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Co-Editors:
Robert Hagan, MD
Ziv M. Peled, MD
Renata Weber, MD
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Dear Members of the American Society for Peripheral Nerve,
It is my pleasure to announce and to anticipate a great Annual Meeting of the American Society of Peripheral Nerve (ASPN) in Puerto Rico at the El Conquistador hotel in January 2018. All our committees, including the programming committee, have gotten off the ground since the last meeting with active participation and new and exciting ideas.
I would like to give you a glimpse of our plans for the 2018 meeting. As you might remember, we hold a number of joint panels with the American Association for Hand Surgery (AAHS) and the American Society of Reconstructive Surgery (ASRM). On the first day, Friday 12th January 2018 there is a joint program with AAHS, the programs with all the societies, ASPN, AAHS and ASRM, being on the morning of Saturday January 13th 2018, and the one with ASPN and ASRM is on Sunday January 14th, 2018. We have another two on the last day of the ASPN program on Sunday that are exclusively ASPN organized panels. The combined panels include "Nerve injuries in 2018" in which we will consider nerve transfers, grafting as well as a consideration of the rehabilitation strategies after the surgeries, "Targeted muscle reinnervation" considering novel strategies, and finally "Facial (re)animation", again considering up-to-date surgical strategies. Our ASPN organized panels on Sunday are an invited Guest Speaker Panel entitled "Nerve Trek - to seek solution where no-one has ever been before" and a panel entitled "Pain – A critical problem".
Of course, there are so many other topics of interest of which we have included a number in our ASPN instructional courses. These include "Innovations in the management of children with birth-related brachial plexus injuries", "Medial to radial nerve transfers", "Novel surgical approaches for headache management", "Nerve transfers following spinal cord injury", "Surgical management of pelvic and trunk pain", and "From the bench to the bedside: hot topics in translational research".
I hope that this 'glimpse' gives you an inkling of the rich programming that is on the books. We received a number of excellent abstracts in July of this year. Our intention is to include as many as 50 of these as talks where we will follow 4 minute talks with planned discussion after each talk. In addition, we will again repeat the very successful and enjoyable poster session hosted by Allan Belzberg where a short succinct presentation of ~ 20 posters by the first author will be followed by questions and discussions – always a lively discussion! It is our intention to accept many more abstracts for poster presentations which will be given on poster boards that we hope to have ‘up’ for viewing during the entire course of the meeting.
Housing for the meeting is currently open. Please be sure to book your accommodations early to ensure that you have a room at the El Conquistador Hotel. Make your housing reservation online or contact the hotel directly and refer to the AAHS/ASPN/ASRM Annual Meetings. Rooms and rates are limited so I encourage you to make your reservation(s) as soon as possible. The ASPN leadership has been following the developments related to the Zika virus in Puerto Rico for well over 18 months. The preparations for the 2018 meeting are well underway as you can see from the plans that I have outlined above. We encourage members and attendees to seek information and travel-related advice on the Zika Virus on the CDC and the El Conquistador websites, as well as other media sources. Recently, the Puerto Rico department of Health declared the Zika epidemic to be over. Read the PRDH press release.
I and our Executive Council welcome your feedback and any questions that you might have. We are looking forward to the meeting and to welcoming you at the meeting.
With all the best,

Tessa Gordon, PhD, DSc
ASPN President
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TARGETED RE-INNERVATION AND PROSTHETIC EVOLUTION
By Ziv M. Peled, MD
Targeted re-innervation is a peripheral nerve surgical concept introduced within the past several years in which transected nerves can be coapted to distal motor and/or sensory targets in an attempt to reduce neuroma formation, mitigate phantom limb pain in amputees and provide differential muscle function to hopefully power an advanced prosthetic in the future.
Targeted re-innervation is therefore an umbrella term encompassing both targeted muscle re-innervation (TMR) and targeted sensory re-innervation (TSR). Interestingly, as the surgical techniques surrounding targeted re-innervation continue to evolve, seemingly concurrently, so have the advances in prosthetic design and fabrication. These parallel events will likely herald a new way of thinking about what it means to be an amputee in terms of ability to function in the future and raises many interesting questions about society as a whole. This article aims to describe some of these prosthetic innovations and their unique contributions.
One of the earliest entrants into the advanced/bionic prosthetic space was the DEKA Arm System whose developer is none other than Dean Kamen, inventor of the Segway scooter. This system now re-named LUKE (for Life Under Kinetic Evolution) is interesting because despite only a maximum of 10 degrees of freedom in optimal configuration, the system is modular enough to be almost commercially readily available and is easily configurable for both trans-radial amputees, trans-humeral amputees as well as shoulder disarticulation patients. There are also sensors for grip force feedback. Funded by DARPA, two LUKE arms have already been delivered to veterans at Walter Reed National Military Medical Center.
Touch Bionics has developed several upper extremity prosthetic products which are already commercially available and which allow users to control the prosthetic using a combination of muscle contractions and smart phone applications allowing up to 36 different hand grip motions. Along those lines, another interesting development driving prosthetic evolution is the increasing availability of lower cost, 3D printing solutions. Lyman Connor is an engineer for GE who was inspired to try to create a low-cost prosthetic hand for a young boy he met in 2013 who had lost his hand in a bicycle accident and was unable to afford an advanced prosthetic as they often cost tens or hundreds of thousands of dollars. His efforts have led to the Bionic Hand Project and the Mano-Matic 3D-printed bionic hand which uses this novel printing technology along with readily available electronic technology to create a more affordable device capable of a number of different functions.
Finally, all advancements in the field of prosthetics are necessarily high-tech related, but can still have very meaningful and profound impacts on their recipients. Until recently, many people in the small South American nation of Columbia were victims of landmine explosions set in place over the last half-century by the competing forces of the FARC rebels and the Colombian government. Unfortunately, many victims of these landmines were children who suffered amputations and the subsequent social isolation that often accompanies such tragedies. Thanks to the work of a Columbian designer by the name of Carlos Torres and his IKO Creative Prosthetic System, many of these children not only are more functional, but more integrated into their social circles. Mr. Torres conducted exhaustive research with prosthetists, clinical psychologists and surgeons, then used his creative talents along with those of the Lego Future lab (yes, that Lego) to design a unique prosthetic system that makes use of the world's favorite building blocks. The end result is a myoelectric, artificial limb which children can modify according to their desires and which allows exchanges of, for example, robotic Lego grippers for light-emitting spaceship configurations and other modular connectors which these young amputees can learn to control as they would any other myoelectric prosthetic. This project has apparently exceeded all expectations with children not only not shying away from social interactions, but proudly showing off their robotic limbs whose limitations in terms of configuration is limited only by the imagination.
In my opinion, the coalescence of several factors including the advent of surgical re-innervation, the ability to fabricate and manufacture moderately complex and complex prosthetics in increasingly lower-cost ways as well as continued improvement in rehabilitation techniques will lead to a revolution not only in the prosthetics themselves, but how we think about amputees. At this point, despite what some amputees themselves may think, most people would say that missing a limb is a disability. However, it is not unreasonable to think that in the near future, people with prosthetic limbs may not only be as functional as their "able-bodied" counterparts, but perhaps even more advanced. Just asked Marcus Rehm, a unilateral below-knee amputee and long jumper who, during the German Athletics Championships in 2014, performed a long jump that would have won the silver medal two years earlier at the 2012 London Olympics.
- https://www.thrillist.com/health/nation/luke-skywalker-bionic-arm-darpa
- https://formlabs.com/blog/3d-printing-powered-startup-manufactures-affordable-custom-prosthetics/
- http://designawards.core77.com/Open-Design/29865/IKO-Creative-Prosthetic-System
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The ASPN continues to benefit from the coding experience of Dr. Raymond Janevicius, the ASPS Liason to the CPT Coding Committee. We thought the membership might find his thoughts on specific nerve-related matters informative, so this particular piece involves a relatively novel surgical approach to a fairly common operation, cubital tunnel surgery.
- Dr. Peled: I was going to ask about endoscopic cubital tunnel decompression. Are there any unusual coding pearls that would be applicable to this type of procedure as it probably requires a bit more work than the typical open cubital tunnel release +/- transposition?
Dr. Janevicius: You can append modifier 22 to the primary code (64718) to indicate that there are increased services. This modification will require documentation in the operative note and usually a letter to the payor post-operatively.
- If you create a local tissue rearrangement (i.e. random pattern fascio-cutaneous flap to help pexy the ulnar nerve anterior to the medial epicondyle during a subcutaneous transposition, does that maneuver get coded separately with a 1402X?
Dr. Janevicius: This maneuver would not constitute an adjacent tissue transfer, so 1402X is not appropriate. Subcutaneous transposition is included in code 64718. One cannot perform an anterior subcutaneous transposition without undermining, so this maneuver is included.
- Does the coding change if you perform a sub-muscular transposition of the ulnar nerve?
Dr. Janevicius: Yes, a flexor tendon/origin slide is reported separately using code 25280.
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ASPN 2018 Annual Meeting
January 12-14, 2018
El Conquistador Hotel
Fajardo, Puerto Rico
ASPN 2019 Annual Meeting
February 1-3, 2019
JW Marriott Hotel
Palm Desert, California
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ASPN 2020 Annual Meeting
January 10-12, 2020
Marriott Harbor Beach
Fort Lauderdale, Florida
ASPN 2021 Annual Meeting
January 15 – 17, 2021
Grand Hyatt Kaua'i Resort
Koloa, Hawaii
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