- Email: [email protected]
The 1988 Bunnell traveling fellow report
THE 1988 BUNNELL TRAVELING FELLOW REPORT William F. Blair, MD, Iowa City, Iowa
During my hand fellowship and initial years of clinical practice I viewed the Bunnell Fellowship as a prestigious but very distant award. At the urging of my teacher and friend, Dr. George Orner, I began the application process while diligently pursuing my academic activities. In September 1988, in Baltimore, I was fortunate enough to receive this award. It was truly one of the most exciting moments of my life. Literally within hours of receiving the award, it began to take on the more weighty appearance of a commitment and significant responsibility. Its many facets were clearly the predominant feature of my life during late 1988 and the spring and summer of 1989. My goal when applying for the fellowship was to gain an international overview of hand surgery, with an emphasis on rheumatoid arthritis. After consulting other members of the American Society for Surgery of the Hand (ASSH) and previous Bunnell Fellowship recipients, I organized a two-part trip. I wrote to my potential hosts, and ASSH President, David Green, provided a supplementary letter of introduction from our Society. With the help of a local travel agent, I planned every detail of the itinerary and obtained as many reservations as possible in advance. The first part of the trip was in western Europe. I departed for Copenhagen February 16, 1989. My sister, now a Danish citizen, met me and began the faltering process of orienting me to European customs. From Denmark I traveled south, to visit nine cities in four countries. I traveled exclusively by Eurail, because the system is affordable, dependable, and very punctual. As I arrived in each city, I found my hosts to be, without From the Division of Hand and Microsurgery, Division of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Reprint requests: William F. Blair, MD, Division of Hand and Microsurgery, Department of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. 3/1/19938
exception, most willing to welcome me into their homes and hospitals. My first host, Professor Dieter BuckGramcko, welcomed me to Hamburg and the Unfallkrankenhaus. In a nearby childrens' hospital, he demonstrated his impeccable polIicization procedure. In his hands, this procedure goes beyond technique; it truly becomes artistic expression. In the Federal Republic of Germany, Dr. Ulrich Lanz was my host in Wurzburg and its fine University. He introduced to me the concept of the volar approach and special plates for osteotomies of the malunited distal radius. He also shared his pride in the reconstructed Bishop's castle, its beautifully preserved Tieppolo fresco, and the imposing Wurzburg castle. The first flowers of early spring were blooming when I arrived in Zurich, Switzerland. There, Viktor Meyer demonstrated his use of a voice-activated microscope in the operating room. His concepts and techniques, including the use of nerve approximators for peripheral nerve reconstruction, were very accomplished. Our discussions concerning the administration and funding of academic departments and the structure of Worker's Compensation in Switzerland carried us into the late evening hours. Over the weekend, the snowcapped mountains seen far across Lake Zurich invited me to come and ski. Instead, I stayed on task and joined the stafffor visiting rounds at the famous Schulthess Clinic. I was introduced to French Hand Surgery by Dr. Guy Foucher in Strasbourg. It was clear from the start that Dr. Foucher's practice was not typical. His home and practice, which included his outpatient clinic, ambulatory surgery unit, and hand therapy unit, were combined in one house. Practice functions and patient clinical features were highly computerized. This endeavor was partially supported by the French government in an effort to investigate innovative practice methods. The extensive computerization facilitated clinical research. Of interest, a psychoanalyst in the clinic examined most patients and assisted with pain management. My next appointment in France, March 1, 1989,
THE JOURNALOF HAND SURGERY
665
The Journal of 666
Blair
HAND SURGERY
was in Toul-Nancy, with Professor Michel Merle. He directed one of the premiere educational programs in Europe, which was comprised of young French hand surgeons, as well as resident surgeons from numerous countries. He demonstrated polyglycolic intramedullary pegs for the arthrodesis of small joints in rheumatoid hands. I also saw patients, some women, with aesthetically pleasing outcomes from radial forearm flaps. One of the more unforgettable moments of my travels was an introduction to Professor Jacque Michon. I met him near the end of his struggle with terminal illness. At the time, he was courageously continuing to provide care to his hand patients at the Hopital Jeanne d'Arc. He brought a patient from his office into the hallway, seeking the opinion of colleagues and to teach the hand fellows. I understand more clearly why he is considered one of our international fathers of hand surgery. My continued travels across northern France brought me to Rheims and Professor Francois Schernberg. He introduced me to a classification of scaphoid nonunions, which better predicts their natural history. He shared with me the pleasures of his community, home, and family-in a fine French fashion. I enjoyed my 4-day stay in Paris, where Professor Rauol Tubiana critiqued our clinical research on crossed intrinsic transfers. He also demonstrated proximal interphalangeal (PIP) joint implant arthroplasty technique, and use of power stapling to quickly facilitate metacarpal to radius arthrodesis in the late-stage rheumatoid wrist. Professor Tubiana was incredibly vigorous, both clinically and politically, and very wise about the nuances of international hand surgery. After a long night's train trip and a boat ride, I returned north to three stops in Sweden. Dr. Goran Lundborg, in Malmo, directed a most impressive hand surgery department. He patiently shared with me his current research emphasis. Of special interest is his experimental method for exploring the histology and physiology of experimental vibration injury. I am awaiting the publication of their extensive experience with vibrometry and its application to clinical conditions. Dr. Ove Engkvist, in Stockholm, extended a warm friendship. He stressed the importance of anatomic restoration during osteotomies for malnunion about the distal radioulnar joint. His protege Dr. Fredrik af Ekenstam was involved in exciting experimental work in Uppsala. His investigation of central motor neuron degeneration after peripheral nerve injury may prove to have profound implications for clinical care. We also took time to see the Medieval Museum in Stockholm
the
and to visit a museum, which featured paintings by Liljefors. All of my European hosts tended to my cultural education, escorting me to their imposing castles, spectacular cathedrals, museums, and other points of interest. My travels left me with many unforgettable images. That winter was unusually mild, and consequently rainy and gray. Close investigation often showed evidences of the extensive destruction of World War IT, including the monotonous features of postwar architecture. I had an eerie, disgusted feeling when my train passed near barbed wire wall fencing that separated the two Germanies in the spring of 1989. In contrast, the bright rising sun over the Swedish archipelago was cheery and encouraging. I have fond memories of excellent dining with all hosts, some quiet evenings with them and their families, and many new international friends. I left Europe with additional, distinct impressions. I was encouraged by the bright, talented, young hand surgeons training in European programs. However, socialization of medical care deprives the medical profession of a variety of incentives, and seems to take a creative energy and sense of optimism out of clinical and academic practice. The exchange of information and technology between the United States and Canada and western Europe is extremely rapid. I was also of the opinion that the development of the European Economic Community will tend to standardize education, evaluation, and eventually certification in hand surgery in western Europe. Recent political changes in eastern Europe have the potential to involve previously communist countries in this exciting process. My European hosts also left me with the impression that the ASSH retains a significant leadership role among hand surgery organizations throughout the world. The second part of my trip, in the United States, began in March when I visited Dr. John Madden in Tucson. His incredible vigor pervades every aspect of his practice. Most notably, he demonstrated a very practical dorsal approach to the PIP joint, for purposes of achieving a capsulotomy and limited flexor tenolysis. In May, I ventured north where the entire hand section at the Mayo Clinic welcomed me to their most impressive facility. I always learn from each member of their outstanding hand faculty, but on this occasion focused on Dr. Beckenbaugh's demonstration of effective salvage techniques for complex, failed wrist arthroplasty in rheumatoid arthritis (RA). I also visited their Department of Rheumatology, which gave me an
Vol. 15A, No.4 July 1990
opportunity to learn more about computerized methods of staging RA severity from hand radiographs and more about experimental arthritides in laboratory animals. I took a break from operating room environments during my visit to Dr. Richard Burton in Rochester, New York. I arrived for the Orthopaedic Department's spring combined Hand Conference and Alumni Meeting. The influence of his interests and dedication to hand surgery was apparent in the quality of the program. In nearby Syracuse; Dr. Andrew Palmer introduced me to the concept of dynamic ulnar variance and speculated on the basis of impingement in the neutral variance wrist. My next visit, to New York City, requires special comment. The chairman of the 1988 Bunnell committee, Dr. Richard Eaton, took great effort to structure an operating room experience for me. The intention was to demonstrate his technique for PIP joint volar plate arthroplasty. When I arrived at the Roosevelt Hospital, a nurses' strike had effectively closed the hospital, not to mention the operating rooms; however, we still enjoyed a very educational exchange in Dr. Eaton's beautifully designed offices. What a privilege it was to present clinical research to both Drs. Eaton and Littler, and to benefit from their insightful critique! My evenings were occupied by fine dining with Drs. Eaton and Littler, their junior partners, and their hand fellows. These occasions, and Dr. Littler's gift of his A Surgical Diary, Viet Nam, 1969, are truly memorable. I left New York by train for Boston, to visit the practice of Drs. Millender and Nalebuff. Again, the camaraderie and generosity were exceptional. Boston was notably beautiful in late May; the rhododendrons in Ed and Marcia's backyard were gorgeous. At the New England Baptist Hospital, the two partners had me evaluating patients with them in their offices. Their collective knowledge about, and experience with, rheumatoid hand surgery is nearly legendary, and rightfully so. I left their practice with many pearls, a deeper respect and an encouragement to continue thinking innovatively about reconstructive surgery in the rheumatoid hand. I returned home Memorial Day weekend mostly to, by this time, rest. A few days later I left for the Indianapolis Hand Center, where Dr. William Kleinman and his colleagues introduced me to their highly organized and comprehensive clinical practice. Aspects of their practice are very practical, such as glass walls between the rooms of their ambulatory surgery center. The size of their practice, their dedication to research,
1988 Bunnell Traveling Fellow Report
667
and their concepts for future development are well expressed in the establishment of their practice affiliated Research Foundation. Their clinical innovations and high clinical volume will allow their group to continue to bring definitive answers to clinical hand surgery. I arrived at my last stop, Denver, Colorado, on June lst. Dr. Mack Clayton welcomed me into his comfortable home. At his office we reviewed numerous cases and his experiences and current enthusiasm for semiconstrained, cemented total wrist arthroplasty. Dr. Donald Ferlic shared his time in the operating room, where we discussed total elbow arthroplasty and techniques for revising unsuccessful wrist arthrodeses. Both men have a wealth of clinical experience and knowledge about the rheumatoid upper extremity. The Claytons and Ferlics hosted me to a delightful dinner at the Denver Country Club the evening before my departure for home. It was near the end of my fellowship trip that I began to appreciate the importance of a concept that I believe will affect the treatment of our patients with rheumatoid arthritis in the future. This concept is that neurogenic processes mediate joint inflammation. The clinical evidence for this concept is that in patients with hemiplegia or peripheral nerve injury who subsequently acquire rheumatoid arthritis, joint inflammation does not develop in the involved extremities. The experimental evidence for this concept includes: (1) elevated neuropeptides in inflamedjoints, (2) the ability to modulate the intensity of inflammation by blocking or decreasing neuropeptide production, and (3) the ability to accentuate joint inflammation by introducing neuropeptides. Because rheumatoid arthritis often affects joints symmetrically, the demonstration of transverse neurologic pathways would strengthen this theory. Dr. Berti! Widenfalk, who presented his work to me in Uppsala, is confirming these pathways with use of hydrogen peroxidase staining techniques in experimental animals. A better understanding of the neurogenic contributions to rheumatoid arthritis will improve medical treatment and, as already suggested by our rheumatology colleagues, may provide new avenues of preventive surgical treatment via the nervous system. The surgical possibilities include central pathway ablation, and other approaches to manipulation of the peripheral nervous system. On my flight home I was exhausted, having experienced more than I could meaningfully incorporate into my professional milieau. I felt a sense of overwhelming graditude to each of my hosts, European and American,
668
Blair
and to their families and friends. They did much more to make my fellowship possible than I ever expected and more than I can ever begin to repay. I also felt a special gratefulness to Dr. Richard Eaton, who was supportive, informative, and encouraging. Through
The Journal of HAND SURGERY
everyone's efforts and assistance I did achieve a truly international overview of hand surgery and much more. I ended my travels knowing that the Bunnell Fellowship is the best academic, political, and cultural opportunity that a young hand surgeon can experience.
Bound volumes available to subscribers Bound volumes of the JOURNAL OF HAND SURGERY are available to subscribers (only) for the 1990 issues from the Publisher, at a cost of $35.00 ($43.00 international) for Vol. 15A (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Circulation Department, 11830 WestlineIndustrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800)325-4177, ext. 7351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
During my hand fellowship and initial years of clinical practice I viewed the Bunnell Fellowship as a prestigious but very distant award. At the urging of my teacher and friend, Dr. George Orner, I began the application process while diligently pursuing my academic activities. In September 1988, in Baltimore, I was fortunate enough to receive this award. It was truly one of the most exciting moments of my life. Literally within hours of receiving the award, it began to take on the more weighty appearance of a commitment and significant responsibility. Its many facets were clearly the predominant feature of my life during late 1988 and the spring and summer of 1989. My goal when applying for the fellowship was to gain an international overview of hand surgery, with an emphasis on rheumatoid arthritis. After consulting other members of the American Society for Surgery of the Hand (ASSH) and previous Bunnell Fellowship recipients, I organized a two-part trip. I wrote to my potential hosts, and ASSH President, David Green, provided a supplementary letter of introduction from our Society. With the help of a local travel agent, I planned every detail of the itinerary and obtained as many reservations as possible in advance. The first part of the trip was in western Europe. I departed for Copenhagen February 16, 1989. My sister, now a Danish citizen, met me and began the faltering process of orienting me to European customs. From Denmark I traveled south, to visit nine cities in four countries. I traveled exclusively by Eurail, because the system is affordable, dependable, and very punctual. As I arrived in each city, I found my hosts to be, without From the Division of Hand and Microsurgery, Division of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Reprint requests: William F. Blair, MD, Division of Hand and Microsurgery, Department of Orthopaedics, University of Iowa Hospitals and Clinics, Iowa City, IA 52242. 3/1/19938
exception, most willing to welcome me into their homes and hospitals. My first host, Professor Dieter BuckGramcko, welcomed me to Hamburg and the Unfallkrankenhaus. In a nearby childrens' hospital, he demonstrated his impeccable polIicization procedure. In his hands, this procedure goes beyond technique; it truly becomes artistic expression. In the Federal Republic of Germany, Dr. Ulrich Lanz was my host in Wurzburg and its fine University. He introduced to me the concept of the volar approach and special plates for osteotomies of the malunited distal radius. He also shared his pride in the reconstructed Bishop's castle, its beautifully preserved Tieppolo fresco, and the imposing Wurzburg castle. The first flowers of early spring were blooming when I arrived in Zurich, Switzerland. There, Viktor Meyer demonstrated his use of a voice-activated microscope in the operating room. His concepts and techniques, including the use of nerve approximators for peripheral nerve reconstruction, were very accomplished. Our discussions concerning the administration and funding of academic departments and the structure of Worker's Compensation in Switzerland carried us into the late evening hours. Over the weekend, the snowcapped mountains seen far across Lake Zurich invited me to come and ski. Instead, I stayed on task and joined the stafffor visiting rounds at the famous Schulthess Clinic. I was introduced to French Hand Surgery by Dr. Guy Foucher in Strasbourg. It was clear from the start that Dr. Foucher's practice was not typical. His home and practice, which included his outpatient clinic, ambulatory surgery unit, and hand therapy unit, were combined in one house. Practice functions and patient clinical features were highly computerized. This endeavor was partially supported by the French government in an effort to investigate innovative practice methods. The extensive computerization facilitated clinical research. Of interest, a psychoanalyst in the clinic examined most patients and assisted with pain management. My next appointment in France, March 1, 1989,
THE JOURNALOF HAND SURGERY
665
The Journal of 666
Blair
HAND SURGERY
was in Toul-Nancy, with Professor Michel Merle. He directed one of the premiere educational programs in Europe, which was comprised of young French hand surgeons, as well as resident surgeons from numerous countries. He demonstrated polyglycolic intramedullary pegs for the arthrodesis of small joints in rheumatoid hands. I also saw patients, some women, with aesthetically pleasing outcomes from radial forearm flaps. One of the more unforgettable moments of my travels was an introduction to Professor Jacque Michon. I met him near the end of his struggle with terminal illness. At the time, he was courageously continuing to provide care to his hand patients at the Hopital Jeanne d'Arc. He brought a patient from his office into the hallway, seeking the opinion of colleagues and to teach the hand fellows. I understand more clearly why he is considered one of our international fathers of hand surgery. My continued travels across northern France brought me to Rheims and Professor Francois Schernberg. He introduced me to a classification of scaphoid nonunions, which better predicts their natural history. He shared with me the pleasures of his community, home, and family-in a fine French fashion. I enjoyed my 4-day stay in Paris, where Professor Rauol Tubiana critiqued our clinical research on crossed intrinsic transfers. He also demonstrated proximal interphalangeal (PIP) joint implant arthroplasty technique, and use of power stapling to quickly facilitate metacarpal to radius arthrodesis in the late-stage rheumatoid wrist. Professor Tubiana was incredibly vigorous, both clinically and politically, and very wise about the nuances of international hand surgery. After a long night's train trip and a boat ride, I returned north to three stops in Sweden. Dr. Goran Lundborg, in Malmo, directed a most impressive hand surgery department. He patiently shared with me his current research emphasis. Of special interest is his experimental method for exploring the histology and physiology of experimental vibration injury. I am awaiting the publication of their extensive experience with vibrometry and its application to clinical conditions. Dr. Ove Engkvist, in Stockholm, extended a warm friendship. He stressed the importance of anatomic restoration during osteotomies for malnunion about the distal radioulnar joint. His protege Dr. Fredrik af Ekenstam was involved in exciting experimental work in Uppsala. His investigation of central motor neuron degeneration after peripheral nerve injury may prove to have profound implications for clinical care. We also took time to see the Medieval Museum in Stockholm
the
and to visit a museum, which featured paintings by Liljefors. All of my European hosts tended to my cultural education, escorting me to their imposing castles, spectacular cathedrals, museums, and other points of interest. My travels left me with many unforgettable images. That winter was unusually mild, and consequently rainy and gray. Close investigation often showed evidences of the extensive destruction of World War IT, including the monotonous features of postwar architecture. I had an eerie, disgusted feeling when my train passed near barbed wire wall fencing that separated the two Germanies in the spring of 1989. In contrast, the bright rising sun over the Swedish archipelago was cheery and encouraging. I have fond memories of excellent dining with all hosts, some quiet evenings with them and their families, and many new international friends. I left Europe with additional, distinct impressions. I was encouraged by the bright, talented, young hand surgeons training in European programs. However, socialization of medical care deprives the medical profession of a variety of incentives, and seems to take a creative energy and sense of optimism out of clinical and academic practice. The exchange of information and technology between the United States and Canada and western Europe is extremely rapid. I was also of the opinion that the development of the European Economic Community will tend to standardize education, evaluation, and eventually certification in hand surgery in western Europe. Recent political changes in eastern Europe have the potential to involve previously communist countries in this exciting process. My European hosts also left me with the impression that the ASSH retains a significant leadership role among hand surgery organizations throughout the world. The second part of my trip, in the United States, began in March when I visited Dr. John Madden in Tucson. His incredible vigor pervades every aspect of his practice. Most notably, he demonstrated a very practical dorsal approach to the PIP joint, for purposes of achieving a capsulotomy and limited flexor tenolysis. In May, I ventured north where the entire hand section at the Mayo Clinic welcomed me to their most impressive facility. I always learn from each member of their outstanding hand faculty, but on this occasion focused on Dr. Beckenbaugh's demonstration of effective salvage techniques for complex, failed wrist arthroplasty in rheumatoid arthritis (RA). I also visited their Department of Rheumatology, which gave me an
Vol. 15A, No.4 July 1990
opportunity to learn more about computerized methods of staging RA severity from hand radiographs and more about experimental arthritides in laboratory animals. I took a break from operating room environments during my visit to Dr. Richard Burton in Rochester, New York. I arrived for the Orthopaedic Department's spring combined Hand Conference and Alumni Meeting. The influence of his interests and dedication to hand surgery was apparent in the quality of the program. In nearby Syracuse; Dr. Andrew Palmer introduced me to the concept of dynamic ulnar variance and speculated on the basis of impingement in the neutral variance wrist. My next visit, to New York City, requires special comment. The chairman of the 1988 Bunnell committee, Dr. Richard Eaton, took great effort to structure an operating room experience for me. The intention was to demonstrate his technique for PIP joint volar plate arthroplasty. When I arrived at the Roosevelt Hospital, a nurses' strike had effectively closed the hospital, not to mention the operating rooms; however, we still enjoyed a very educational exchange in Dr. Eaton's beautifully designed offices. What a privilege it was to present clinical research to both Drs. Eaton and Littler, and to benefit from their insightful critique! My evenings were occupied by fine dining with Drs. Eaton and Littler, their junior partners, and their hand fellows. These occasions, and Dr. Littler's gift of his A Surgical Diary, Viet Nam, 1969, are truly memorable. I left New York by train for Boston, to visit the practice of Drs. Millender and Nalebuff. Again, the camaraderie and generosity were exceptional. Boston was notably beautiful in late May; the rhododendrons in Ed and Marcia's backyard were gorgeous. At the New England Baptist Hospital, the two partners had me evaluating patients with them in their offices. Their collective knowledge about, and experience with, rheumatoid hand surgery is nearly legendary, and rightfully so. I left their practice with many pearls, a deeper respect and an encouragement to continue thinking innovatively about reconstructive surgery in the rheumatoid hand. I returned home Memorial Day weekend mostly to, by this time, rest. A few days later I left for the Indianapolis Hand Center, where Dr. William Kleinman and his colleagues introduced me to their highly organized and comprehensive clinical practice. Aspects of their practice are very practical, such as glass walls between the rooms of their ambulatory surgery center. The size of their practice, their dedication to research,
1988 Bunnell Traveling Fellow Report
667
and their concepts for future development are well expressed in the establishment of their practice affiliated Research Foundation. Their clinical innovations and high clinical volume will allow their group to continue to bring definitive answers to clinical hand surgery. I arrived at my last stop, Denver, Colorado, on June lst. Dr. Mack Clayton welcomed me into his comfortable home. At his office we reviewed numerous cases and his experiences and current enthusiasm for semiconstrained, cemented total wrist arthroplasty. Dr. Donald Ferlic shared his time in the operating room, where we discussed total elbow arthroplasty and techniques for revising unsuccessful wrist arthrodeses. Both men have a wealth of clinical experience and knowledge about the rheumatoid upper extremity. The Claytons and Ferlics hosted me to a delightful dinner at the Denver Country Club the evening before my departure for home. It was near the end of my fellowship trip that I began to appreciate the importance of a concept that I believe will affect the treatment of our patients with rheumatoid arthritis in the future. This concept is that neurogenic processes mediate joint inflammation. The clinical evidence for this concept is that in patients with hemiplegia or peripheral nerve injury who subsequently acquire rheumatoid arthritis, joint inflammation does not develop in the involved extremities. The experimental evidence for this concept includes: (1) elevated neuropeptides in inflamedjoints, (2) the ability to modulate the intensity of inflammation by blocking or decreasing neuropeptide production, and (3) the ability to accentuate joint inflammation by introducing neuropeptides. Because rheumatoid arthritis often affects joints symmetrically, the demonstration of transverse neurologic pathways would strengthen this theory. Dr. Berti! Widenfalk, who presented his work to me in Uppsala, is confirming these pathways with use of hydrogen peroxidase staining techniques in experimental animals. A better understanding of the neurogenic contributions to rheumatoid arthritis will improve medical treatment and, as already suggested by our rheumatology colleagues, may provide new avenues of preventive surgical treatment via the nervous system. The surgical possibilities include central pathway ablation, and other approaches to manipulation of the peripheral nervous system. On my flight home I was exhausted, having experienced more than I could meaningfully incorporate into my professional milieau. I felt a sense of overwhelming graditude to each of my hosts, European and American,
668
Blair
and to their families and friends. They did much more to make my fellowship possible than I ever expected and more than I can ever begin to repay. I also felt a special gratefulness to Dr. Richard Eaton, who was supportive, informative, and encouraging. Through
The Journal of HAND SURGERY
everyone's efforts and assistance I did achieve a truly international overview of hand surgery and much more. I ended my travels knowing that the Bunnell Fellowship is the best academic, political, and cultural opportunity that a young hand surgeon can experience.
Bound volumes available to subscribers Bound volumes of the JOURNAL OF HAND SURGERY are available to subscribers (only) for the 1990 issues from the Publisher, at a cost of $35.00 ($43.00 international) for Vol. 15A (January-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Circulation Department, 11830 WestlineIndustrial Drive, St. Louis, Missouri 63146-3318, USA; phone (800)325-4177, ext. 7351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.