly necrotic tissue with Integra, and then just nibbled down her tuft of the middle finger that was exposed. And three weeks later, unfortunately, you can see, there's an arrow, she's starting to get some open wounds along her IP joints. And then we got some more non-invasive vascular studies that showed the bypass graft was patent, but some of the digital pressures were too low to obtain pressures, so that wasn't good. And then she disappeared again. And at this point, she called back and said, you know, over the last six weeks that things had been worse than when we met her, but she didn't really want to come back in because she knew what was going to happen. And so she was amenable at this point in angiogram to see if there was anything we could intervene upon and to come in. And so this is what she looked like at this point. Not good, obviously. Worse than when we started, and much worse than her post-op. So this is four months after the second operation. And then on that angio, there were really no targets for a bypass procedure. The previous bypass graft wasn't open on the angio. And so I discussed with her options, which was to do nothing, but that she may eventually lose her hand if it progressed further. Revision amputations, but I was really concerned about healing. And then really this was like a Hail Mary on my part. The only other option that I was comfortable with that could give her any chance of improvement was arterialization of the venous system. And she wanted to go with dressings some more. So we basically just let her do that. And you can see even from what it was before, five months later, progressed even further. And now at this time, she was ready to have something done. And you can see, unfortunately, this was her final result. So this is, although not an error on my part, but you can see this was obviously a nightmare case because this had lasted for, how much, 17 months from when I first met her. And what I really learned was that some patients have disease processes that you will not be able to fix for everyone. And you just have to accept that and help them through that course. And one really important thing that you all will come in contact with, especially dealing with hand trauma patients who are going through often very difficult situations, is that they have a loss of control in the bigger picture of what's happening to them. And therefore, I think it's really important to allow them to have some sense of control over their treatment when it's safe to do so. And this example was early on, I would have been more eager to do something surgically about how her fingers looked, debridement, amputations, and it actually turned out much better than I thought it would in that intervening period, but not in the end. And then also be available for patients when they're ready for your help, even when they don't want your help right away. So I'll just end again on complications are a part of surgery, remember that. Try to get as much sleep as you can at night. When things don't go as well as you'd like, just reflect on opportunity for improvement and don't be afraid to ask for help. Thank you. Thank you. All right, way to hang in there, guys. I was thinking I'm glad those were my cases because I would probably lose a lot of sleep over it. But I think we've all, here's a spoiler alert. You operate enough, you're gonna have complications. And I think the purpose of, I guess the objective of this case that I'm gonna present to you is I wish I had some good pearls to tell you about this case. But if anything, I just wanna tell you the side of the attending or the attending surgeon who, when these things happen, they may, I'm sure all of your attendings are really polished and very professional, and they may not show you all the anguish that they go through. But we're all friends here, so I'm just gonna share with you exactly what I was thinking throughout this case. This case was almost nine years ago when I was early on staff. I still, my heart races when I think about this case. And this will, it's imprinted in me. And I think everyone probably has those cases too. These complications, again, stay with you forever. But it's good. I'll tell you that at the take-home as a good cheery, cheery response. So this is a patient who had this soft tissue mass in his shoulder. It was confirmed to be a myxofibrosarcoma and had this new adjuvant radiation therapy. And just like most all of you that do any reconstructive surgery, your tumor guy says, hey, or gal, says, hey, I'm gonna shwack this out. Can you cover it? You're like, okay. Not quite knowing what you're gonna expect no matter how much you prepare for it. So this was really right in the deltoid area. You can see these imaging studies that show exactly where things are. And my tumor surgeon, Nicole, you know who I'm talking about. He completely undersold how much he was gonna take. So then he says, hey, here, cover it up. And luckily, you know, I was prepared for this because I've known him for a long time. And so I thought that in this situation for the patient, I thought, you know, I need a lot of muscle. I need to reconstruct his deltoid. Perfect opportunity to just use a pedicle functioning latissimus, right? That makes sense. So I was super prepared and did this, just pedicle flap. Everything looked great. Skin grafted it. I didn't tunnel anything. I always open up my skin bridge so I know that nothing's being compressed. I even took the circumflex scapular down just to give a much greater arc of rotation. So basically, in other words, just anticipating any complication, I thought I did this really well. And I was really happy because for this patient, I guess to me, if I, and I remember telling my wife this, if I don't cover this, there's no limb salvage. You know, you're kind of at the end of the road and that's a lot of stress that we carry with our patients. And so, you know, it's a lot on you. And, you know, I kept him in the hospital for a couple of days. We just Doppler it out, even for a pedicle flap, you know, everything sounded great. He went home. Came back in seven days and that's what it looked like. And he's like, hey, how's it look? I mean, not good. But, you know, I think at this point, I think I knew where this was going, but I convinced myself that everything was still okay. You know, I could still Doppler out at least that medial transverse branch. The lateral bench, I couldn't really detect, but I would, I even got like a 25 gauge needle. I poked it, it was bleeding. And I was like, you know, I think things are okay. You know, I'll see you back next week. And then two weeks later, it comes back and a portion of it still doesn't look good. But I, you know, I was like, I don't know what's going on with my dad. So I'm like I'll see you back next week and then it's it smells just completely nasty and I'm like look I gotta take it to the OR. So I cut all that off it was all dead and just got a lay of the land in here. I didn't know really what to make of it, but at least here I cleaned everything out, and I said, you know, I'm going to think about this and just slow play it, because I don't want, I mean, the next stage for salvage is going to be quite big, and so this is a lot of no one to ask, because at least in my program that no one else was doing reconstructive micros, so it's just me trying to figure this out, and it's very lonely. So then I, at that stage, I kind of doppled everything out just to make sure I had some potential options for doing whatever I was going to do. I had an arteriogram just to show the thoracochromial was there. I then scanned down to the arm, just having plan A, B, and C, and I thought I was pretty prepared, and we went with an ALT, and even though not functional now, I'm just in damage control. I just want to get this covered. There's a lot of text there, but bottom line, you know, I do an end-to-end into the thoracochromial, and I did a vein cleftation to the cephalic, and everything looked awesome, and I was like, oh, I think I saved it, you know, and this guy's now in the ICU for two days. Everything's going great, and I had that sigh of relief, but for anyone that does reconstructive micro or any type of flaps, you know you're probably on call for the next seven days anyhow, right? And so I was really relieved at this point, was super, super cautious with him, even had him in the ICU, and I just saw him after I left clinic, long day of clinic, and then at nine o'clock. So then it's in the middle of the night. I take them back. This is me It's a training center, but this is me all by myself and then by about Like midnight. I start looking at this ALT and and I'm just kind of going through like different checks to see like what could be wrong and I take down my anastomosis and You know the thoroughcrocomial it has some flow but not much I keep whittling it back till I'm now at the axillary artery I just don't know what else to do. And this is now I Don't know me like four o'clock. I have a full clinic ahead and I just am helpless so really without much other option I Really no one to bounce things off of I went to his leg and harvested a Saffron is graph. I think it was about 30 30 centimeters or so And this is a huge graph, nowhere else really to go. My clinic is running, you know, residents are And I still think about this, that moment. I literally cried. And I did. And I think that you guys, Steve's like, oh yeah, I know. It's, I felt so alone. And you're going to have this. You will have this. And I tell my fellows that every time you operate on someone, it's like you're launching a satellite into space. And in your career, you're going to have thousands of satellites that when one of those come crashing down, that's you, you're taking care of that. So I don't mean to make it sound like your career is just like always a lot of pins and needles. But it is, no one else understands. Like an ER doc, or an anesthesiologist, or a medicine, my wife's an internist, doesn't understand that these patients are your patients forever. Remember, I saw this guy months afterwards. He was disease free at the time. And he was so appreciative. And I don't think anyone, you know, realized that if, you know, we didn't go through this heroics to cover this, then he wouldn't have an arm. You know, and that's a lot to bear on you. And without getting into a whole talk on like wellness, and burnout, and things like that, you have to take care of yourselves. Because these complications will happen. So I just had some take home points with I think what may have happened. You know, pedicling ethereal zone of radiation, maybe not very good. You know, in my initial anastomosis when I thought that I just wanted to do something easy, end to end, like it was not very good flow to begin with. Like in flow, I probably shouldn't have accepted that. Just not burying your head in the sand in persistence. But probably more importantly, what I want to tell you is, there are going to be times that you're going to feel very lonely, it's true. But you have people like within your practice that you can lean on. And certainly in your fellowships, you have mentors that you can reach out to. And I did that many times. You will get stressed. Just rely on each other, and the best that you can, be prepared. And of all, I've had a ton of complications. I don't think I'm a bad surgeon, but I've had a lot. But those bad outcomes that I've had, I know they have benefited tenfold future patients. So I think you just have to realize that these things you learn from, and then it makes you a better surgeon to help many more people. So I just thought, you know, Paul Brand had this wonderful quote, basically saying that you develop this relationship with your patient, and you are their lifeline, right? And in creating that relationship with them and seeing outcomes like this, I know so many times I did a replant or whatnot, and then walking across the skywalk from the OR to my office like at two in the morning, just when no one else is around, just making that walk and just feeling so happy I could do that, crying a little bit, and things like that, that you may not see your attendings do that, but you will. Because you'll have those moments, too. All right. Thank you very much. Thank you. I feel like I can barely see over this podium. So don't worry, this is not going to be, you know, like you're joining your job and you have to get through this DEI click-through thing, pop quiz part of the day, if that makes sense. We're going to hopefully make this a little bit more exciting. And so we all know what diversity, equity, and inclusion are. We all go to, we all are in residency and fellowships, and this is trained throughout. And so what we're developing is essentially a task force. And I think of myself as the raccoon at the bottom for providing diversity. So this is Dr. Sterling Bunnell, the father of hand surgery. And he introduced this concept of bringing together several surgical specialties. You guys likely know this already, of taking care of all of the tissues of the hand and the upper extremity. And that essentially allows us to repair and reconstruct everything in a coordinated fashion, right? That's what you've heard all about today. And so, but what defines a hand surgeon, you know, we know this, right? You can be, you can either be an orthopedic surgeon, a plastic surgeon, or a general surgeon, and then you do another year of fellowship. And then besides becoming board certified in your specialty, you then get a certification in the subspecialty of surgery in the hand. But there is variability. So the starting point of who you are as a hand surgeon really depends on the amount of hand surgery that you've seen in your residency. And that's variable. And it's the same thing with your fellowship, right? You can be doing shoulder, you can be doing more hand-related things, you can be doing an orthopedic hand fellowship, you can be doing a plastic surgery hand fellowship, and that results in a variability in your level of comfort when it comes to taking care of complex problems. And so, don't take this offensively, but orthopedic surgeons can be less comfortable with microsurgery, and they're less likely to do that. That is, there definitely are many skilled orthopedic surgeons that do a ton of micro, and it's not to, not to take offense, but when you go out into the community, when you're out there seeing patients in the United States, that is the trend. And for plastic surgery, same thing with distal radius, where you're less likely to do that, even if you're hand surgery trained. And so we just saw another diagram, which is awesome, but no offense to neurosurgery, no offense to general surgery, but I think of it as plastic surgery, microsurgery, and orthopedic surgery, where plastic surgery can change the form and anatomy, can change the function. Plastic surgery is the change of form and the anatomy, and it uses cool gadgets like the microscope, and then orthopedics changes function and uses large tools to fix things. Just kidding. Uses hardware and complex fixation, and so we value this diversity in training. This is why I trained with my hand fellowship in my residency, doing additional training in pediatric hand. I wanted to be comfortable to take care of any problem, and so in that same light, we should value diversity in who is trained. And really, hand surgeons, just like other medical specialties, should reflect the population at the goal of recruiting the next generation, and that's why I'm excited to talk to you guys. And so we know that at the healthcare level, there's an underrepresentation of cultural, gender, and ethnic diversity in training and in leadership. We see that everywhere. And it's not this concept of things are diverse enough. We have a percentage, we met a quota. It really, I think, that diversity drives excellence, and that's a quote from Dr. Quinn Capers from UT Southwestern. And there are many benefits of diversity. There are papers written on this. For example, women physicians are more likely to follow evidence-based guidelines. African-American physicians are less likely to have a negative racial bias to other groups. Minority patients are more likely to follow recommendations of their physicians that share their background. I don't need to go, there's just, there's a lot of benefits that have been described, and so it's not the diversity of thought. And when we look at our populations, right, the United States, this is looking at the Bay Area, where I, you know, I'm from the Bay Area. You know, it's, this population is, you know, white, this breakdown at least, and it's only a few populations, right? You can go into really the nitty-gritty, but this is just showing white, Caucasian, Latino, Hispanic, Asian, African-American, and Native American, and you can see there's differences in the Bay Area, in those four graphs on the, four bars on the right side. It's a, we live in a different place here in the Bay Area, and just like that, across the United States, there's different populations. And so the AAMC has said this for a very long time, but there is this definition of underrepresented in medicine, and all that means is simple question of do your physicians reflect the patients that you're taking care of? And it's well established that if that increase in gender and ethnic diversity has been correlated to increasing accessibility to healthcare resources of underserved populations, right? The pandemic, right, has been a perfect example of our broken healthcare system, of how we had, we've had patients and people from underserved backgrounds and minority groups that have died at disproportionate levels. And so all this, the lack of diversity in regards to women and in regards to underrepresented in medicine continues in both orthopedics and plastic surgery. There's a paper from 2005 by Gordon Bay and Charles Day about ethnic and gender diversity in hand trainees. It seems, you know, this is about six years ago, but it's still very relevant, and this is looking at plastic surgery trainees. You can see there's an increase in Asian plastic surgery trainees. And you can see that the Hispanic population increased a little bit from like 4% to like 6%. And then the black and African American has been stagnant at about 3%. And this is reflected the same way in hand surgery trainees. And it almost mirrors it exactly. And the orthopedic one is the same. But it's not just a problem in hand surgery, right? This is a problem throughout other surgical specialties, right? There are just hard to get into. They're challenging residencies. But there are definitely gatekeepers to this. And looking at gender diversity, you can see in hand surgery, 19%, at least when this paper was written, I think this one was from three or four years ago. But it's 19% for hand surgery. It's a lot worse in orthopedic sports medicine. But it's a lot better in plastic surgery. It's about 28%. And I think that's gotten even better since. There are other specialists. This is Dr. Paris Butler, a plastic surgeon who's written extensively on the scarcity, specifically within plastic surgery, about this disparity. And so we know these are just papers out of our hand surgery literature showing that if you have limited health literacy, you're less likely to ask questions. And so what orthopedic surgeons, hand surgeons should do is take universal precautions and assume that a patient may not understand otherwise and things need to be explained on a more basic level. This is another paper by Dr. Ring looking at language barriers in Latino patients and their relation to upper extremity disabilities. And it's important consideration to take because we can be in a clinic, specifically in California, where most of our patients are Latino and you want to think about this so that you can provide the best care and have them not comply, but have them follow directions. And so we were just going to go through our stories just to provide some kind of background of who we are and what we're interested. And so I am Michael Galvez. I work at Valley Children's. It's in the middle of nowhere in Fresno, Central California. It's about three hours south. But it covers three hours north and then three hours south from there as well. So midway to Los Angeles. And this is my mentor, Dr. Amarjeet Dosanjh. He was a UCSF plastic surgery resident taking hand call. I was shadowing in the ER. And he took me under his wing. It was amazing. I had no idea what I was doing. I went to community college and was applying to medical school. And he helped me figure things out, think about the application process for medical school. I got rejected from Stanford initially. And he's like, why don't you just appeal? And I appealed because I've been doing research and I ended up getting in. And so this mentorship that I'm sure there's been talks about this today are so important because it makes you realize things that may otherwise not be possible. A little bit more about myself. I'm from the Bay Area. Both of my parents are from Peru, from Lima, Peru. And I did terrible in high school, but I got it together eventually. And so I'm working at Valley Children's. And I could have worked anywhere, in my opinion. I was on a trajectory to work in an academic environment just looking at my CV. But I wanted to take care of underserved patients. And I'm committed to this. And I'm very grateful that the state of California is actually going to pay off my loans to do this on top of my salary. And so what I've been doing is essentially expanding pediatric hand surgery care. They were doing some hand trauma, some congenital hand. And now I've expanded that to wrist trauma, peripheral nerve, microsurgery, with the goal of building a cerebral palsy program as well as a brachial plexus program. And so just to share a few cases, this is a girl with a myoplasia, which is a subtype of arthrogryposis. The shoulders are internally rotated. Their arms are in full extension typically. She's in a little bit of flexion here. Wrists are contracted down. And then she has a thumb and palm deformity. And so she actually, her lower extremities, her left side, she had no hip flexion. And the right side, she had some hip flexion. And so she's unable to elevate her shoulder, unable to flex her elbow, a little bit of flexion of the wrist. And so the only way she gets her hand to her mouth is by using her right knee and lifting her arm to get her hand into her mouth. And so she wasn't using her left hand. And so in combination with the pediatric occupational therapist, we decided her best interest would be to straighten her hand on the left side so she can actually use it. So this is just some intraoperative photos showing her wrist inflection and the technique that was utilized is called a carpal wedge osteotomy. It's a biplanar wedge. What's interesting about these patients is they have carpal coalitions. And so you're able to actually excise a piece of their carpus and correct the ulnar deviation and then the flexion deformity and put their wrist in a new position of flexion. You can see that there. It's like a triangular wedge in a biplanar fashion. And here are the x-rays showing the before and after with the pin fixation holding the carpus straight. And the other thing is she had this thumb and palm deformity, which is very common in these kids. And so I did an index, a stiletto flap, getting an index flap and putting into the web space and several other aspects, including tendon transfers. We don't need to get into the details. But this is her hand after the surgery. She was in flexion. Now she's in a neutral position, still maintaining a little bit of wrist motion. And so now she can hold her. This is when she was still recovering from her therapy. But she's holding a Barbie doll with that hand. So she's actually using it within her space. But you can see she's actually combing that Barbie doll with her foot. And so the other patient, just another case that I've done, is a five-year-old with a radial ulnar synostosis. So this kid sits in hyperpronation. So the hand just sits, also not in a position of function, just sitting out there. So when he grabs a cup, he holds it like this. And for him, it's bilateral. But we know that this is an unsolved problem. We can't recreate the radial capitellar joint. And so our best option is to reposition the hand in a position that's a little bit better. And so you can see the hand sitting out, wasn't using it. And so the technique, and these are the X-rays, showing the proximal radial ulnar synostosis. And so the technique is what I was trained at, is essentially incising the periosteum. This is a combination of plastics and orthopedic surgery, being very careful with that tissue, and then doing, taking out a wedge, a one-centimeter wedge of bone, morselizing it, shoving it back in, closing the periosteum at two separate levels in the radius and the ulna, and then rotating the hand. And you also do a fasciotomies, because you don't want to get compartment syndrome. And what's awesome about this case is there's no fixation. So kids are amazing as far as their ability to heal. And so this is just through casting. And so you can see the hyperpronation in a slight position of, sorry, hyperpronation, slight position of pronation. He now can put his hands on his lap. He can put his hands together. And more importantly, he can use an iPad. The other aspect is free flap surgery. So I'm a plastic surgeon as well. And so this is just working with the hospital. This hospital's been here for 60 years. They've never done a free flap before. How to start from the bottom, right? How to train the nurses in the ICU, the floor. I lived at the bedside. And for this particular case, it was for doing an MFC flap. So a patient who had a proximal pole avascular necrosis and needed structural bone graft. And so this is an enticide anastomosis. And before and after with the fixation, you can see the clips and then healed. And there's so much chronic pain in kids. And so it's awesome to be able to help them with that. And so to my knowledge, and please tell me and approach me if you know otherwise, but I'm the only full-time Latino, Latina pediatric hand surgeon in the United States. And there are 18 million Latino children in the United States. They make about 25% of all children. And so that shouldn't be the case. And that's why I'm here today. And that's what the advocacy is for. When I was interviewing, when I was in your space, interviewing for residency, Dr. Linda Sandales, who's at Duke, and she's a general surgeon initially. And then as a hand surgeon as well, she was the first Latina that I had ever met in my many 11 years in training from medical school and residency. So that's my story. Thank you. I've entered, for those that I didn't meet earlier, I'm Megan Konmika. So my story is obviously very different. The picture here is me with my father when I graduated. My dad is my hero. He was the first one to go to college. He was born in a family of factory workers and he was the American dream as far as I'm concerned. So anytime that you feel like you don't belong here, just know that that is just imposter syndrome and that you do belong here and there is a million other people who feel lonely like you and that there is a community here in the Hand Society that can support you. Here's a picture of me with my wolf pack, which is my co-residence when I was at Loyola in Chicago for residency and I was the only female in my class and at one point I was the only female in my residency. It was sometimes very lonely but I had a really good class that took great care of me and then I went to practice and did a lot of bony fixation as Dr. Galvez liked to point out about the orthopods, but I also did soft tissue stuff. So take that plastic surgeons, we can do it too. So practice started to focus on elbow and I work with a lot of athletes. Here's some of the athletes I've worked with and this is a picture of me running in the bottom corner and the only reason why I did that in there is I somehow became a stock photo for the university. So whenever they have anything to do about athletes or anything, they put this horrible picture of me up on the website and I get a call like every couple months being like, oh, I saw this picture of you running in 100 degree weather in like 100% humidity. I'm like, great, I'm glad that became my stock photo. So there's my claim to fame is that horrible picture. This is also how my department started and you could see that I'm the only female attending in a large group of males, which is fine. That's how I trained, I knew no difference. I didn't even have a female faculty or female mentorship until I was in my second year of practice. So I wasn't really aware that that was weird or that there was a part of my growth in residency and then into practice that I didn't have. But this is where my department is now. There's actually two more females in here. So we have a large female faculty. You can see Dr. Jennifer Wolf is part of my squad and I'm very thankful for that because we have a lot of wonderful, wonderful multidisciplinary female orthopods in my group. And as things changed, my life changed. So here's two pictures of me with my first and second pregnancy. Both times operating in my last weeks of pregnancy went all the way through. And actually that picture right here on your right, your left, was the highest commented and liked picture for the academy on their social media. And it broke all these records. They kept emailing me being like, oh my God, this picture. And it's just a picture of me operating. And I just got so many emails from people saying, thanks for putting it. I can be an orthopedic surgeon and be pregnant. That's crazy, right? Even people thought that that's not possible, but totally possible. I have two kids. They know who I am, so we're good. So, and things are changing. So there's a couple of articles if you're interested in reading about it, is things are changing. From maternity leave for having children, post-maternity leave, returning back to work, breastfeeding, all those things for females is changing. It's making it open so that females can be orthopedic surgeons or plastic surgeons or whatever they want and still be mothers and still be all the things that you want to be. And you don't have to be a mom if you're a female. Those are all your choices. So right now, we have only about 5% of orthopedic surgeons are female. And of residents, only 14%. And those numbers are pretty low with plastic surgery. Does anyone know off the top of their head? Those, 30%? Yeah, low. 60% of female residents in orthopedics experience are female. 60% of female residents in orthopedics experience biased gender, biased due to their gender. I definitely did. And it wasn't meant in any harm because I knew my co-residents loved me and that I was part of the gang. But still, there are certain things that were said or done that just not, I don't even think now would be okay. So 48% of females defer in having children, which increases complications later on by having advanced maternal age. I waited to have children until after I was on residency. But I also didn't marry my husband until after residency. So those could be correlated. Uh. Details. Maternity leave. So our maternity leave is horrible. Residents are only taking a couple weeks off. The actually, the average female orthopod takes about nine weeks off. Residents take about six weeks off. And our colleagues are recommending 12 weeks off. So that just shows you, like, people are going back, even breaking their post-surgical protocols. Like, they're restricted from lifting patients and they're lifting them. And we have physicians who are going back to work because they have to. And our colleagues are saying not to, but we have no choice. So it's something to think about for if, not only as, like, for allyship of the males in here, is supporting your female colleagues. Because it's hard. Because you're, we're treated right now as it's like a privilege as opposed to a right. And there's a huge financial impact for taking time off. It's over $45,000 for a surgeon. I have several female pregnant residents who I take, who I have been mentoring, who are too scared to tell their faculty that they're pregnant. Like, it's 2021. So these are things to think about. Other things is it's high risk for females to be pregnant. Increased preterm labor. We have a 31% complication rate opposed to, that's compared to 15% in the general population. That's like double. Would you recommend a surgery that had a 31% complication rate? I hope not. So, and miscarriage, stillborns, infertility, all higher. These are my two little girls. And so, as my practice has gone on, I've pulled on different roles. I'm now the Associate Fellowship Director under Dr. Wolfe, Jennifer Wolfe, who is an amazing mentor. I am the Medical Student Education Director. And just recently I became an assignment scholar, which is working in the diversity in our department. So this is something I'm really passionate about. So if we don't continue to push for diversity, we're gonna miss out on a lot of people. And we're gonna miss out on a lot of leadership opportunities. So a lot of females have to choose between family and work. And the qualities that make women great mothers are also the qualities that make them great leaders. So things like nurturing, passionate, empathy, those make great leaders. And we're pushing them out of the workforce because of those qualities. It's kind of backwards. So hopefully it's a little food for thought. And hopefully it also pushes all of you guys to think about work-life balance. I love to be with my family. I love to operate. I love to ski. I love to scuba dive. I love hanging out with my husband. I love running with my dogs. These are all things that you are not exclusive to being a surgeon. So I push you guys to work for your work-life balance. And as millennials, we are made fun of for wanting work-life balance. But it's not a bad thing. So it's really about changing that culture. It's understanding and not laughing when people wanna take maternity leave. And one of the best things you can do for the males in here is take paternity leave. Two weeks of paternity leave, just two weeks, have increased your relationship with your significant other. It will increase your relationship with your children. It will also start normalizing taking time off after having kids. So that's just one thing. You can take longer than two weeks. Take as much time as you need. But at least just two weeks, the statistics have shown how much that supports. Also, transitioning back to work after having kids is a really hard thing. It's really hard. Ramping back, I've had to rebuild my practice three times. Scheduling around childcare, like picking kids up, dropping them off is not even a joke. Trying to drop a kid off and then go to do the OR or be on call and you're freaking out because you're like, oh my god, I gotta be done with this case because I had to pick up my kid. Those are crazy things to think about. So scheduling around childcare, breastfeeding with female surgeons, they are pumping less. And we all know the benefits of breastfeeding. Obviously, these are things that we need to work on with regulations that are not being met and mentorship. So anyone out there who needs mentorship, I'm here for you. I mentor a lot of females and males on a lot of these things. I am always a resource. And again, paternity leave is the best way that you can help people. It's not a female-only issue. These are pictures of Wade and also Chancellor Rapper who both took paternity leave. They took time off to be with their families and raise their kids. You know, obviously they lost a lot of money, but they didn't care about it. They were there for their kids. So it helps normalize things. This is my husband who is a spine surgeon. And he has been doing a lot of allyship for the females in his group. For his nurse, he basically, before she left, he demanded that she got longer maternity leave. She was in her first year of being with the group, so she had no FMLA. So he took the hit so that she could take longer. And then he set up her breasts for her to have pumping sessions and that she had specific needs for her and her children and that her times were changed within the group so that she could still be a mom and a nurse. So there are things that you can do to be an ally. And I won't go too much longer because we're way over, is a little bit about allyship, just getting involved. Set an example, stop microaggressions, be advocates. And be present. This is just giving a lecture for medical students. And after the lecture, one of the medical students wrote me and was like, I now wanna be an orthopedic surgeon. What an impact, right? Just one lecture and now someone wants to be an orthopod. That's pretty awesome. So be present, you don't know who you're impacting. That's one of the reasons why I share my story is hopefully it impacts one of you. And if it's just one, that's great. But it's important to know that you're wanted, you're included, you're important. And one of the ways you can make a difference is also here in the Hand Society. We have, as Dr. Galvez had talked about, we have a long way to go. And if you want to be involved, there's a lot of different ways to be involved here, some of the different ways. But we are also the co-chairs of the Diversity Committee here on the Hand Society. So we would love, love, love for you to show up, be involved, be part of the group. We're having a really early 6 a.m. breakfast tomorrow. I will be there. You get a free ribbon. And you get a free ribbon. It's the only ribbon I put on here. So more than welcome to join us for breakfast tomorrow. We also will be having our committee meeting, but we also have ICLs and symposiums and ways to learn how you can get involved. And if you're interested in being involved with us, feel free to email us. Our email is somewhere right here. We would love to have you part of our committee. We'd love to get you involved with social media and all different other ways. We are way over, so I'm gonna stop here. But hopefully this inspires somebody in here. So thank you. Thank you. All right, it's time for my favorite Jeopardy category, Potpourri. So let's bring up Curtis Henn, who's going to moderate this last session. And if we could have our three paper presenters come on up and take a seat on the podium, and we'll load up the first talk. Impressed with how many people stuck around. I think it's because there are cocktails coming after this, so thanks for sticking around. So, the first paper in this session, we just have three more papers, and then we're done with the whole program. First talk is by Dr. Bedar, Combined Effect of Surgical Androgenesis in Stem Cell Seeding of Acellular Nerve Allografts on Return to Motor Function in a Rat Cyanic Nerve Defect Model. Hello. I'm Mayun Bedar, and I'm a research fellow at the Mayo Clinic. We have no disclosures. Motor recovery following segmental nerve defect repair with acellular nerve allografts remain inferior to autologous nerve reconstruction, and the independent addition of surgical angiogenesis and mesenchymal stem cell seeding has previously shown to improve functional motor outcomes of acellular nerve allografts. The purpose of this study was to see whether the addition of undifferentiated or differentiated mesenchymal stem cells to acellular nerve allografts enhanced with surgical angiogenesis would further improve the motor recovery of rat cyanic – motor recovery in a rat cyanic nerve defect model. Lewis rats were divided into five groups with two survival times. In the first group, a 10-millimeter section of the cyanic nerve was reversed and interposed as an autograft. In all other groups, the cyanic nerve defect was reconstructed with the acellular nerve allograft, which was harvested from a Sprague dolly rat and decellularized according to our elastase-based protocol. In groups three to five, the nerve allograft was wrapped in a superficial inferior epigastric artery flap to provide surgical angiogenesis. And finally, in groups four and five, the nerve allografts was additionally enhanced with either undifferentiated or differentiated mesenchymal stem cells dynamically seated on the nerve graft. During the survival period, we looked at the tibialis anterior muscle cross-sectional area using ultrasound imaging. And at non-survival procedures at 12 and 16 weeks, we looked at ankle contracture angle, CMAP compound muscle action potential, and the muscle force and muscle weight. All results were expressed as a percentage of the contralateral non-operated side. So during the survival period, we did not see any significant differences in tibialis anterior muscle cross-sectional area between the groups. And the surgical angiogenesis demonstrated less ankle contracture angle and higher CMAP amplitude recovery compared to allografts alone at 12 weeks. The muscle force in autografts were significantly superior to all groups at 12 weeks, and this was similar in the muscle weight. In conclusion, the addition of mesenchymal stem cells either undifferentiated or differentiated did not further improve the functional outcomes of Acellar nerve allografts enhanced with surgical angiogenesis. The adipose tissue of the C-flap may provide adequate mesenchymal stem cells and may not necessitate local addition of mesenchymal stem cells. Superior studies in larger animal models could provide more conclusive results. Thank you. So first, I'd like to congratulate you on a lot of work. That's really a lot of work you did there. I haven't done animal studies as a medical student myself. I'm really impressed that all 100 rats survived the study, so congratulations on that as well. I think your data clearly supports allograft over anything else. I think that's worth mentioning, or excuse me, autograft over anything else, and you concluded that the MSCs don't provide any additional benefit for surgically induced angiogenesis. The question I have for you is, do you think your data supports surgical angiogenesis over allograft when you compare the two? Thank you very much. Next paper is the effects of pre-mixing beta-methadone with lidocaine on counter-site inflammation in an in vitro model presented by Dr. Sayegh. Sage. Sage. All right. Thank you. So we have no disclosures. We observe that some hand surgeons pre-mix steroids with local anesthetics and store these mixtures in pre-loaded syringes to increase efficiency during their clinic. Local steroids like commonly used beta-methadone can potentially form microcrystalline precipitates that may have negative effects. We sought to determine if pre-mixing beta-methadone with lidocaine in pre-loaded syringes up to 24 hours prior to treatment decreases efficacy, and to our knowledge this wasn't studied before. Human articular chondrocytes were cultured and expanded in solution and partitioned into a negative and positive control group and four experimental groups. Interleukin-1b and oncostatin were used to stimulate an inflammatory environment. The four experimental groups were treated with beta-methadone alone. Beta-methadone mixed with lidocaine at either 0, 4 hours or 24 hours prior to treatment. One hour after treatment we measured expression of these inflammatory genes listed here. So chondrocytes treated with beta-methadone alone and with beta-methadone and lidocaine mixtures prepared at 0 hours, 4 hours, and 24 hours prior to injection showed significantly decreased levels of TNF-alpha, ADAMTS-4, MMMP3 compared to the positive control. There was a significant decrease in TNF-alpha with both the 24-hour pre-mixture group and beta-methadone alone compared to the 0-hour pre-mixture group. MMP1 and IL-8 also showed similar significant decreases without significant decreases amongst the experimental groups. IL-6 and MMP13 did not show significant decreases compared to the positive control and there was also no differences among the experimental groups. So our results showed that pre-mixing up to 24 hours did not diminish the anti-inflammatory effects of the mixture. The only time-dependent difference between the experimental groups was with the expression of TNF-alpha, suggesting that TNF-alpha may require a longer duration of inflammation or incubation with the treatment for experimental groups to exhibit adequate responses. The in-vitro design and the use of chondrocytes rather than synovial cells or tenocytes may be some limitations of our study. And then Celestone is a trade name commonly for beta-methadone. It contains a preservative. This was included from our study because it was found to be cytocondrotoxic in vitro. So in conclusion, the study shows that beta-methadone and lidocaine pre-mixed and pre-loaded into syringes at various times up to 24 hours prior to treatment does not significantly impact the ability of the mixture to reduce expression of key inflammatory mediators in vitro. And we find that our findings may reassure hand surgeons that the quality and efficiency of anti-inflammatory effects of steroid injections are not reduced by pre-mixing and pre-loading into syringes, which are an important diagnostic, therapeutic, and prognostic intervention in hand surgery. Thank you. Very nice job, also a lot of work, and something that's very applicable to practice. I know my staff pre-fills these syringes. I'm curious, you know, what led you to do this study? Did you notice a clinical decrease in effectiveness after pre-loading them? We didn't notice any decrease in clinical effectiveness, but it was always that what they're doing might not necessarily be impacting their patients. Great. Thank you. Final paper here is Tendon Repairs After Risk Utilizing a Novel Tendon Stapler Device, an Efficiency and Biomechanical Study Across Different Experience Levels, presented by Evelyn Reed. Dr. Reed. Hi. I'm Evelyn Reed. I'm a third year plastic surgery resident at the University of Utah. This was an investigator-initiated study that was funded by a grant from Connections Medical, which is the manufacturer of the stapler device used in the study. No other disclosures. So Connections is a medical device company founded in Salt Lake that recently developed a novel tendon stapler device. And in the studies they've been performing for FDA approval, they've noted both faster and stronger repairs in comparison to sutures. So our hypothesis was that compared to a traditional suture repair, the stapler device would demonstrate faster overall tendon repair times across the board in users of different abilities, as well as stronger repairs in those different users, kind of leveling the playing field. All participants, novice student, intermediate trained resident, and hand attending underwent identical training on the device. And then on matched cadaver arms, suture repairs were performed with a 3-0 braided polyester suture for a Kessler repair with an additional horizontal mattress stitch. And the stapler repairs were performed with the novel Connections device with a single polypropylene suture stitch for approximation of the tendon ends rather than for strength. Efficiency was timed by a non-participating data recorder. And immediately after repairs, tensile strength to a two millimeter gap force, as well as ultimate failure loads were measured. In total, 228 tendon repairs from 12 donor arms were analyzed. The attending surgeon was significantly faster at performing suture repairs. However, tendon repairs performed with the stapler were significantly faster and consistently fast across all experienced groups. Forces required to create a two millimeter gap were statistically higher in the stapler group for the expert and novice and directionally higher for their intermediate. The mean between groups was significantly higher for the stapler. Similarly, ultimate failure loads were statistically higher in the stapler group for the novice and the expert and directionally higher again for the intermediate. Suture repairs had a 30% device failure, whereas the stapler device had zero failures in the study. So in summary, the stapler device repairs were faster, they were stronger, and in comparison to standard suture repair, the novel stapler device produced more efficient and stronger repairs across users of varying experience level in this cadaver study. Thank you. Great, thank you for that presentation. A couple of quick questions about that. In a couple of comments, I was struck by how little time it takes to repair a tendon, even in a novice medical student, it's really only a minute and a half difference. So next time I'm in the operating room with a third year resident, I'm not gonna worry about the time it takes to repair the tendon. But the question I have for you is, you've mentioned you did a Kessler suture with a horizontal mattress. How many core sutures did you have? Four. And then did you do an epitendinous repair? No. And then the next question would be, what is the next step in this device? Yeah, so they, I believe they just wrapped up a clinical trial in South Africa, and I don't have the results of that yet, but they have at least a few months of follow-up for that, and I know that they're excited about the results, so stay tuned. That's good? Yeah. That's it? Great job. Thank you. All right. I guess there's not much else to say. A final thank you to all the presenters today and all the faculty who helped us out in putting this together. I believe we have snacks and cocktails on the terrace. Thank you all for coming. I hope you had a great time. Thank you all for joining us. And one final plug to give us your feedback. Grab us for a drink here or send in those evaluations when you get them in the email so that we know what you liked and what to do better next year. Thank you guys.

video

Etan Melamed

International Traveling Fellowship

ASSH

hand surgeons

India

China

hand pathologies

surgical techniques

funding

mentors

accommodations