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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