Lessons in Orthopaedic Leadership: An AOA Podcast
Members and affiliates of the American Orthopaedic Association (AOA) interview guests to highlight lessons in orthopaedic leadership. Interviews include orthopaedic leaders, faculty and leaders within orthopaedic departments at academic institutions and large practices, health care system leaders, rising leaders, and other medical leaders. Thanks to @iampetermartin for his contribution of introduction and conclusion jazz music.
Lessons in Orthopaedic Leadership: An AOA Podcast
Exploring the Future of Hand Surgery and Orthopaedic Innovations with Peter Murray, MD, FAOA
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Peter Murray, MD, FAOA, from the Mayo Clinic shares his groundbreaking insights on hand surgery and leadership. Discover how this unique specialty, sitting at the crossroads of general, plastic, and orthopaedic surgery, is not only evolving but also leading advancements in areas like wound management and peripheral nerve reconstruction. Dr. Murray sheds light on the exciting integration of genetic and regenerative medicine within hand surgery, emphasizing the growing demand for skilled surgeons in this dynamic field.
Explore the cutting-edge developments in orthopaedic fracture treatment, where traditional methods meet innovative techniques. Learn about the transformative role of PCR testing in diagnosing atypical infections and the evolution of treatments for distal radial fractures. From the effectiveness of Volar plates to the promising use of spanning wrist plates for older patients, our discussion highlights a pivotal shift towards less invasive, more adaptable solutions that hold the promise of better patient outcomes.
Finally, we turn our attention to the future of hand therapy and the evolving landscape of hand surgery education. The essential role of certified hand therapists is emphasized, along with emerging therapies like desensitization and mirror therapy. We also contemplate the training of future hand surgeons, where the balance between competency-based education and traditional residency models comes into play. Ending on a note of gratitude, we celebrate the camaraderie among orthopaedic professionals, acknowledging the AOA's support and relishing in 11 years of meaningful exchanges.
Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for this podcast series. Joining us today is Dr Peter Murray. Dr Murray is professor and chair of the Department of Orthopedic Surgery at Mayo Clinic in Florida and he holds a joint appointment with the Department of Neurosurgery at the Mayo Clinic in Florida as well. Dr Murray specializes in hand surgery and microsurgery and has special interests in the surgical reconstruction of peripheral nerve injuries, including brachial plexus reconstruction.
Speaker 2Peter earned his bachelor's degree in chemistry, graduated magna cum laude from West Virginia University in Morgantown, west Virginia. We also completed his doctor of medicine degree. He received his orthopedic surgery training at the University of Iowa Hospitals and Clinics in Iowa City, iowa, followed by a fellowship in hand and microsurgery at the Mayo Clinic in Rochester, minnesota. Ship in hand and microsurgery at the Mayo Clinic in Rochester, minnesota.
Speaker 2Dr Murray was a distinguished graduate of the United States Air Force ROTC program at West Virginia University and he served an active duty, rising to the rank of Lieutenant Colonel. He was deployed in support of Operation Desert Storm in 1991 and was awarded the USAF Meritorious Service Medal and the USAF Commendation Medal. Peter is author of more than 120 scientific publications and three books and has lectured on hand surgery internationally in more than a dozen countries. Dr Murray is recognized for his work and education with the Mayo Clinic Distinguished Educator Award. He's past president of the American Board of Orthopedic Surgery, past president of the American Association for Hand Surgery, past chair of the Orthopedic Surgery Residency Review Committee and is the vice president of the American Society for Surgery of the Hand. So, dr Murray, sir, welcome to the podcast series.
Speaker 3Thank you, Dr Lundy. It's a real honor and pleasure to be here with you today.
Speaker 2Thank you, peter, and you and I have been friends for quite a long time. Thank you for joining us today and I think everybody would recognize that. If anybody and I would say nobody does but if anybody has any insight onto where hand surgery is going in the future, I think you were in that small group of folks. So, peter, you've had an extensive history in leadership in orthopedics, both at Mayo and other, of course, significantly through our national organizations and such, especially since this is an AOA podcast. Where do you see the role of leadership going in the future, specifically within hand surgery and any other venue that you feel appropriate, sir?
Speaker 3Well, I think you know hand surgery is a very unique field and, as you know, it amalgamates three different specialties.
Speaker 3You come to hand surgery through general surgery, you can come to hand surgery through plastic surgery and you can come through hand surgery through orthopedic surgery.
Speaker 3And so, as a hand surgeon in an institution, you automatically take on leadership responsibilities just by virtue of the fact that you're a hand surgeon, because there requires a lot of integration of subspecialty management and I think it's becoming increasingly more important for the hand surgeon to take a role in things like wound management, peripheral nerve reconstruction, trauma care as it relates to the upper limb, and reconstructive care, because there are so many, there's so much interplay among different specialties, for example.
Speaker 3Let's just take tumor, for example, the hand surgeon is often asked to reconstruct the defect following tumor management, tumor resection by virtue of a free tissue transfer, and that requires the interplay of radiology, orthopedic oncology, radiation oncology and sometimes collaborating with plastic surgery and sometimes collaborating with plastic surgery. So the hand surgeon is really poised to take a leadership role in that patient management arena. Beyond that, I think, as we see the practice of hand surgery migrating more and more into the basic science realm as it relates to migrating more and more into the basic science realm as it relates to genetic and regenerative medicine. There's an opportunity for the hand surgeon scientists to take a leadership role in collaborating across many different research subspecialties as it relates to relates to neurosciences and regenerative medicine. So I think the science and medical subspecialty of hand surgery is a very, very exciting field to be part of from a leadership perspective.
Speaker 2Thank you. That's very enlightening. I think hopefully that'll inspire a lot of folks inside and outside of hand surgery to consider opportunities that they may have within their specialty. All right, my friend, let's look forward. You picked a timeline five years, 10 years, 50 years. I thought I'd get a laugh out of you on that one. Where is hand surgery in the future? Where are we going? What are we going to see? Be a savant and tell us what's out there, buddy.
Speaker 3Well, I can tell you that I won't be practicing in 50 years. Maybe 40, but I don't think 50. You know, I often tell the residents that you know, when they tell me that they're going to go on to sports medicine no disparagement to our esteemed sports medicine colleagues but I say, what are you thinking? I mean, hand surgery is such a fantastic field. Tell me any other orthopedic subspecialty where you can practice the gamut of orthopedic science in one specialty. So you can practice tumor reconstruction. You can practice wound management reconstruction. You can practice pediatric orthopedics. You can practice trauma care. You can practice sports medicine. You can practice any subspecialty with the exception of spine, any subspecialty in orthopedics you can practice as a hand surgeon. So I see hand surgery becoming more and more in demand. I see hand surgery on a molecular level being able to reconstitute soft tissues in the upper limb, soft tissues in the upper limb.
Speaker 3And I think you know that the idea that we manage wounds the way we do in 2024 is going to be entirely different. In 50 years. I think we're going to be regrowing tissues. I think we're going to be managing bone defects in a completely different fashion. And the most exciting thing to me is I think we're going to be able and this is really looking out here a ways but I think we're going to be able to grow nerves. I think we're going to be able and this is really looking out here a ways but I think we're going to be able to grow nerves. I think we're going to be able to grow nerves because you know, if you think about nerve injury and nerve defects, the number one problem with nerve reconstruction is the length of time that it takes for an injured, repaired nerve to regenerate, for an injured, repaired nerve to regenerate, and that regenerative distance impacts ultimately function and muscle recovery. So if we can figure out a way to and I think we're getting closer and closer to that we can figure out a way to grow nerves faster, more completely, we're going to see quicker and more complete restoration of upper extremity function.
Speaker 3And then, finally, the whole science of prosthetic reconstruction of the upper limb is extremely exciting and I think if you look at where we've come in the last 20 years with prosthetic reconstruction in the upper limb, if we can mimic that in the next 10 years to the next level, I think we'll be seeing some extraordinary advances. We're now able to do targeted muscle re-innovation in such a way that we can more accurately motor upper extremity, upper extremity prosthetic limbs in a more meaningful fashion. And you know it was, you know, 25, 30 years ago. You know we didn't have any of this technology and now we do, and so, with AI and a lot of other interplays, it's. I think it's really exciting what we're going to be able to do. So, in a nutshell, you know, soft tissue restoration, prosthetic restoration. So, in a nutshell, soft tissue restoration, prosthetic restoration, and the hand surgeon, I think, is really poised to be on the forefront of all that no-transcript.
Speaker 2Do you see other forms of technology perhaps coming in that will, because y'all do some pretty very specialized microvascular small unit things. Any other forms of technology that you think might be developed that would enable hand surgeons to be even more effective than they are now?
Speaker 3Sure, I think some of the ways we monitor perfusion to wounds and to bone, the way we monitor the healing process of bone, and then to maybe getting off subject a little bit, but more in your arena how we can better restore function quicker in the hand following trauma.
Speaker 3And what I mean by that is, you know, the fixation techniques we have in the fingers are not as forgiving as they are in other parts of the body, such as plates and screws, for example. And what I mean by that is that there's a setup for stiffness and joint contractures based on the type of plates and screws and osteosynthesis we can use in the phalanges. And although tempting, you know, plates and screws in the fingers sometimes just don't work out very well like they do in other parts of the body. So anyway, perfusion techniques, monitoring techniques and perhaps techniques.
Speaker 2We were just talking with Charlie, our mutual friend, charlie Saltzman, and Charlie brought up a fascinating, as you know, because Charlie's always bringing up fascinating things that nobody has thought of.
Speaker 2But one thing that Charlie brought up that I had not considered and he gave a very eloquent way eloquent way of saying this is that he believes that his foot and ankle surgery as you well know, he's a foot guy that the injuries, the trauma, the conditions will be vastly different in the future than they are now. And his point in that was he picked up things like polio and leprosy and other things like that, which have essentially been eradicated off the face of the planet or at least within North America, and how now foot and ankle surgeons are dealing with issues that may not have even been relevant in the distant past. Do you see, especially with the increase in occupational safety and other things, that perhaps the surgery of the hand and a lot of the processes that y'all treat now may be, may be adequate in the future? Or or the disease patterns change or no, that's a, that's a.
Speaker 3That's a great subject and a great point, Doug. You know, I think we have seen and I I don't, I'm not aware of the numbers off top of my head, but we've seen a decrease in industrial injuries, and so when I went through training we would see a large number of industrial injuries, and so when I went through training we would see a large number of industrial injuries at various plants, various farms and so on. And now I think that the public is much more educated about safety techniques. I think our machinery and our different utensils that are used in the industrial environment are safer, smaller, more compact, and so I think that automatically cuts down on the frequency and types of things we see in the emergency department that involve the hand, involve the hand. But I think you know, the broader topic that you brought up kind of brought a couple of things to mind is we see the population age and we've all seen the numbers about the number of patients we'll be treating over the age of 65 and 2030.
Speaker 3We know that osteoporosis, osteopenia, is going to continue to be something that we're going to be faced with and every distal radius fracture we see over the age of typically has a component of insufficiency osteoporotic or osteopenic patient with an insufficiency fracture. So that is only going to excel. So we need to be thinking about our fixation techniques and, as the population ages, maybe we need to rethink the question of what distal radius fractures we fix and which ones we don't fix. And, as you know, there's been an abundant amount of data that have come out in the last five to seven years to kind of tell us that over a certain age that age is arguably 65 or 70, the results of operative treatment for distal radius fractures in that age group are no worse than if they're treated operatively with internal fixation. So that's sort of the way we're approaching those fractures now. But in 20 years, 30 years, 40 years, 50 years, if our life expectancy is longer, then that may bring to play a completely different set of circumstances and we may have to be thinking about alternative fixation techniques.
Speaker 3The second thing that comes to mind are the type of infections we're seeing. When I was going through, you know, we never saw or at least I didn't. I saw very, very few atypical microbacterial infections, very few fungal infections. I mean, we saw them, but in our transplant population it's an every week occurrence that we see is someone with an obscure fungal infection, a mucormycosis, a micro bacteria, avium or meridium or fortuitum infection. Now we're here in Florida so we see a little bit more of the AFB infections. But the point is is that we have to be better and more aware, better at taking care of these infections and more aware of them and be looking for them. You know, pcr testing has just been, I think, one of the greatest achievements in my career, seeing how we can almost instantly make a diagnosis, even if the bacteria are no longer viable, and not only that, they can tell you what they were susceptible to. And so it's just, it's been a game changer, at least in my practice. So anyway, those are just some, just some thoughts.
Speaker 2So about distal radial fractures for just a minute. So you and I have been through the external fixation craze. I can't tell you how many hundreds of those I put on. Then it seemed like we started putting in dorsal fixation. I can't remember the company that was doing those dorsal nails that went through lister's tubable. I like those. I thought those were kind of cool that was the.
Speaker 3That was the Orbe nail plate.
Speaker 2That's right. That's right. Thanks for reminding me of that.
Speaker 2Then the Volar plate came out and it seemed other than modifications to the plate to get specific fragments and make it a little lower profile, so it irritated folks less once they healed. It seems to be the grand slam home run of how to fix distal radius fractures. Do you think I'm just using that as an example? Are there certain patterns or certain injury patterns that we now have that fixed and there might be increases in technology and improvement in the future? Or do you see the Volar locking plate is just in future iteration? As we continue to get more and more cool stuff out there Never ceases to amaze me. Going to the trauma association, meaning how fractures I thought we had completely figured out now have this whole different crazy thing on there.
Speaker 3Yeah, well, I think the VolarPlate has advanced certain fracture care treatments and I think that there are certain fracture patterns that the VolarPlate is very amenable to. I think you don't want to, however, fall into the conundrum, or the knee jerk reflects that a boulder plate treats every distal radius fracture because it doesn't. I mean there are certain patterns that the boulder plate is, I don't think, best for there are certain instances, especially in younger individuals, where fragment specific fixation is very successful. I think with the volar plate you have the opportunity at times to do some indirect reduction techniques and I think in my practice, more and more I've been supplementing the volar plate with interarticular fixation from dorsal. From the dorsal approach because some of the lower profile plates that are available can be used in such a way dorsal because from the dorsal approach, because some of the lower profile plates that are available can be used in such a way dorsally that they don't they don't really cause any morbidity or very little morbidity.
Speaker 3One thing you didn't mention that that I think has become quite popular is the spanning wrist plate, and I think the spanning wrist plate is kind of one of those things where you look at it and say I don't think I'd ever want to try that, but you know it is pretty successful.
Speaker 3I found it successful in my practice, particularly for the very comminuted fracture in the older individual where you really don't want to put an X-fix on. It's something that I would have used an X-fix for, you know, years ago would have used an X-Fix for years ago. But the spanning wrist plate is really less fixation and it's something that you remove in three weeks or three months and, remarkably, patients get their wrist motion back pretty quickly. So I think you're going to see more and more. You're going to see more less invasive techniques. So smaller incisions, smaller plates. Even now, with many of the DVR plates, you have the variable angle option where you can take that fixed angle plate and put the screws in at various angles. But I think what you're going to see are smaller incisions. You're going to see smaller plates, sturdier plates and the availability to supplement those with fragment specific options.
Speaker 2And you guys y'all have a very heavy influence and direct buy-in with your therapist. You guys have certified hand therapists. Mine are just regular physical therapists that help me with the stuff that I do. You guys have these elite therapists that do all sorts of cool things in terms of helping and working with you guys to help you all get your patients as functional as possible afterwards. Where do you see hand therapy cooking off in the future? Are there, are there big strides around the corner in that, or is it going to be more of the same, or what do you think?
Speaker 3Yeah, I think you know I can't say enough positive things about our CHTs and CHTs in general certified hand therapists. They provide a service and a skill and an expertise for us that is really unmatched and things that we can't do. And a lot of hand therapy was developed around flexor tendon protocols and so many of the nuances to flexor tendon repair and extensor tendon repair and they're really the hands-on and so much of hand surgery is the post-operative protocol within that first six to eight weeks, whether it be a scaphoid fracture or whether it be a flexor tendon injury. So I think things like desensitization, mirror therapy, early active range of motion, lymphedema control I think we'll see our hand therapists, I think, do more and more of those things in that arena. But being able to sit down with a patient for 30 minutes and work on mirror therapy, that's irreplaceable. That's something I can't do and it's something that has been shown time and time again to increase outcomes or improve outcomes Thanks to our hand therapist.
Speaker 2Yeah, yeah, I'm sure they. I'm sure they understand your appreciation for them. You've been extensively involved in education throughout your career, certainly as past chair of the orthopedic RRC. That's a big thing. Where do you see the education, the training and development of hand surgeons being in the future? Are we going to continue? I mean, do hand surgeons still need to do the whole gamut of oproduction, internal fixation of proximal femoral fractures and all the stuff that we do? Or are we going to have a thing in the future where somebody wants to be a hand surgeon, we push them into that specialty pretty quick, refine their, because you know the general surgeons and the plastic surgeons, they don't. They've never fixed a proximal femur. How are we going to make hand surgeons in the future? What's that going to look like?
Speaker 3Well, you know, doug, you're very well aware and very versed in a lot of the discussions we had on the board between time-based and competency-based education, and you know I'm a fan of competency-based education. I think that we're going to see more of that and I think that's something that's more doable in a fellowship arena. It's harder to do, I think, in a residency. We can debate that all day, but it's harder to do, I think, in a residency than it is a fellowship. I think I don't really see and maybe I'm a little biased, old school, whatever, chuck Taylor tennis shoes guy I don't see hand surgery branching off at like PG level two or three into a different arena. I just think that for some of the comments I made earlier, I really think that the interplay, interdisciplinary collaboration that you get in your orthopedic surgery residency or plastic surgery residency or especially, I guess, general surgery residency, is really, I think, critical to becoming a competent hand surgeon because we deal with so many subspecialties and so many different disease processes. So I'll just kind of throw that out there that I would be inclined to not favor. You know, branching off, for example, like vasculars done in other subspecialties, I think that we'll also see we're already seeing it developing a little bit in some of our hand fellowships, more of a niche type fellowship.
Speaker 3You know, I think there are some fellowships. You know, if you want to learn to be a brachial plexus surgeon, then you know Mayo Clinic in Rochester is a great place to go to do your fellowship. If you want to learn to be an arthroscopist, perhaps a hospital for special surgeon might be a great place to go to get your fellowship. Or if you wanted to do shoulder and elbow in addition to that, maybe New York would be a great place for you to go. So I think we'll probably start seeing a little bit more subspecialization within hand fellowships, just as the different treatment modalities become so diverse and so subspecialized. But I think those are the things that I kind of foresee and it's going to be exciting thing to watch.
Speaker 2You did this a little earlier, but for the sake of say, some of my residents, your residents who are contemplating being a hand surgeon. They've got 30, 35, 40, perhaps years ahead of themselves in career and they're saying Dr Murray, why should I be a hand surgeon? What would I look for in the future? You would say.
Speaker 3Well, I think that I can't say enough about the intrigue that you have as a hand surgeon, because every subspecialty represented in orthopedic surgery saves spine. I think the surgical skills that you have to acquire to be a hand surgeon go from being extraordinarily delicate with 10-0 nylon suture to being able to put in a total elbow arthroplasty in which requires a completely different set of haptic skills. So I think there's such a broad range of things that you now maybe that doesn't appeal to everybody. It always appealed to me to be able to have a certain subset of skills that you can apply to a lot of different disease processes, and I think that that's, to me, is the attraction of hand surgery.
Speaker 3I think there is no doubt that there's going to always be hand injuries. There's always going to be carpal tunnel syndrome, there's always going to be a plethora of patients and really no one in orthopedic surgery or plastic surgery or other. Well, let me back up. It's sort of to me hand surgery. This is a strange analogy, but hand surgery is a lot like obstetrics.
Speaker 3You know no one wants to take care of hands. You know they don't really want to go there, they don't really want to, they don't want to, just like obstetrics. You know, if I see a patient in my clinic and I'm contemplating doing this, that and the other, and they're, you know, five months pregnant, you know I have absolutely no idea what my obligations are at that point or what my responsibilities are, I have to pick up the phone and call somebody. So I kind of see hand surgery a little bit like that, in the sense that no one really in other subspecialties and other specialties understands the science of hand surgery. So there's always that very unique build and a very unique disease process. So I think it's intriguing for those reasons and attractive for those reasons.
Speaker 2Thank you very much. That was very eloquent. It has been an absolute pleasure and honor to talk with my friend, Dr Peter Murray, who is professor and chair of the Department of Orthopedic Surgery at the Mayo Clinic in Florida and is a very distinguished hand surgeon known throughout North America and who's talking about the future in hand surgery. Dr Murray, thanks for being on the podcast, sir.
Expressions of Gratitude in Orthopedics
Speaker 3It's been a real pleasure, Dr Lundy, and you're very gracious to invite me, and I'll just just for clarity I'm no longer chair. I've just stepped down from that role the last few months as we rotate chairs here at Mayo Clinic. But anyway, I did that for 11 years, so I very very did. I very much enjoyed that. But anyway, thank you again. It was a real honor to be with you today.
Speaker 2Thanks to the AOA as well, I appreciate you clarifying that too. Thank you Before we go, peter, let me just thank you on behalf of the AOA for your service to our country, sir.
Speaker 3Oh, thank you very much, dr Lundy, and the same to you.
Speaker 2All right, thank you. Y'all. Stay tuned for a future AOA and orthopedic surgery on this podcast series channel.