Download Shoulder and Elbow Session, moderated by Anand Panchal, DO

AOAO 2015 Annual Meeting Needs Assessment
Thursday, October 15, 2015
CO*RE REMS Course, Mark Bailey, DO, PhD
The “ER/LA Opioid REMS” program has been developed by the Collaborative for REMS Education
(CO*RE). The American Osteopathic Association (AOA) is a CO*RE partner. CO*RE recently
received approval from the REMS Program Committee (RPC) for its national initiative to support
educational activities addressing the public health crisis surrounding the use, abuse, diversion and
overdose associated with Extended Release/Long Acting (ER/LA) opioids. As a result of that action,
the AOA invited affiliates to apply for block grants to present the REMS program. The American
Osteopathic Academy of Orthopedics has received an AOA block grant to present the program at
the 2015 AOAO Annual Meeting.
A Risk Evaluation and Mitigation Strategy (REMS) is a risk management program required by the
U.S. Food and Drug Administration (FDA) to ensure that the benefits of a drug outweigh its risks. The
FDA has determined that a single, shared REMS is required for all brand and generic ER/LA opioid
pain medicines. This is the first time the FDA has mandated a REMS to include accredited
professional education. The FDA has also required the pharmaceutical companies that produce these
agents to provide the financial support for independent professional education. The “ER/LA Opioid
REMS” program uses a standardized education module based on the approved FDA Blueprint. The
program is presented by DOs who have participated in the CO*RE master faculty training.
In the mid‐1990s, the use of prescription opioids traditionally reserved for treating cancer and acute
pain expanded to include treatment of other chronic pain conditions. In part, this change resulted from
ethical concerns related to the under-treatment of chronic pain. State medical boards and legislatures
changed regulations, ending a prohibition on opioid use for chronic non-cancer pain, while new
policies from state and national medical boards encouraged the use of opioids for long‐term pain
control. Following this change, a dramatic increase in opioid prescriptions was seen, with a parallel
increase in deaths due to drug poisonings and hospitalizations.1 In 2012, prescription opioid drug
abuse, misuse, and addiction are considered an epidemic and a significant public health concern.2
The problems of pain and misuse of pain treatments are well documented.3, 4 Opioids now exceed
cocaine and heroin in causing unintentional overdose deaths, having increased from causing 2,901
deaths in the US in 1999 to 11,499 in 2007. The misuse of opioids has become the most common
form of poisoning treated in US emergency departments (EDs).5 With regard to diversion of opioids in
particular, the National Drug Intelligence Center (NDIC) estimated the costs to public and private
insurers to be $72.5 billion per year.
At the same time, numerous clinical reports suggest that chronic pain remains undertreated.6, 7, 8, 9,
10, 11 Approximately 100 million people in the US experience chronic pain.12 However, the
percentage of patients receiving appropriate and adequate treatment has been reported to be as low
as 10‐25 percent.13, 14, 15 In terms of financial impact, large corporations each pay about $2 million
annually to cover absences, lost productivity, short‐term disability, and health care costs due to
chronic pain.16
In response to a 2006 Institute of Medicine (IOM) report on drug safety,17 the Food and Drug
Administration Amendments Act (FDAAA) was signed into law in 2007; this gave the FDA authority to
require risk evaluation and mitigation strategies (REMS) to have an increased focus on drug safety
and post-marketing surveillance.18 In July 2012, the FDA approved a REMS for extended-release
and longacting (ER/LA) opioids, mandating that manufacturers of these drugs implement a multifaceted program to “reduce risks and improve safe use of ER/LA opioids while continuing to provide
access to these medications for patients in pain.” A central component of these efforts is an education
program for prescribers, outlined in the document FDA Blueprint for Prescriber Education for
Extended-Release and Long-Acting Opioid Analgesics.
In the spring and summer of 2011, the CO*RE Partners designed and conducted an in-depth,
multimethod needs assessment to evaluate current literature, barriers to change, barriers to best
practice, perceived educational needs, health care professionals’ attitudes, and gaps in knowledge,
skills, and competence. Findings revealed that respondents perceive significant need for education,
including initial assessment of the patient, development of a treatment plan, assessment of risk for
abuse, and ongoing reassessment of the patient.
Results of a quantitative assessment of perceived competency gaps are illustrated in the figure
below. Primary care and specialist providers rated their current and desired levels of competency; the
average difference between these represents the gap, or perceived need. All of the measured
competencies recorded gaps above 0.5, which is considered meaningful; many gaps fall between 1.0
and 2.0, the ideal range for health care professional education.
1 Washington State Department of Labor and Industries. Interim Evaluation of the Washington State
Interagency
Guideline on Opioid Dosing for Chronic Non‐Cancer Pain. Available at:
http://www.agencymeddirectors.wa.gov/Files/AGReportFinal.pdf. Accessed July 27, 2011.
2 White House. Epidemic: Responding to America's prescription drug abuse crisis.
Accessed March 28, 2013.
3 Nurse Practitioner Healthcare Foundation. Managing Chronic Pain With Opioids: A Call for Change.
2010.
4 Centers for Disease Control and Prevention. Public Health Grand Rounds. Prescription Drug
Overdoses: An
American Epidemic. Available at: http://www.cdc.gov/about/grandrounds/
archives/2011/pdfs/PHGRRx17Feb2011.pdf. Accessed July 21, 2011.
5 Arnstein P, St. Marie B. Managing Chronic Pain with Opioids: A Call for Change: A White Paper by
the Nurse
Practitioner Healthcare Foundation. Nurse Practitioner Healthcare Foundation, December 15, 2010.
http://www.nphealthcarefoundation.org/programs/downloads/white_paper_opioids.pdf.
6 Lin JJ, Alfandre D, Moore C. Physician attitudes toward opioid prescribing for patients with
persistent noncancer
pain. Clin J Pain. 2007;23(9):799-803.
7 National Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations.
Pain: current
understanding of assessment, management, and treatments. Reston, VA; Oakbrook Terrace, IL
2001.
8 Reddy BS. The epidemic of unrelieved chronic pain. The ethical, societal, and regulatory barriers
facing opioid
prescribing physicians. J Leg Med. 2006;27(4):427-442.
9 Ricci JA, Stewart WF, Chee E, Leotta C, Foley K, Hochberg MC. Pain exacerbation as a major
source of lost
productive time in US workers with arthritis. Arthritis Rheum. 2005;53(5):673-681.
10 Ricci JA, Stewart WF, Chee E, Leotta C, Foley K, Hochberg MC. Back pain exacerbations and lost
productive time
costs in United States workers. Spine. 2006;31(26):3052-3060.
11 Smith BH, Macfarlane GJ, Torrance N. Epidemiology of chronic pain, from the laboratory to the
bus stop: time to
add understanding of biological mechanisms to the study of risk factors in population-based
research? Pain.
2007;127(1-2):5-10.
12 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and
Education: Relieving
Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The
National Academies
Press, 2011.
http://books.nap.edu/openbook.php?record_id=13172&page=1.
13 Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam
Pract.
2001;14(3):211-218.
14 Katz WA, Barkin RL. Dilemmas in chronic/persistent pain management. Am J Ther.
2008;15(3):256-264.
15 McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life
and the unmet
needs of pain management: results from pain sufferers and physicians participating in an Internet
survey. Am J
Ther. 2008;15(4):312-320.
16 Pizzi LT, Carter CT, Howell JB, et al. Work loss, healthcare utilization, and costs among US
employees with chronic
pain. Dis Manag Health Outcomes. 2005;13(3):201-208.
17 Institute of Medicine. The future of drug safety: promoting and protecting the health of the public.
September 22, 2006; Available at: http://books.nap.edu/catalog.php?record_id=11750. Accessed July
7, 2011.
18 110th United States Congress. Food and Drug Administration Amendment Act of 2007. Available
at:
http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=110_cong_public_laws&docid=f:publ085.110.
Accessed July 7, 2011.
Shoulder and Elbow Session, moderated by Anand Panchal, DO
The subspecialty of shoulder and elbow has garnered much attention in the last 10-15 years, with
significant technological advances that arguably have vaulted the field into the forefront of
orthopedics. New Implants like the reverse shoulder arthroplasty, and the explosion of arthroscopic
devices, manufacturers, and implants, have revolutionized the field; At the same time, however, they
have also led to a gap between the highly specialized “shoulder” surgeon, who is up on the latest
techniques and most advanced treatment options, and the general orthopedic surgeon in the
community who, at times, is required to “step up their game” in order to meet the needs of their
community. To that end, the overall goal of this session is to bridge this divide by providing a solid yet
thorough foundation of relevant topics presented by top shoulder and elbow surgeons in a manner
designed to bring the general orthopedic surgeon up to speed, thereby meeting the needs of both the
surgeon and the patients.
The first session the Shoulder and Elbow section meeting will focus on relevant topics that are
germaine to the subspecialty. Topics to be covered include the glenoid in shoulder arthroplasty, the
role of the reverse shoulder arthroplasty in this day and age, posterior shoulder instability, massive
rotator cuff tears and biologics, and finally recurrent elbow instability. These topics were designed
with the notion that general orthopedic surgeons are likely to see these cases in their offices but
might not be entirely facile and experienced in addressing the myriad of issues surrounding these
pathologies. In particular, the number of orthopedic surgeons performing shoulder replacement
continues to rise, even though past research has show that 75% of surgeons who perform shoulder
replacements perform less than 1-2 per year (Hasan, S. S., Leith, J. M., Smith, K. L., & Matsen, F. A.
(2003). The distribution of shoulder replacement among surgeons and hospitals is significantly
different than that of hip or knee replacement. Journal of shoulder and elbow surgery, 12(2), 164169.)
The average native glenoid surface area and glenoid vault volume - 8.67 +/- 2.73 cm2 and 11.86 +/5.06 cm3 respectively (Kwon, Y. W., Powell, K. A., Yum, J. K., Brems, J. J., & Iannotti, J. P. (2005).
Use of three-dimensional computed tomography for the analysis of the glenoid anatomy. Journal of
shoulder and elbow surgery, 14(1), 85-90.) and the average width of 24-32 mm and average superior
to inferior height of 36-44mm (multiple authors). This points to the inherent difficulty in implanting a
three dimensional component into a pyramidal shaped structure in which the surgeon only sees the
base (one side). Accordingly, it is paramount to understand the anatomy, the biomechanics, and the
fundamentals of glenoid implantation in total shoulder arthroplasty.
The explosion of reverse shoulder arthroplasties in the last ten years belies its subtle nuances, and
the lack of rigorous training and standardization of implantation should serve as a reminder that just
because it is new does not mean it is better. The complication rate for the reverse shoulder
replacement can be high, with cases upwards of 50% reported (Nam, D., Kepler, C. K., Neviaser, A.
S., Jones, K. J., Wright, T. M., Craig, E. V., & Warren, R. F. (2010). Reverse total shoulder
arthroplasty: current concepts, results, and component wear analysis. The Journal of Bone & Joint
Surgery, 92(Supplement 2), 23-35.). Understanding what role the RSA plays today and in the years to
come is of vital importance in ensuring its appropriate utilization
Posterior shoulder instability and recurrent elbow instability are pathologies that, anecdotally, are
typically referred to those surgeons who specialize in their treatment. JP Bradley from Pittsburgh has
written extensively on the technical components of posterior instability and posterior labral repair, and
our lecture will attempt to breakdown this technically demanding procedure into a stepwise, logical
sequence. Similarly, Recent research on elbow instability has led to new techniques to restore motion
and stability to the elbow. O’Driscoll and company at the Mayo clinic have published recently on this
topic, examining the role of allograft utilization and novel technique creating a one graft/two ligament
repair. (Finkbone, P. R., & O'Driscoll, S. W. (2015). Box-loop ligament reconstruction of the elbow for
medial and lateral instability. Journal of Shoulder and Elbow Surgery, 24(4), 647-654) and Baghdadi,
Y. M., Morrey, B. F., O’Driscoll, S. W., Steinmann, S. P., & Sanchez-Sotelo, J. (2014).;
Revision Allograft Reconstruction of the Lateral Collateral Ligament Complex in Elbows With
Previous Failed Reconstruction and Persistent Posterolateral Rotatory Instability. Clinical
Orthopaedics and Related Research®, 472(7), 2061-2067.).
Lastly, massive rotator cuff tear have received significant attention in the recent literature, focusing on
possible biologic enhancements that might alter the natural course of retearing/irrepairability. Recent
literature has shown that platelet rich plasma does not alter the course of large and massive Rotator
cuff repairs ( Charousset, C., Zaoui, A., Bellaïche, L., & Piterman, M. (2014). Does Autologous
Leukocyte-Platelet–Rich Plasma Improve Tendon Healing in Arthroscopic Repair of Large or Massive
Rotator Cuff Tears?. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 30(4), 428-435.),
while augmentation of massive rotator cuff repairs could potentially ebenfit from the use of allograft
patches (Ciampi, P., Scotti, C., Nonis, A., Vitali, M., Di Serio, C., Peretti, G. M., & Fraschini, G.
(2014). The Benefit of Synthetic Versus Biological Patch Augmentation in the Repair of
Posterosuperior Massive Rotator Cuff Tears A 3-Year Follow-up Study. The American journal of
sports medicine, 0363546514525592.). With the plethora of data published in the last 5-10 years on
the subject, the need exists for continual education of best practices for large and massive rotator cuff
tears in light of these technological and biological advances.
The gaps mentioned above highlight the difference in approaches and techniques between the highly
trained and experienced shoulder and elbow surgeon and the general orthopedic surgeon. The need
to bridge this gap and to ensure appropriate patient selection, proper pre-op planning including
understanding the role of each surgical option, and carrying out the surgery with technical expertise in
all facets of the operation are paramount to ensuring positive patient outcomes.
The second session of the shoulder and elbow section will look at cases, submitted by both the
moderator and/or local residents, reviewed and vetted by the moderator for content and
breadth/depth of information clinically useful and applicable to the general orthopedic surgeon. We
will first examine one of the most common procedures in the field of shoulder surgery – rotator cuff
repair. Utilizing illustrative cases, with a stepwise process of decision making shared by the panel of
shoulder surgeons, we will undertake a rigorous and methodical approach to rotator cuff repair, from
soup to nuts. We will then review cases in the “what would you do format?” in complex shoulder
arthroplasty with our panel, focusing on the thought process behind decisions for treatment in the
setting of revision arthroplasty, managing bone loss, arthroplasty in the young patient, and
complications of shoulder arthroplasty. In this second session we will also have available a interactive
format so that the physician learners/audience members can participate by answering questions
posted on the big screens, and then match their answers/thought process with the panel. By doing
this, we will fill the need to match best practices and current practice.
AOA Core Competencies




Medical Knowledge
Patient Care
Practice Based Learning and Improvement
Systems Based Practice
Residents and Fellows Session, moderated by Fred McAlpin, DO, FAOAO
For this session a review committee chooses, with Board approval, the best papers submitted by
residents during their training year. Those selected are then offered an opportunity to present their
research during this session at the Annual Meeting. Once they present, an “expert” or practicing
orthopedic surgeon comments on how that research is considered or used in daily practice.
Research has shown that resident research has many benefits, including fostering skills relevant to
clinical practice and promoting lifelong learning. Suemoto CK1, Ismail S2, Corrêa PC3, Khawaja F4,
Jerves T5, Pesantez L5, Germani AC6, Zaina F7, Dos Santos AC Junior8, de Oliveira Ferreira RJ9,
Singh P10, Paulo JV11, Matsubayashi SR12, Vidor LP13, Andretta G14, Tomás R15, Illigens BM16,
Fregni F, Five-year review of an international clinical research-training program, Adv Med Educ
Pract. 2015 Apr 1;6:249-257.
The Center for Primary Care Education and Research at New York Medical College in Valhalla
conducted a study and found that skills are best acquired in an environment which promotes active
learning - supervised by experts. They also found that added benefits for residents include creating
materials for presentation with experienced faculty, making presentations for peer groups, and
assuming the role of teacher (Pediatric residents as learners and teachers of evidence-based
medicine, Edwards KS, Woolf PK, Hetzler T., Center for Primary Care Education and Research, New
York Medical College, Valhalla, 10595, USA).
Fred McAlpin III, DO, FAOAO
Moderator
AOA Core Competencies addressed during this session:
 Medical Knowledge
 Patient Care
Friday, October 16, 2015
General Session, moderated by Richard Crank, Jr., DO
In this section, we will divide the session into two different topics. The first part of the session will
focus on the medical optimization of elective arthroplasty patients and geriatric hip fracture patients.
We will also focus on how to address the patient with metal-on-metal hip replacements.
Medical optimization of elective arthroplasty has become more than just “cardiac clearance”. In this
time of bundle payments, outcomes and value, we must optimize our patients to maximize their
outcomes prior to surgery. This topic will focus on the key points that must be addressed and review
of the current literature. A recent article in the Journal of Arthroplasty , Volume 29 , Issue 8 , 1610 –
1616 showed how outcomes greatly improved by implementation of a preoperative protocol to
optimize patients. A recent article in the The Journal of Bone & Joint Surgery Feb 2013,95(4) actually
discusses risk stratification and how to optimize outcomes. Medical optimization prior to geriatric hip
fracture and timing to surgery has become very important. An article in Clinical orthopaedics and
related research 425 (2004): 72-81 showed how clinical pathways have optimized survival and
outcomes. The excitement of the metal-on-metal hip arthroplasty has now passed. Unfortunately, the
fall out of such is still occurring. The appropriate work up and evaluation of the patient must be
evaluated and followed for years to come. A recent article in The Journal of arthroplasty 26.4 (2011):
511-518 explains the risk for this bearing surface and discusses the need for different modalities to
evaluate this patient.
The second part of the session will focus on the treatment of hip fracture and humerus fractures. We
will then discuss orthobiologics and how these adjuncts can be used in fracture management.
Hip fracture treatment has evolved significantly in orthopedics. Arthroplasty surgeons have begun
treating more hip fracture with total joint arthroplasty rather and hemi-arthroplasty. Also, fixation
techniques have improved. An article in Injury 31.10 (2000): 793-797 directly addresses outcomes for
patients and how they were treated. This is also reiterated in The Journal of Bone & Joint Surgery
88.2 (2006): 249-260. Proximal humeral fractures are still a very challenging fracture to manage. A
recent article in Instr Course Lect. 2015 directly addresses the current option for treating these
fractures. There are several different options for biologics in orthopedics. A recent article in Arthritis
Res Ther. 2012 Nov 30;14(6):225 provides a non-biased overview of current options in orthobiologics
and fracture healing.
In conclusion, as outcomes and value based medicine continue to involve, the above session topics
and current literature will help surgeons to improve outcomes based on current evidence based
literature.
AOA Core Competencies Addressed:
Medical Knowledge
Patient Care
Practice Based Learning and Improvement
Systems Based Practice
Adult Reconstructive and Arthritis Surgery Session, moderated by Brian Keyes, DO
The field of Adult Reconstruction is again at the forefront of advancements when it comes to patient
centered care and improvement processes. Advances such as multimodal pain regimens, advanced
robotic/computer assisted technology, and improvements in rapid rehabilitation processes are specific
examples just to name a few. Continued education in our subspecialty is critical in staying current
with improved surgical techniques and evidence based outcomes. This education is vital to meet the
increasing demands laid upon Hip and Knee Reconstruction surgeons as we move into the future of
the profession.
In the first session of the Adult Reconstruction and Arthritis Section (ARAS) educational program, the
focus will be on the principles of extensor mechanism reconstruction with synthetic mesh,
management of complex acetabular defects, flexion instability in total knee arthroplasty (TKA), direct
anterior revision hip arthroplasty, and the use of orthopedic databases in orthopedic surgery to push
quality measures.
Extensor mechanism disruption associated with total knee arthroplasty is an uncommon but
potentially disastrous complication. Repair with isolated suture fixation is insufficient, and autograft
and allograft tendon reconstruction techniques have variable results. Browne and Hansen (J Bone
Joint Surg Am. 2011 Jun 15;93(12):1137-43.), discussed a novel technique in management of this
difficult problem. The authors concluded successful outcomes in 9/13 patients at short-term followup, with statistically significant Knee Society scores for pain and function. Furthermore, synthetic
mesh used to reconstruct a disrupted extensor mechanism was considered technically easier and
eliminated the possibility of disease transmission and proved more cost-effective.
One of the many challenges in revision hip arthroplasty is management of complex acetabular
deficiencies and how to address such deficiencies in reconstruction surgery. The surgical
management options are extensive, and include use of jumbo cups, highly porous metals, impaction
grafting, metal and allograft augmentation, cage technology, and custom implants. Often times the
original decision for the solution to the problem comes from advanced imaging and appropriate
understanding of defect classification. In the landmark article and work by Paprosky et al., (J
Arthroplasty. 1994 Feb;9(1):33-44. Acetabular defect classification and surgical reconstruction in
revision arthroplasty. A 6-year follow-up evaluation. Paprosky WG, Perona PG, Lawrence JM. ),
acetabular defect classification and clinical outcomes were first elucidated to help with these difficult
reconstruction dilemmas.
In the second session, our the program will discuss dual mobility technology in hip arthroplasty,
infection management, mobile v. fixed bearing unicompartmental knee arthroplasty, and the
management of post-traumatic deformities and arthritis.
Literature has supported several advantages with unicompartmental knee arthroplasty vs. TKA.
These include; less invasive, less blood loss, decreased pain scores, faster rehabilitation, and
preserving more normal kinematics to the knee. Recently another reported advantage is preservation
of proximal tibial bone density (Richmond B1, Hadlow SV, Lynskey TG, Walker CG, Munro JT., Clin
Orthop Relat Res. 2013 May;471(5):1661-9). Bone mineral density (BMD) in the proximal tibia
decreases after TKA and is believed to be a factor in implant migration and loosening.
Unicompartmental knee arthroplasty (UKA) is a less invasive procedure preserving knee
compartments unaffected by degeneration. This research support that bone mineral density was
preserved 2 years after UKA with no major differences seen between implant types.
Infection as a complication in Hip and Knee arthroplasty is a devastating to both the patient and
surgeon. This surgical complication is also consuming substantial revenue on a yearly basis in our
healthcare system. The management of periprosthetic infection is complicated by the fact that there
isn’t a clear consensus on how to effectively minimize and or eradicate the known infections. The
Mayo Clinic has recently investigated seronegative periprosthetic joint infections (McArthur BA, Abdel
MP, Taunton MJ, Osmon DR, Hanssen AD. Bone Joint J. 2015 Jul;97-B(7):939-44. Seronegative
infections in hip and knee arthroplasty: periprosthetic infections with normal erythrocyte sedimentation
rate and C-reactive protein level.) Their data identified 538 TKAs and 414 THAs with periprosthetic
infection. Of these, 4% of confirmed infections were seronegative (21 TKA and 17 THA). Of those
who underwent pre-operative aspiration, cultures were positive in 76% of TKAs (n = 13) and 64% of
THAs (n = 7). Cell count and differential were suggestive of infection in 85% of TKA (n = 11) and all
THA aspirates (n = 5). The most common organism was coagulase-negative Staphylococcus.
Seronegative infections were associated with a lower aspirate cell count and a lower incidence of
Staphylococcus aureus infection. Two-stage revision was performed in 35 cases (95%). At a mean of
five years (14 to 162 months) following revision, re-operation for infection occurred in two TKAs, and
one THA. From this study the investigators estimate around 4% of patients with PJI may present with
normal ESR and CRP. When performed, pre-operative aspirate is useful in delivering a definitive
diagnosis. When treated, similar outcomes can be obtained compared with patients with positive
serology.
In conclusion, the program above discusses many topics that each and every adult reconstruction
orthopedic surgeon faces on a daily basis. The goals of the program would be to teach advanced
principles for complex scenarios, understand how evidence-based medicine and outcomes are
shaping our practices, learn from experienced fellowship trained adult reconstruction orthopedic
surgeons who have a passion for education.
AOA Core Competencies addressed during this session:
• Medical Knowledge
• Patient Care
• Practice Based Learning and Improvement
• Systems Based Practice
Hand Session, moderated by Adam Dann, DO
The variability in hand surgical fellowship training as well as hand surgical training in residency has
lead to gaps in knowledge for not only the practicing hand surgeon, but also the general orthopedist
who treats disorders of the upper extremity. The goal of the hand section lectures is to help bridge
that gap, as well as update practitioners on new and emerging techniques in hand surgery.
During the first half of the section lectures, we will begin with discussing Essex Lopresti injuries and
forearm instability. As stated by Green and Zelouf in 2009 (J Hand Surg Vol 34, Issue 5, p953-961
(http://dx.doi.org/10.1016/j.jhsa.2009.03.018)), this complex problem is often under diagnosed and
inadequately treated, resulting in inferior outcomes. This lecture is needed to improve the clinical
acumen of practitioners that may encounter these injuries, so that proper recognition of this injury can
lead to the best practice in treating these, whether that would be referral to a specialist or treating the
injury themselves for the hand specialists present. Flexor tendon injuries are one of the most studied
disorders in the hand, and one of the newer techniques in this arena is the use of local anesthesia
only procedures, which are revolutionizing rehab protocols as well. Pioneered by Don Lalonde and
described in 2013 (Hand Clin. 2013 May;29(2):207-13,
http://www.ncbi.nlm.nih.gov/pubmed/23660056) the hand surgeon will be updated on these newer
techniques during this lecture. Scapholunate ligament injuries continue to confound even the most
experienced hand surgeons, and recognition and treatment of these continue to be a challenge.
There continue to be advances in both surgical techniques as well newer technologies for the
treatment of not only acute scapholunate injuries, but also more chronic ones. Despite this, there is
still no “gold standard” of treatment, and this lecture will describe the pros and cons of the various
treatment types, providing all treating providers with more options for these complex injuries. The
final lecture of the first section will be dealing with practice management issues. With the advent of
the Affordable Care Act, as well as the upcoming transition to ICD-10, this lecture on E & M coding
and philosophy will help equip not only hand surgeons, but general orthopedists with the tools they
need to face the coming challenges.
The second half of lectures will deal with topics rarely lectured upon, but nonetheless need to be
discussed for both hand surgeons and general orthopedists to recognize and treat appropriately.
Brachial plexus injuries are a rare, devastating problem associated with traumatic injuries to the
shoulder girdle that often times require complex reconstructive procedures. Nerve transfers, or
muscle transfers to restore function such as elbow flexion (http://www.jhandsurg.org/article/S03635023(13)01722-X/abstract) are just a couple of options. This lecture will provide information in
regards to what can be done to treat these debilitating injuries. Patterson et al. (J Hand Surg Volume
36, Issue 9, Pages 1553–1562(http://www.jhandsurg.org/article/S0363-5023(11)00830-6/abstract)
described the challenge in diagnosing complex regional pain syndrome, and the importance of early
diagnosis and treatment for an optimal outcome. The need of recognition of, and early treatment of
both of these conditions will be addressed through these lectures. Soft tissue reconstruction of the
upper extremity is an area with great variability in training, and in surgeon comfort level with
performing different flap procedures. The need for increasing this comfort level of hand surgeons will
be addressed. As newer technology is developed, it invariably affects our daily lives and practices.
We have a duty as providers of medical care to familiarize ourselves with this technology, and it’s
implication in the treatment of upper extremity disorders, its affect on interpersonal and
communication skills, as well as issues regarding patient privacy. This gap in understanding with be
addressed.
As physicians treating disorders of the upper extremity, there will always be deficiencies in medical
knowledge that can affect patient care. Through this series of lectures, some of these deficiencies
will be addressed for both the practicing hand specialist as well as the general orthopedist
AOA Core Competencies Addressed:
Medical Knowledge
Patient Care
Interpersonal and communication skills
Practice Based Learning and Improvement
Foot and Ankle Session, moderated by Robert Marsh, DO
The profession and experience of the foot and ankle surgeon continues to expand. In the last 5 years
the number of new implants has been some of the most diverse on the market. However, we still see
simple complications from routine injuries. Additionally with complex limb salvage the literature still
remains scarce on directing treatment. The goal of this session with be to start with the simple ankle
sprain and expand the on the management of complex injuries.
In the first session, the focus will be on the basic principles of managing ankle sprains and
syndesmotic injuries. There are relatively few articles directed in orthopedic literature to the
persistently painful ankle (JAAOS Oct 1994, vol 2 no. 5 270-280). On the other hand there are
numerous articles on the management of syndesmotic sprains. This is the most commonly injured
joint in the body but yet the treatment varies extremely between not only foot and ankle surgeon, but
sports medicine orthopedic surgeons, general orthopedics and the primary care physician. In this
discussion we will review the current state of the art of handling these injuries, but the management of
the complications.
Ankle fusions continue to remain the gold for ankle arthritis. Well aligned primary osteoarthrosis of
the ankle is a fairly predictable outcome with generally favorable results. As the ability to salvage a
limb following trauma or congenital deformity the need to be familiar with different approaches
increases. In the first lecture approaches to the ankle fusion the goal of the lecture is simply as
stated to review the relevant anatomy and complications to different approaches to ankle fusions.
The second lecture on complex ankle fusions expands on the approaches to ankle fusions but also
introduces the work up necessary to manage complex deformities. Additionally, with complex
deformity multiple devices are available to perform this procedure. This includes simple screw
configurations, retrograde fusion nail, but also complex Illizarov frames.
With the improvement in the designs of ankle replacement we have seen an increase in demand for
ankle replacement especially in complex siturations.. This is the trend for not only primary ankle
arthritis but avascular necrosis, rheumatoid arthritis, and deformity. As the results and familiarity with
the procedure improve the demand has increased. The outcomes of total ankle replacement have
been very favorable. Zaidi et al (Bone Joint J. 2013 Nov;95-B(11):1500-7) found that total ankle
replacements had a positive influence on the patient’s lives lasting 10 years.
Converting an ankle fusion to an ankle replacement is an attractive option when the patient develops
arthritis is the surrounding joints. The painful ankle fusion is a dilemma and may ultimately require an
amputation (Clin Orthop Relat Res. 2004 Jul;(424):80-8.). In this article Hansen reports when there is
a clear source of pain converting ankle fusions to ankle replacement has a favorable result. The goal
of this lecture is to assess patients that are candidates , review the technique, and finally review the
current literature regarding outcomes.
Finally, diabetes continues to be a problem for all foot and ankle surgeons. Despite the many
advances in diabetic care we still see many avoidable complications. The last lecture will provide
insight on the management of diabetic ankle.
In summary, the foot and ankle surgeon has more tools than at any time to manage complex injuries.
However, as the technology evolves we need to also continue to expand the ability to apply these
new technologies to the current practice of foot and ankle surgery.
AOA Core Competencies addressed during this session:
 Medical Knowledge
 Patient Care
 Practice Based Learning and Improvement
Saturday, October 17, 2015
Pediatrics Session, moderated by Julieanne Sees, DO
Journal references attached.
Pediatric subspecialty training is a field in orthopedic surgery to improve the care of children with
musculoskeletal disorders through education, research and advocacy. Although many orthopedists
have a special interest in the treatment of children, there are those pediatric orthopedic surgeons who
look after children exclusively. Consequently, it has become important not to isolate the two but to
provide knowledge to surgeons who see pediatric patients in their practice and share up to date
essentials to pediatric medical care and fracture management.
In the first session of the pediatric section meeting, the focus will be on the concept of staying out of
trouble when treating all ages of children. General orthopedists should be familiar and comfortable
assessing the pediatric patient. The newborn nursery is where life begins not only for the pediatric
patient but also for the orthopedist who is often asked to examine a hip click, foot deformity or flail
arm. These are fairly common problems ranging from 1-3 per 1000 births having possible
developmental hip dysplasia, clubfoot deformity, or a brachial plexus palsy. (POSNA 2015, EPOS
2015) Understanding the current practice with identifying the condition will bridge the educational gap
as well as provide the highest standard of care those performing the exam and imitating treatment.
Athletes with developmental conditions are also among a group of children with who comfort in
examination and knowledge of safety issues can and must be implemented in daily practice. With
expansion of involvement in recreational sport safe participation relies on appropriate screening,
injury prevention and sport adaptation. Evaluation of the limping child is common for orthopedists who
treat children and competence of focused diagnosis, treatment and management includes knowledge
of spine, hip, leg and foot etiologies to develop best practice strategy of pediatric care. With
discussion and cases, the orthopedic surgeon treating pediatric patients will better formulate and
evaluate standard treatment plans for common pediatric orthopedic conditions.
In the second session, our focus will shift to pearls and pitfalls with recognition and management of
pediatric fractures. There continues to be current concepts of treatment which range from casting, to
external fixation, to internal fixation, open versus closed treatment, and numerous guidelines with
respect to weight, fracture severity, associated injuries and underlying medical or musculoskeletal
conditions (Heyworth. Curr Rev MM 2012, Palmu. Acta Orthop 2014, Shrader. Orthop Clin North Am.
2008, Abbott. JCO 2014) Timing of open fractures, pelvic injuries and spinal trauma with regards to
initial presentation in the emergency room to treatment in the operating room continues to bring
debate as well. (Bazzi. JCO. 2014, Goldstein JPS 2014) The resultant gaps show the need for
reviewing current literature and discussing options available for various injuries of the upper
extremity, lower extremity, and axial skeleton. The focus includes in depth discussions of
management strategies, operative techniques and advice to avoid complications. Broadening in the
scope we will compare conventional practices in the United States to those experienced with patients
treated overseas.
In conclusion, a variety of areas of pediatric orthopedics have maintained traditional treatment while
some have made changes to conventional methods for better care of our children. With continuous
improvement and expanding our knowledge we can enhance performance and provide even better
outcomes in our growing population for all orthopedic surgeons dedicated to their care.
AOA Core Competencies addressed during this session:
 Patient Care
 Medical Knowledge
 Practice Based Learning and Improvement
 Professionalism
Sports Session, moderated by Ryan Geringer, DO
Sports Medicine subspecialty training is one of the more advancing specialties in the field of
orthopedic surgery. The development of newer techniques and instrumentation, as well as the
advancements in diagnosis and treatment techniques, have expanded immensely over the last 10-15
years. As such, it is critical in regards to not just patient outcomes, but also to surgeon knowledge
and performance as well; that these changing ideas and techniques are shared between
subspecialty and general orthopedic surgeons alike.
In the first session of the sports medicine session, the focus will be on shoulder pathology including
diagnosis, treatment options, new techniques and outcomes. The comfort level of general orthopedic
surgeons with sports medicine care is variable, often dependent upon the experiences and training
received in residency and the presence or absence of a sports medicine fellowship trained
orthopedic surgeon within the same group or in the area. Some of the areas of interest will focus on
shoulder instability, AC joint pathology, labral and biceps pathology, and rehabilitation pertaining to
these areas.
Regarding rotator cuff pathology, a recent randomized prospective trial in The American Journal of
Sports Medicine (2014, April: 42(6): 1296-1303) does not support the routine use of partial
acromioplasty or coracoacromial ligament release in the surgical treatment of full-thickness rotator
cuff tears. Although many general orthopedic surgeons’ current practice is to perform a partial
acromioplasty, F. Familiari showed in a recent review (Journal of Orthopaedics and Traumatology
2015, May 24) that in some instances, a partial acromioplasty and release of the coracoaromial
ligament can even result in anterior escape and worsening symptoms. Furthermore, efficacy of
physical therapy has improved greatly in alleviating patient symptoms despite continued tears in the
rotator cuff. A large multicenter prospective cohort study recently demonstrated that a specific
physical therapy protocol can be very effective in treating symptoms in patients with atraumatic full
thickness rotator cuff tears (Journal of Shoulder and Elbow Surgery, 2013, October: 22(10): 13711379). The suggestion is that weakness or loss of function should be a better indicator for surgery
than pain. These small gaps demonstrated by the above example show the need for discussing the
literature and options for various shoulder conditions and how they continue to evolve over the years.
Educating orthopedic surgeons not only in the different procedures available, but what criteria need to
be met to justify the procedure would be part of the intervention needed.
In the second half of the session, our focus will shift towards upcoming and controversial surgical
techniques in sports medicine involving the knee. As training in knee surgery has evolved, so have
some of the therapeutic and surgical options available, as our diagnosis and treatment of various
knee ailments has changed. One of the most common presenting complaints to an orthopedic
surgeon’s office is that of “knee pain”. Patellofemoral pain has traditionally been treated in current
practice with combinations of corticosteroid injections icing, NSAIDs and bracing. Newer techniques
involving MPFL reconstruction and VMO advancements have been debated. Current literature on
MPFL reconstruction contains diverse methods of recording preoperative and postoperative
variables. Most studies report on a homogenous population, with inconsistent applicability to the
broad spectrum of patients. Hence, we need more clarity and consistency regarding the reporting of
methodology to be of value. Advancing technology including minimally invasive techniques with
quicker recovery have had promising results. Another common complaint in a sports medicine
physician’s office pertaining to the knee is instability. During this section of the lectures, we will be
able to discuss the complex anatomy of the posterior lateral corner of the knee as well as meniscal
pathology. In addition to furthering our knowledge of the anatomy, we will discuss new techniques
and treatment for both repair and reconstruction of these important structures.
In conclusion, as demonstrated above, multiple areas of sports medicine surgery have developed
newer techniques and instrumentation as well as upgrades or changes to some of the more
traditional techniques. Many of these changes have resulted in quicker recovery, improved patient
outcomes and decreased morbidity due to improvements in the surgeon’s knowledge base and
technical performance.
AOA Core Competencies addressed during this session:
 Patient Care
 Medical Knowledge
 Practice based learning and improvement
Trauma Session, moderated by Michael Leslie, DO
The core of Orthopedic Surgery lies within fracture care. As Trauma surgery has evolved and
developed in both General and Orthopedic Surgery, the subspecialty has provided ever evolving
critical evaluation of fracture treatment, reduction and fixation.
The Trauma Session will provide critical education in an interactive format that will include both
didactic and case review. The first session will concentrate on fractures of the lower extremity. Each
Orthopedist who takes call faces increasingly complex challenges with respect to patients who suffer
from injuries they do not often treat and many of those that they often treat but that are becoming
increasingly complex. One of the most common procedures performed by all Orthopedic surgeons is
hip fracture care and with increasing awareness of patient outcomes there is a need to develop
protocols and systems that help avoid readmission and fracture stabilization complication. In a recent
publication the influence of hip fracture stability was measured against reoperation (Chehade MJ,
Carbone T, Awward D, Taylor A, Wildenauer C, Ramasamy B, McGee M.
J Orthop Trauma. 2015 May 9) On the same night of call it would not be uncommon for an
Orthopedist to encounter a few osteoporotic pelvic ring injuries. With the increasing activity levels of
aging patients the simple answer of nonoperative care is not always valid. The details of evaluation
and care, particularly those who need tertiary care referral has been highlighted in recent
publications. Orthop Clin North Am. 2013 Apr;44(2):217-24. doi: 10.1016/j.ocl.2013.01.007. Epub
2013 Feb 5. The goals of this pat of the module is to illustrate modern care of these patients. The
final component of the lower extremity module will highlight an ever evolving topic of complex ankle
fractures. This is designed to highlight the injury that lies between a standard ankle fracture and a
pilon fracture where an appropriate intervention can lead to a successful outcome. Current
controversies include arthroscopic evaluation of the tibiotalar articulation, syndesmotic reduction
evaluation and types of fixation for the syndesmosis.
Evaluation and care of upper extremity fractures is the focus of the second portion of the session.
This session will focus on fractures of the proximal humerus, articular fractures at the elbow and the
the dorsal spanning approach to fractures of the distal radius. The proximal humerus requires careful
attention to decide whether surgical stabilization versus arthroplasty provides the most optimal patient
outcome. As the injury progresses to the elbow the stakes of treatment continue to rise with
adequate evaluation and management of the terrible triad, complex transolecranon fractures and
distal humerus fractures remains a common concern.
20. (Unstable fracture-dislocations of the elbow.Sotereanos DG, Darlis NA, Wright TW, Goitz RJ,
King GJ.Instr Course Lect. 2007;56:369-76. Review.)
Finally the increasing complexity of fractures in conjunction with the increasing complexity of patient
comorbidities has lead to extreme distal radius fractures that cannot be adequately treated with
standard volar plating.
The goals of this session will be to link the General Orthopedist to the subspecialty of complex
fracture care and bring new and novel approaches to complex fracture patterns to all learners and to
highlight contemporary literature.
AOA Core Competencies Addressed:



Medical Knowledge
Patient Care
Practice based learning and improvement
Spine Session, moderated by John Malloy, DO
Spinal surgery as an orthopedic surgical subspecialty has evolved immensely over the last 10 years.
Newer minimally invasive or less invasive techniques continue to challenge traditional techniques as
the "gold standard" in spinal care. Even the more commonly encountered every day clinical scenarios
have many different treatment options. It is critical that both spinal surgeons and general orthopedic
surgeons alike are able to identify the appropriate pathology and recommend appropriate treatment
based on subtle indications present in common clinical scenarios. This can only correlate to better
patient outcomes and higher quality of care.
In the first session of the spinal surgery section meeting we will focus on cervical spinal pathology.
Case presentations will be introduced and experts in the field of spinal care will present and debate
various treatment strategies for these conditions. For example the case of a cervical disc
herniation with radiculopathy maybe treated with cervical epidural injections, decompressive
procedures, fusion procedures or motion preservation procedures. These procedures may be done
through anterior or posterior approaches through open approaches or smaller less invasive
approaches. Guidelines have been published and the literature supports early success of some of the
newer techniques although not necessarily better than traditional procedures such as reported in this
recent comparison of cervical disc replacement versus fusion: Zechmeister I, Winkler R, Mad P.
Artificial total disc replacement versus fusion for the cervical spine: a systematic review. European
Spine Journal. 2011;20(2):177-184. doi:10.1007/s00586-010-1583-7. Spinal surgeons and orthopedic
surgeons need to be informed and up-to-date. Understanding the indications and benefits of these
procedures is crucial to successful outcomes and avoidance of complications.
In the second session lumbar spinal pathologies will be addressed in a similar fashion. Case
presentations of common clinical lumbar spinal pathology such as spondylolisthesis with low back
pain and lower extremity radiculopathy will be made. The current practice guidelines for nonoperative
treatment and operative treatment will be reviewed and presented.Surgical techniques will
be described and indications and contraindications will be reviewed. This will educate the attendees
in the various treatment options available and the current standards of when to implement such
methods.
In the third section the various biologic options will be reviewed. There has been significant changes
in the area of Biologics over the last five years with debate raging over the use of bone morphogenic
protein after the release of the findings from the YODA study. Yale School of Medicine. Yale
University Open Data Access (YODA) Project. New Haven, CT: Yale School of Medicine; 2012.
Accessed at http://medicine.yale.edu/core/projects/yodap/index.aspxon 15 August 2012. Newer stem
cell technology's have been emerging to challenge the gold standard autologous bone graft. These
products are often well marketed but their efficacy and potential complications are not so fully
understood. The current state of Biologics and the future of these newer technologies needs to be
reviewed and understood by spinal surgeons and orthopedic surgeons to ensure successful
implementation and usage for appropriate outcomes.
AOA Core Competencies addressed during this session:
 Medical Knowledge
 Patient Care
 Practice Based Learning and Improvement