AANA
Arthroscopy Association of North America Newsletter
Viva
J
Volume 29 Number 2
Education
by Benjamin Shaffer, MD
oin us in exciting Las Vegas this November for the 32nd Fall Course. To be held at the beautiful Cosmopolitan Hotel,
the meeting is already taking shape into what will undoubtedly be an exceptional educational experience designed to
meet your MOC and MOL needs. This fall’s meeting continues AANA’s
tradition of combining an interactive and dynamic educational didactic program
with a personalized hands on surgical training experience. This year’s academic
course features a comprehensive program covering the shoulder, knee, hip, foot/
ankle and elbow/wrist. Point/counterpoint debates, focus videos, and traditional
didactic talks will feature renowned faculty discussing appropriate indications,
treatment strategies and demonstrate state-of-the-art surgical techniques for the
spectrum of orthopaedic problems encountered in our practices.
The core of the course emphasizes surgical technique training for virtually
every arthroscopic procedure. A variety of different instruction is available, including traditional cadaveric and anatomic model labs which accompany the Knee
and Shoulder lecture series. Set up as an Orthopaedic Learning Center equivalent,
these labs feature a 2:1 faculty/attendee ratio to ensure personalized instruction and
assistance. The lab affords participants the opportunity to individualize their lab
experience so that they may develop and hone their surgical skills.
For those who want a more personalized experience, the popular minifellowship program has been expanded to include 15 available opportunities
to work one-on-one with an arthroscopic instructor of your choice. Providing
In This Issue
Continued on page 11
Viva Education
History Continues
New Board Members
President’s Message
Ask the Experts
New Members
Health Policy Update
Annual Meeting
Upcoming Dates
Recognized Fellowships
Changing of the Guard
Transit Teaching
Scientific Papers
Coding Corner
Committee Members
Spring 2013
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History
I
Continues
by Neil J. Maki, MD
n 2011 AANA distributed a fabulous book 30 Years of Excellence. At that
time we were soliciting items of historic interest for our arthroscopic archives.
Today the Archives Committee continues to solicit items that members believe
would be of historic interest, such as original instrumentation, books, etc…that are
in excellent condition. Currently we have a storage problem which will be rectified
once we move into our new headquarters in the new AAOS building; therefore,
as a result of this problem we can no longer accept items. Instead we are asking
members to take photos and submit these photos along with a written story about
the items that they believe to be of historic interest to AANA.
Let’s not lose our momentum in archiving our great history for surgeons to
come. David McCullough said it best when he stated, “History is who we are
and why we are the way we are.” Support the Archives Committee by sending
photos along with a written story to LaTosha Holden at [email protected]. This
correspondence will be appreciated, acknowledged, and a reviewed by the Archives
Committee at its annual meetings.
AANA
General
Information
6300 North River Rd, Ste 600
Rosemont, Illinois 60018
Telephone: (847) 292-2262
Fax: (847) 292-2268
Officers
2013 - 2014 Board Members
EXECUTIVE OFFICERS
President
J. W. Thomas Byrd, MD
First Vice President
William R. Beach, MD
Second Vice President
Jeffrey S. Abrams, MD
Secretary
Robert T. Burks, MD
Treasurer
Louis F. McIntyre, MD
BOARD OF DIRECTORS
Thomas R. Carter, MD
Brian J. Cole, MD
Julie A. Dodds, MD
Mark H. Getelman, MD
Victor M. Ilizaliturri, Jr., MD
Larry D. Field, MD
Immediate Past President
Nicholas A. Sgaglione, MD
Past President
Richard L. Angelo, MD
MEMORY
In
C. Robert Biondino, MD
Wallingford, Connecticut
James S. Mulhollan, MD
Little Rock, Arkansas
Membership
T
Inside AANA is a publication of
the Arthroscopy Association of
North America’s Communication
Committee.
Chairman
Vipool K. Goradia, MD
Robert Afra, MD
Michael P. Bradley, MD
Paul E. Caldwell, MD
Sherwin S. W. Ho, MD
John D. Kelly, IV, MD
Patricia A. Kolowich, MD
Bryan T. Leek, MD
Mark C. Pinto, MD
Michael E. Pollack, MD
Joshua Port, MD
Steven M. Stoller, MD
Sabrina M. Strickland, MD
Richard J. Thomas, MD
Christopher W. Uggen, MD
Editor
LaTosha Holden,
Director of Member Services
Desktop Publisher
Tiffiny J. Duensing,
Director of Information Systems
Update
he Membership Committee continues to receive large
numbers of highly qualified applicants for membership. Under the leadership of Dr. Bill Stetson the
Membership Committee has seen the membership increase
over 15%. Congratulations to Bill who will be stepping down
to focus his considerable skills as the new Chairman of the
International Committee for AAOS. Dr. J. Emory Chapman
will be assuming the position of Chairman of the Membership Committee for AANA which will continue to devote
2
Arthroscopy Association
of North America
its efforts in recruiting and evaluating high quality Active,
Associate, Fellow and Resident candidates to enhance the
growth of the organization. The development of the on-line
application has allowed for a more streamlined and effective application process which will facilitate this. Efforts are
underway to create an easier transition from Associate to
Active membership and to increase International Members.
The Committee’s efforts will be spearheaded by LaTosha
Holden with the assistance of Meghan Farrell.
Inside AANA
President’s Message
I
t is a privilege to sit in the President’s chair and reach out to the membership through our AANA
newsletter. There are many exciting actions on the horizon that I will be communicating to you over
this next year. Soon, ground will be broken for the Academy building, which will house a new state
of the art AANA/AAOS Learning Center that will now include a collaboration with AOSSM. Much of
this comes to fruition through the sweat of the brow of our immediate past president, Nick Sgaglione. You
will hear more about how AANA is revamping surgical skills training through the Copernicus Project
initiated by Nick’s immediate predecessor, Rick Angelo. These are exciting times for me and AANA. It
certainly brings to mind the old anonymous quote, “If I have seen further, it is because I have stood on
the shoulders of giants.”
For now, we are on the heels of a remarkably successful Annual Meeting in San Antonio, stewarded
by our leader, Nick Sgaglione. The accomplishments of teamwork were evident, especially with the collaboration of our Program Chair, Rob Pedowitz, and Education Chair, Ben Shaffer. Nick’s presidential
address moved the hearts of all of those in attendance with his theme on leadership in the face of adversity.
This was further highlighted by his invited Presidential Speaker, Eric Greitens, who shared strategies and
examples of how many can overcome so much. It was also a special occasion where we were able to collaborate with our AMECRA partners from Mexico. Then there was the great scientific and educational
program which has drawn rave reviews and included a special program for fellows and residents.
I am honored to begin this term as your 32nd President of the Arthroscopy Association of North
America. This is a time that the AANA membership has grown to more than 3700 members, including
the brightest and most innovative surgeons in our profession. The opportunities to improve on the diagnosis and treatment of diseases and injuries are boundless. Good science is important but also, in a time
of increasing emphasis on evidence-based medicine, AANA finds itself in a position that it must serve as
an advocate for patients’ rights, including access to the latest available technology. Sometimes there is
a gap between science and sound clinical judgment on behalf of the patients for whom we care. AANA
will continue to devote considerable resources to assure that its members and non-members alike maintain
the broadest scope of treatment options available that can be provided for the patients that we serve. Stay
tuned and have a great summer.
2013 Fall Course
November 7-9, 2013
The Cosmopolitan Hotel
Las Vegas, Nevada
Watch for registration materials coming in August!
Inside AANA
3
Ask the Experts
Postoperative Protocols for Routine Arthroscopic Procedures
by Michael E. Pollack, MD
P
ostoperative protocols for routine arthroscopic procedure are often arbitrary, informed as much by custom and training as objective evidence. We’ve asked our distinguished panel of experts to describe their postoperative approach
after common arthoscopic procedures including Knee Arthroscopy, ACL Reconstruction, Meniscus Repair and
Hip Arthroscopy. Subsequent newsletters will feature experts’ postoperative protocols for procedures including Standard
Shoulder Arthroscopy, Rotator Cuff Repair, Biceps Tenodesis and SLAP Repair. We gratefully acknowledge our panel
for devoting their time and sharing their wisdom: Drs. James Lubowitz, Peter Kurzweil, Stephen Howell, Marc Philippon,
and Benjamin Domb.
1) Please describe your standard postoperative b) CPM?
Lubowitz: 3° to tolerance for initial three weeks.
Knee arthroscopy protocol.
Kurzweil: No CPM - no study has ever shown it’s effective.
a) Use of a brace and/or crutches?
Howell: No.
Howell: No.
b) Whether you utilize Physical Therapy and, c) Whether you utilize Physical Therapy and,
if so, when?
if so, when?
Howell: No.
c) Restrictions placed on the patient in the
immediate postoperative period?
Lubowitz and Kurzweil: Twice weekly starting postoperative
day four for three to four and a half months.
Howell: No, Physical Therapists slow my patients down and
their ‘remedies’ result in worse motion and more pain to the
patient than a self administered exercise program.
Howell: None.
d) Timing of return to running and sport?
Howell: When the knee is pain free and functional.
e) Use of DVT prophylaxis?
Howell: None, unless on Oral Contraceptives and then on
ASA for three weeks.
d) Restrictions placed on the patient in the
immediate postoperative period?
Lubowitz: No Weight Bearing or ROM restrictions
Kurzweil: TTWB for three to seven days. Wean off crutches
as pain and swelling allow.
Howell: WBAT with no restrictions.
e) Timing of return to sport?
f) Type of closure utilized for portals?
Howell: Nylon sutures patients can remove at five days or
I will see them in 10-14 days.
2) Please describe your standard postoperative
ACL protocol.
a)Use of a brace and/or crutches?
Lubowitz: Brace for six weeks with 90 degree flexion stop
when ambulating and during at risk activities. Crutches for
two to seven days.
Kurzweil: We use a knee immobilizer only until they have
leg control ( i.e. can do a straight leg raise.) This is typically
two weeks - slightly longer for autografts than allografts.
Crutches for three to seven days.
Howell: Braces are ineffective, detrimental. Crutches only
until they are comfortable, generally one to two weeks.
4
Lubowitz: No running for three months and no cutting or
pivoting for six months
Kurzweil: No cutting and pivoting for nine months with
autograft and 12 months with allograft
Howell: Four to six months when the knee is pain free and
functional.
f) Use of DVT prophylaxis?
Lubowitz: Selective DVT prophylaxis using ASA 325 mg
daily if risk factors including smoking, prior DVT, on Estrogen replacement or Oral Contraceptives.
Kurzweil: 81 mg ASA daily for six weeks unless significant
risk factors also warrant Xarelto for 10 days.
Howell: None unless on Oral Contraceptives and then ASA
for three weeks.
Continued on page 5
Inside AANA
Ask the Experts Continued from page 4
g) Does your graft choice influence any on the
above?
Lubowitz: Not influenced by graft choice.
Kurzweil: Yes, as above.
Howell: No
3) Please describe your standard postoperative
ACL and Meniscus Repair protocol.
a)Use of a brace and/or crutches?
Lubowitz: Brace with full weight bearing and locked in
extension when ambulatory for six weeks. Two to seven
days for crutches.
Kurzweil: WBAT with knee brace in extension for three to
four weeks. Two weeks for crutches.
Howell: No brace. Crutches only until they are comfortable,
generally One to two weeks.
4) Please describe your standard postoperative
Hip Arthroscopy protocol.
a)Use of a continuous passive motion machine
and/or crutches?
Philippon: CPM machines are employed four to eight hours/
day while on crutches, starting at 10°-45° and progressing to
0°-80° of flexion while maintaining 10° of abduction. Weight
bearing is limited to 20 lbs of flat foot crutch-assisted weight
bearing for three to eight weeks depending on procedures
performed.
Domb: Continuous passive motion machine for four hours
a day or with a stationary bike on the lowest resistance for
two hours a day. Patients use crutches and are partial WB
with 20 lbs flat foot for two weeks for routine hip arthroscopy, six weeks for gluteus medius repair and eight weeks
for microfracture.
b) Whether you utilize Physical Therapy and, b) Whether you utilize Physical Therapy and,
if so, when?
if so, when?
Lubowitz and Kurzweil: Twice weekly starting postoperative
day four for three to four and a half months.
Howell: None
c) Restrictions placed on the patient in the immediate postoperative period?
Lubowitz: Full ROM when NWB for initial 6 weeks.
Kurzweil: TTWB for two weeks, then WBAT in knee brace
in extension for three to four weeks. No squatting for four
months.
Howell: No restrictions.
d) Timing of return to sport?
Lubowitz: No running for three months and no cutting or
pivoting for six months.
Kurzweil: No cutting and pivoting for nine months with
autograft and 12 months with allograft.
Howell: Four to six months when the knee is pain free and
functional.
Philippon: Physical therapy is implemented day after surgery if not day of surgery. Physical therapy is focused on
protection of repaired structures, return of ROM, increasing
strength, proper firing sequencing, and return to functional
activity.
Domb: PT on POD #1 and emphasizing passive motion.
Continued on page 6
Arthroscopy Association of North America
Masters Experience
Arthroscopic Surgical Skills Series
Orthopaedic Learning Center Rosemont, Illinois
2013 Course Catalog
Featuring:
Foot/Ankle
Shoulder
Knee
Wrist/Elbow
Hip
Resident
e) Use of DVT prophylaxis?
Lubowitz: Selective DVT prophylaxis using ASA 325 mg
daily if risk factors including smoking, prior DVT, on Estrogen replacement or Oral Contraceptives.
Kurzweil: 81 mg ASA daily for six weeks unless significant
risk factors also warrant Xarelto for 10 days.
Howell: None unless on Oral Contraceptives and then ASA
for three weeks.
Inside AANA
5
Ask the Experts Continued from page 5
c) Restrictions placed on the patient in the
immediate postoperative period?
Philippon: Weight bearing is limited to 20 lbs of flat foot
crutch-assisted weight bearing for three to eight weeks
depending on procedures performed. ROM restrictions
include external rotation and extension beyond 0° to
protect repairs to the anterior hip structures.
Domb: A brace is worn for two weeks, limiting flexion to
90° and extension to 0°. PROM within range limitations
for six weeks: Flexion: 90°, Extension 0°, Abduction
25-30°, Internal Rotation: 90 ° hip flexion: 0° neutral
(prone); External Rotation 90° hip flexion: 30°. After
six weeks, gradually progress ROM as tolerated and
within pain-free zone.
d) Timing of return to running and sport?
Philippon: Return to running is approximately six to
eight weeks non-microfracture and 10-12 weeks microfracture. Return to sport is approximately 10-14 weeks
non-microfracture and 14-16 weeks microfracture.
Domb: Return to sport and jogging begins at >12 weeks
with criteria for beginning sport specific training as
follows: Hip flexor strength:4+/5; Hip adduction, abduction, extension, internal and external rotation: 5-/5;
Cardiovascular endurance equal to pre-injury level;
Demonstrates proper squat form and pelvic stability with
initial agility drills, stable single-leg squat.
e) Use of DVT prophylaxis?
Philippon: Standard post-operative DVT prophylaxis
consists of sequential compression devices (SCDs)
bilaterally in conjunction with manual ankle pumps
while on crutches. Use of 75 mg of diclofenac taken
daily for the first two weeks, followed by 81 mg of
aspirin daily for the remainder of time on crutches also
as DVT prophylaxis.
Domb: ASA 325 mg BID is utilized for DVT prophylaxis and HO prophylaxis. If there is a previous history
of blood clots or HO, Lovenox and Indocin are used,
respectively.
f) Is there a role for Hyaluronic Acid
injections?
Philippon: Hyaluronic Acid injections are performed
at the conclusion of every surgery barring contraindications and at the first follow up appointment for those
patients who underwent a microfracture procedure.
Domb: For continued pain after hip arthroscopy, we
often use PRP injections rather than HA injection,
although patient preference due to cost can alter this
treatment modality.
6
WELCOME
The following is a list of new members.
The Actives were approved at the Annual Meeting.
Active
Resident
Berry, Robert E. DO
Buchko, Greg M. MD
Butkovich, Bradley MD
Castillo, Jesus A. DO
Christoforetti, John J. MD
Davis, Daniel K. MD
DeSimone, Alfred A. MD
Detterline, Alvin J. IV MD
Hannula, Todd Taylor MD
Hutter, Andrew Mark MD
Kindl, Brian MD
Lane, Clayton MD
Levitz, Craig L. MD
Liddell, Travis MD
Mangone, Peter MD
M. Villalobos, Mario MD
Mills, Edward L. MD
Perez Jimenez, Francisco MD
Rolf, Robert H. MD
Saliman, Justin D. MD
Sciortino, Robert A. MD
Stanwood, Walter Gales MD
Steingart, Michael A. DO
Vetter, Carole S. MD
White, Brian Joshua MD
Wilson, Philip L. MD
International
Arianjam, Afshin MD
Baker, Matthew C. MD
Beck, Jennifer J. MD
Belisle, Jeffrey MD
Chant, Chris MD
Dominguez, David E. MD
Ford, Gregory M. MD
Gardner, Elizabeth C. MD
Gonzalez, Mauricio MD
G. Campos, Mauricio MD
Huang, Gangyong MD
Joyner, Patrick W. MD
King, Joseph John MD
Kroner, Joseph Michael MD
Muxlow, Chad Jamison DO
Nelson, Ian R. MD
Pappas, Diana Rebecca DO
Park, Sam Si-Hyeong MD
Richards, Jason P. MD
Roberson, Troy MD
Romine, Lucas Brandon MD
Saliken, David Jason MD
Saper, Michael Garrett DO
Skelley, Nathan William MD
Tessier, Darin Douglas MD
Ward, James Patrick MD
Xiang, Qun MD
Young, Simon William MD
Zafonte, Brian M. MD
Bruno, Andrea Antonio MD
Associate
Acevedo, Jorge MD
Bassett, Robert L. MD
Crepeau, Allison E. MD
Dean, Jeffrey A. MD
Dewing, Christopher B. MD
DiGiovanni, Christopher MD
Keene, Roxanne R. MD
Moore, Ralph E. III MD
Nicandri, Gregg MD
Reino, Pasquale F. DO
Singhal, Manuj MD
Taber, Casey D. MD
Inside AANA
Health Policy
Committee
by Louis F. McIntyre, MD
F
or the past several years, AANA has been involved with assessing, critiquing and improving evidence based guidelines that affect our members and their patients. These guidelines have been promulgated by insurers, state agencies
and by the American Academy of Orthopedic Surgeons (AAOS). Our goal in this area has been to insure that our
patients continue to enjoy access to the best, high quality orthopaedic care available. We understand that there are disparities in healthcare utilization and delivery that are not supported by the surgical literature and that it is essential that our
members consider the evidence-based efficacy of treatments they recommend for their patients. We are also cognizant of
the fact that evidence based guidelines are not standardized and are used differently by governments, insurers, physicians
and patients in trying to formulate the best possible way to treat disease states. Evidence based medicine is, by definition,
use of the best available information to direct treatment. It also takes into account patient preference and expectation as
well as clinical expertise. With these tenants in mind, I would like to inform the membership of the recent publication
of Clinical Practice Guideline (CPG) on Treatment of Osteoarthritis of the Knee, 2nd Edition by the AAOS available at:
http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp
AANA leadership has been significantly involved in trying to improve these guidelines through written literature based
critique, online webinars and face to face discussions with the presidential line of the AAOS. While we were able to make
some improvements, we are still concerned with several of the recommendations and the potential ramifications that may
spring from their publication. Our concerns were summarized to the AAOS as follows:
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The evidence synthesis inclusion criteria of the CPG
process discount much of the surgical literature. As
a result, only 46% of all guideline recommendations
have a strong, moderate or weak strength.
The process is evolving and there are methodology
differences among all the published CPGs. This lack
of standardization leads to inconsistency which diminishes the value of the final product.
The process may contain a bias against surgical procedures as treatments. The recruitment and retention,
cost and ethical problems in conducting level I studies
in surgical patients are well documented. We believe
this potential bias is worthy of study as a part of the
CPG process.
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There is widespread concern that the process and semantics of the guidelines will limit access to care. This
has occurred with both AAOS CPG guidelines (New
York State Medicaid Redesign Taskforce denial of
coverage for arthroscopy in knee OA) and with other
published evidence-based endeavors (Washington
State Health Care Authority Health Technology Assessment and Oregon Health Effectiveness Research
Committee non coverage of FAI surgery).
There is concern that the CPG process may lead to
legal liability for our membership based upon establishing new, different standards of care through
such guidelines.
The CPG process currently is a good tool for assessing the quality of the surgical literature but a poor way
to educate physicians on appropriate, evidence-based
treatments in real time to improve and standardize
patient care.
AANA made several recommendations to AAOS leadership regarding potential improvements to the process including delaying publication to revise some of the recommendations, simultaneous publication of a corresponding Appropriate
Use Criteria (AUC) that allows for a broader inclusion of available evidence and convening a summit of involved specialty
societies to improve CPG value. In addition, we proposed a resolution at the Board of Specialty Societies (BOS) that would
1) increase specialty society input into the questions posed in the CPG process and 2) allow simultaneous AUC publication. We are hopeful that these recommendations will be adopted and implemented. AANA will continue to advocate for
improved evidence based processes to protect our patients and enhance the quality of orthopedic care.
Inside AANA
7
Annual Meeting
What I Learned in San Antonio
by Mark R. Hutchinson, MD
“Be always sure you are right - then go ahead.”
Davy Crockett (killed at the Alamo 12 Feb 1836)
“No man ever drowned in his own sweat.”
Stephen Burkhart’s grandfather
T
he 32nd Annual Meeting of AANA was an incredible meeting led by President
Nick Sgaglione and designed by Rob Pedowitz with his fellow members on the
Program Committee. The program kept the audience’s interest peaked with
carefully selected, high-quality, academic papers intermingled with brief practical
pearls from leaders in the field as well as clinical case panels. The latter two formats
brought the attendee from the lab and current science to a very practical sense of
current practice for the arthroscopic surgeon. Featured lectures were a literal who’s
who of the go-to leaders in arthroscopy including Lars Engebretsen, Freddie Fu,
Stephen Burkhart, Marc Philippon, James Andrews, and Stephen Snyder who each
personalized their approaches for all to mimic.
While I am confident that every attendee gathered their own set of clinical pearls
that will have immediate impact on their practice, several that I found of particular
interest are as follows:
Consider bone loss of the glenoid in all cases of revision shoulder
instability surgery. (R. Ryu, MD)
1
2
3
4
5
6
Isolated SLAP 2 repairs have 85% good results at 10 years.
(M. Carlson, MD & S. Snyder, MD)
Femoral nerve blocks for ACL reconstructions may decrease quad strength
at 6 months post op. (S. Kuzma, MD)
Above:
President Nicholas A. Sgaglione, MD
Hamstring grafts for ACL reconstruction may have a higher risk of post-op infection (G. Maletis, MD)
The risk of OA after isolated ACL is 0-13% but after combined injuries with meniscus loss jumps to 21-48%.
(L. Engebretsen, MD)
Shavers and burrs can leave metal particulate debris which is not healthy for the synovium or joint.
(R. Pedowitz, MD)
Ultimately, attendance at the Annual Meeting can serve two key purposes: first, to gather clinical pearls that will change
and validate your practice; the second is to reinvigorate the purpose behind why you practice. The latter was achieved at
the Annual Meeting through Steven Arnoczky, Stephen Burkhart, Eric Greitens, and Nick Sgaglione. Arnoczky provided
a wonderful, historical based and motivating presentation of why clinical research is a two way street. Collaboration between clinicians and researchers provides an ideal set of checks and balances directing both needs and quality of research.
Burkhart reminded us that creativity is made up not only of inspiration but also perspiration, the need to see an idea to
completion through hard work.
Clearly the most motivational messages came from President Nick Sgaglione and his guest speaker, Eric Greitens.
Greitens, a Navy SEAL, taught us about the evolution of character modeled after his SEAL training but exemplified by
his continued dedication to serve our injured warriors. Injured soldiers do not simply need to overcome their physical
disability, but more importantly need to fulfill an internal, personal mission to continue to serve and be valued by society.
He has created a remarkable program called The Mission Continues that successfully addresses that need. Nick Sgaglione
provided a personal, emotional, and heartfelt message (dedicated to Leslie Sgaglione) of how to overcome personal adversity.
He reminded us that adversity is a fact of life; the key is not the challenge but how we react to it. A great message for not
only our clinical practice but also our personal challenges. Kudos to Nick Sgaglione as a great AANA President and Rob
Pedowitz for creating an educational and motivational program.
Continued on page 9
8
Inside AANA
Annual Meeting Continued from page 8
Presidential Address: Overcoming Adversity
by Ronald P. Karzel, MD
At the AANA Annual Meeting in San Antonio, AANA President,
Nicholas Sgaglione, MD, addressed the audience with a speech that combined humor, advice, and emotion. Dr. Sgaglione was introduced by the
First Vice President, J.W. Thomas Byrd, MD. Dr. Byrd noted that Dr.
Sgaglione was born in humble circumstances and was the first member
of his family to attend college. After completing his medical training and
many years in a successful private practice setting in Long Island, Dr.
Sgaglione assumed an academic position as a professor of orthopedic
surgery at Einstein Medical College and became Residency Director of
the Long Island Jewish Orthopaedic Residency Program in 2007. In 2010,
he became Chairman of the Department of Orthopaedic Surgery at the
Long Island Jewish combined program as well as a full professor at that
program.
In his speech, Dr. Sgaglione particularly thanked the AANA Board
Members and AANA staff, whom he noted were essential to the successful
Above:
running of the arthroscopy organization. As Dr. Sgaglione noted, AANA
President Nicholas A. Sgaglione, MD
continues to thrive. He described the organization as stable, vibrant, and
introducing incoming President, J. W.
growing. AANA now has 3651 members, with 300 new members joinThomas Byrd, MD
ing over the past year. Thirty percent of these members are 40 years or
younger.
Dr. Sgaglione also reflected on the process by which he achieved success in his professional career. He emphasized
the importance of mentors. He noted that he would have been unable to be successful without having had the privilege to
work with an amazing group of mentors who taught by example and support.
Dr. Sgaglione stressed the importance of arthroscopy in orthopedics and how the field of arthroscopy has changed
the way that we take care of patients. He reminded the audience that when the initial leaders of this society introduced the
concept of arthroscopy to the orthopedic world, they had to fight an uphill battle. Arthroscopy was initially frowned upon,
then was reluctantly embraced, and now has grown to become an essential and ubiquitous procedure.
Dr. Sgaglione felt this was an example of a tipping point, as popularized by
the economist, Malcom Gladwell. Early leaders of AANA were able to change the
behavior of others through vision, initiative, measured innovation, and ultimately,
through a focus on the needs of the arthroscopy membership. He attributed the
success of AANA to leaders who were shaped by mentoring. Mentoring reflects
the essence of education, which is shared learning and shared teaching. He related
that a great mentor inspires his student to achieve full potential. The student then
in turn effectively adopts and imitates the practices of his mentor, particularly when
placed in a challenging position.
Such challenges and adversity are inevitable. As Dr. Sgaglione observed, “Adversity is a fact of life which cannot be controlled. However, what can be controlled
is how we react to the adversity.” He praised the presidential guest speaker, Eric
Greitens, a Navy SEAL, who had presented in the guest lecture his experiences
working with veterans who had sustained severe, life-changing combat injuries.
Mr. Greitens described the experience of getting knocked down, the importance of
getting back up, and the need to continue learning from the adversity. Ultimately,
by resetting priorities and expectations, veterans found a new sense of fulfillment
by contributing to the lives of others.
Dr. Sgaglione shared that he had also suffered his own personal adversity.
While on vacation with his wife, Leslie, and his four children in August of 2010, Above:
tragedy struck the family. While at the beach, Leslie witnessed a 10-year-old boy Presidential Guest Speaker, Eric Greitens,
discussing his experiences working with
being pulled out to sea by a riptide. She dove in to save the boy, and although the veterans.
boy was saved, Leslie drowned. Dr. Sgaglione’s life changed instantly, and as he
Continued on page 10
explained, “you never get over such a tragedy.” However, with the help of his
Inside AANA
9
Annual Meeting Continued from page 9
family, friends, and mentors, he realized he could survive
and adapt. He resolved to be positive despite the tragedy. He
resolved to continue to try to make a difference in the lives
of others. Dr. Sgaglione shared a quote from Helen Keller:
“What we have once enjoyed we can never lose. All that we
love deeply becomes a part of us.” Finally, Dr. Sgaglione
quoted Albert Einstein who said “Life is like riding a bicycle.
To keep your balance, you must keep moving.” It was a fitting ending to a moving and eloquent speech.
Annual Meeting Guest Speakers
Research Award Winners
The J. Whit Ewing Resident/Fellow Essay Award was
presented to Joshua David Harris, MD. The paper was
entitled Long-term Outcomes Following Bankart Shoulder
Stabilization- A Systematic Review. Ryan K. Harrison,
MD was awarded the Basic Science Resident/Fellow Award
with his paper entitled, Location Dependent Progression of
Traumatic and Post-traumatic Lesions of the Knee Cartilage
in a Rat Model of Osteoarthritis. The Richard O’Connor
Research Award was presented to David Clint Flanigan, MD
for his paper on Sub-Impact Loading Differentially Damages
Deep Layer of Cartilage in Medial and Lateral Condyles of
Porcine Knees.
Peter B. MacDonald, MD was awarded $21,000 for his
research entitled, Biceps Tenodesis Versus Tenotomy in the
Treatment of Lesions of the Long Head of Biceps Brachii
in Patients Undergoing Arthroscopic Rotator Cuff Repair:
Randomized Clinical Trial. The Dose Dependence of IntraArticular Growth Hormone Augmentation of Microfracture
Surgery for the Treatment of Chondral Defects in a Rabbit
Model Project by Eric J. Strauss, MD was awarded $25,000.
Peter Chalmers, MD was awarded $5,000 for his research
entitled, Function of the Long Head of the Biceps Muscle in
Kinematics of the Glenohumeral Joint During the Overhand
Throw: Evaluation of Tenodesis for SLAP Tears. $7,000 was
presented to Kevin D. Martin, DO for an AANA Resident
Education Course Validation Study Utilizing a Simulator
Model. Scott A. Rodeo, MD was awarded $21,000 for his
research on Cell-based Biological Repair Approach for
Partial Meniscectomy. Shane J. Nho, MD research on The
Effect of Hip Capsulotomy, Capsulectomy, and Capsular
Repair on Hip Stability: A Biomechanical Investigation was
awarded $21,500.
AANA’s 32nd Annual Meeting had the opportunity to
host four Keynote Lectures. The Presidential Guest Speaker
was Eric Greitens, a Navy Seal, founder of The Mission Continues, as well as an award-winning and best-selling author.
Greitens began his journey as a humanitarian working across
the globe. His doctoral thesis, Children First, investigated
how an organization can best serve war-affected children.
This inspired his award winning book of photographs and
essays, Strength and Compassion, which was recognized as
Forward Magazine’s “Photography Book of the Year,” and
was the winner of the 2009 New York Book Festival. In
his latest book, the Heart and the Fist, Greitens draws from
his experience as a Navy Seal, humanitarian and volunteer
working with veterans and presents a story of leadership and
service. During his presentation, he encouraged attendees
to find a way to live with courage and purpose. In his book,
the Heart and the Fist, he explains that a leader must learn to
serve others with a compassionate heart and with the courage
of his fist. His message inspired attendees to look at themselves as leaders and realize that all have untapped courage
and have the potential to be leaders in their everyday lives.
He challenged attendees to develop the courage
to just begin, to build on a set of positive habits
and inspire others. He takes on this challenge
personally through his program, The Mission Continues, which gives military veterans the ability to
continue to serve and develop a sense of worth.
AANA’s Annual Meeting attendees also had
the pleasure of International Guest Speaker, Lars
Engebretsen, MD, PhD who has served on the
faculties of the University of Trondheim and the
University of Minnesota as Associate Professor in
Orthopaedic Surgery. The Clinical Guest Speaker
was Donald L. Resnick, MD a professor of Radiology and Chief of Musculoskeletal Imaging
at the University of California, San Diego. The Above Research Award winners: Jeff R.S. Leiter, MD, Jonathan B. Ticker,
Scientific Guest Speaker was Steven P. Arnoczky, MD, Research Committee Chairman, Eric J. Strauss, MD, Anthony A. Romeo,
DVM, Dipl ACVS, Dipl ACVSMR Director of MD, Shane J. Nho, MD, Russell F. Warren, MD, and Kevin D. Martin, MD
the Laboratory for Comparative Orthopaedic
Research at Michigan State University.
10
Inside AANA
Viva Education
Continued from page 1
technical assistance and sharing personal and professional insights, experiences and tips,
this opportunity to interface with renowned and skilled orthopaedic pros is a distinctive
AANA offering not replicated in other courses. In addition, this year for the first time will
be offered three “maxi” fellowships, in which a particular arthroscopic procedure will be
demonstrated on a cadaver by an experienced expert. An opportunity to interact directly
with, and actually participate hands-on during the fellowship will be afforded to the five
attendees permitted in each of the three areas. We expect that this new combination of
hands-on experience and close intimate interaction with a skilled arthroscopic instructor
will prove to be both valuable and informative.
In the ongoing AANA tradition of providing an opportunity to learn about the latest
in technological trends and innovations, we will be featuring 18 Focus Demonstrations
instructed by experienced expert faculty. AANA makes this opportunity available to attendees at no charge, permitting small groups of approximately 20 attendees to learn from
an experienced instructor and moderator in a cadaveric or model workshop session. The
small faculty to attendee ratio is intended to facilitate interaction and maximize opportunities to identify some of the often subtle nuances when learning indications and techniques
for new and evolving arthroscopic procedures. In addition, the Fall Course will offer an
opportunity to catch the latest information on coding updates and the consistently popular
Clinical/MRI correlation course.
So make sure not to miss this year’s Fall Course, which promises to be an exceptional
learning opportunity in the exciting and entertaining city of Las Vegas. Whether hitting the
links on one of the area’s many golf courses, playing on one of the hotel’s many premiere
tennis courts, working on your fitness in their spa, playing your hand at one of the many
available games, allowing yourself to be pampered in their exclusive full service spa, or
dining in one of their many restaurants, you and your family will enjoy the topflight learning experience in a spectacular entertaining setting. We look forward to seeing you there!
2013 Learning Center Courses
Knee
208 Knee “Ligament”
June 7-9
LL
UMD
Gregory C. Fanelli,
F
E
RM.SHowell, MD
Stephen
U
O
C
Donald H. Johnson, MD
Jason L. Koh, MD
214 Knee “Cartilage”
October 18-20
Robert E. Hunter, MD
Jack M. Bert, MD
Thomas R. Carter, MD
Brian J. Cole, MD
Nicholas A. Sgaglione, MD
Inside AANA
Hip
209 June 28-30
Thomas G. Sampson, MD
LL
U
J. W. Thomas Byrd,
MD
F
E
Michael
B.S
Gerhardt, MD
R
U
O
C Y. Shonnard, MD
Paul
210 July 19-21
LL
Marc J. Philippon, U
MD
F
Benjamin
Domb, MD
SE
RG.
U
O
Victor
M.
Ilizaliturri,
Jr. MD
C
Allston J. Stubbs, MD
Resident
215 October 24-27
John F. Orwin, MD
ULL
F
E
Michael R
P. S
Bradley, MD
Robert
COUA. Pedowitz, MD
Paul D. Fadale, MD
Ronald M. Selby, MD
Shoulder
212 September 20-22
Larry D. Field, MD
Paul E. Caldwell, MD
Kevin D. Plancher, MD
Stephen C. Weber, MD
Foot/Ankle
213 September 28-29
James W. Stone, MD
Mark A. Glazebrook, MD
James P. Tasto, MD
Alastair S. Younger, MD
Upcoming
Meetings
Annual Meeting
2014, May 1-3
Hollywood, FL
2015, April 23-25
Los Angeles, CA
2016, April 14-16
Boston, MA
Fall Course
2013, November 7-9
Las Vegas, NV
2014, November 6-8
Palm Desert, CA
2015, November 12-14
Grapevine, TX
2016, November 10-12
Las Vegas, NV
Specialty Day
2014, March 15
New Orleans, LA
2015, March 28
Las Vegas, NV
11
Recognized
Fellowships
The following is a list of the AANA Recognized Fellowships. As you know, many AANA members help train the next
generation of arthroscopists. If you have a fellowship and would like AANA recognition, please contact the office at 847292-2262 for details regarding the procedures.
Orthopaedic Center of Southern
Illinois Fellowship
James C. Chow, MD
University of Toronto Orthopedic
Sports Medicine
Richard M. Holtby, MD
University of Pittsburgh
Christopher D. Harner, MD
American Sports Medicine Institute
St. Vincents
Jeffrey R. Dugas, MD
Boston University Orthopaedic
Sports Medicine Fellowship Program
Thomas A. Einhorn, MD
Cincinnati Sports Medicine and
Orthopaedic Center
Frank R. Noyes, MD
Mississippi Sports Medicine and
Orthopaedic Center for Sports
Medicine - Arthroscopy
Gene R. Barrett, MD
Larry D. Field, MD
San Diego Arthroscopy and Sports
Medicine Fellowship
Jan Fronek, MD, Heinz Hoenecke, MD,
James P. Tasto, MD
West Coast Sports Medicine
Fellowship
Keith S. Feder, MD, Carol Frey, MD
University of Wisconsin Hospital
and Clinic
John F. Orwin, MD
Massachusetts General Hospital/
Harvard Sports Medicine Fellowship
Thomas Gill, IV, MD
Sports Medicine and Arthroscopy
Fellowship
Wesley M. Nottage, MD
Kerlan Jobe Orthopaedic Sports
Medicine Fellowship Program
Neal S. ElAttrache, MD
Rush Sports Medicine Fellowship
Program
Bernard R. Bach, Jr., MD
UCLA Sports Medicine Fellowship
David McAllister, MD
Sports, Orthopedics and Spine
Shoulder Arthroscopy and Sports
Medicine Fellowship
Keith D. Nord, MD
Mercy Hospital Anderson/University
of Cincinnati
Angelo Colosimo, MD,
Denver T. Stanfield, MD
University of Utah Orthopaedic
Sports Medicine Fellowship
Robert T. Burks, MD
Steadman Philippon Clinic Sports
Medicine Fellowship
J. Richard Steadman, MD
UCONN Sports Medicine Fellowship
Program
Robert A. Arciero, MD
New England Baptist Hospital Sports
Medicine Program
Mark E. Steiner, MD
Aspen Sports Medicine Foundation
Fellowship
Tomas Pevny, MD, Eleanor Van Stade,
MD, Ferdinand Liotta, MD, Mark
Purnell, MD, N. Lindsay Harris, MD
Orthopaedic Research of Virginia
Arthroscopy and Sports Medicine
Fellowship
William R. Beach, MD, Paul E.
Caldwell, MD, John F. Meyers, MD,
Julious P. Smith, MD,
Shannon M. Wolfe, MD
Western University Fowler
Kennedy Orthopaedic Sport
Medicine Fellowship
J. Robert Giffin, MD
New Mexico Orthopaedics
Arthroscopy & Sports Medicine
Fellowship
Samuel K. Tabet, MD
Plano and Associated Orthopedics &
Sports Medicine Fellowship
F. Alan Barber, MD,
Alexander I. Glogau, MD
University of Kentucky Sports
Medicine Fellowship
Scott D. Mair, MD
Southern California Orthopedic
Institute
Richard D. Ferkel, MD
The Hughston Foundation Orthopaedic Sports Medicine Program
Champ L. Baker, Jr., MD
Doctors Hospital Program
(Baptist Health of South Florida)
Harlan Selesnick, MD
12
ASMI-Trinity/Lemak Sports
Medicine
Lawrence J. Lemak, MD
Hopsital for Special Surgery/Sports
Medicine Fellowship
David W. Altchek, MD
Scott A. Rodeo, MD
Taos Orthopaedic Institute Sports
Medicine Fellowship
Dan Guttman, MD, James H. Lubowitz,
MD, John B. Reid, III, MD
Continued on page 13
Inside AANA
Changing
I
of the Guard
by Patricia A. Kolowich, MD
n our history’s great pomp in circumstance lies the notable changing of the guards, a symbolic Army regulation that
has been practiced since 1937. Respectfully guards take watch over their fallen comrades with precision and same can
be said in regards to J. Whit Ewing MD as he served AANA in many roles over the years. This year marks the end
of his dedicated service. He was instrumental in the development of the Orthopedic Learning Center (OLC) and greatly
influenced the current Committee on Committees structure to appoint committee chair persons and committee members
which has supported the organizational growth since 1991.
In 1992, Dr. Ewing was elected President of AANA and during his tenure, guidelines were developed for the use of
cadavers in skills courses. Also during that time the OLC Board of Directors was established and representation was shared
equally with AAOS. Whit became the first Chairman of the OLC BOD in 1994.
On July 1, 2000, J. Whit Ewing MD assumed the role of Executive Vice President of AANA. He has remained in
this leadership role for AANA until April of this year. In 2013 he retired from this position. He has been instrumental in
leading AANA in many successful endeavors. He has truly been a giant among men and will be greatly missed.
During the 2013 Annual Meeting Jack Bert, MD was appointed as the new Executive Advisor to the AANA Board.
It is his goal to assist the board and staff with any issues related to the success of our organization including development
of the new OLC and continuing relationships with industry and AANA members. He also believes that in the future it
will be critical for AANA to maintain an advocacy position to government, payers and the AAOS in order to survive the
dramatic changes we all will face with declining
reimbursements and the effects of the Affordable
Care Act. AANA must represent our members’
concerns enabling them to deliver the highest
quality of care.
Other changes in the staff this year at AANA
include the retirement of Donna Nikkel and the
addition of Susan Carlson, MS, Ed as Director of
Education; LaTosha Holden, MSIMC as Director
of Member Services and Meghan Farrell as the
Member Services Coordinator. Also, Christine
DiGiovanni is the new Learning Center Coordinator. As each of these new staff persons, in addition
to the new board members and committee chairs,
step into their new roles with AANA, they have
accepted their charge and in true guard fashion
they respond, “Orders acknowledged.”
Above: Past Presidents at a dinner honoring J. Whit Ewing, MD
Recognized Fellowships
Continued from page 12
Santa Monica Sports Medicine
Fellowship
Bert R. Mandelbaum, MD
Sports Medicine Fellowship- Union
Memorial Hospital
Richard Hinton, MD
Orthopaedic Foundation for Active
Lifestyles Sports Medicine
Fellowship
Kevin D. Plancher, MD
Center for Shoulder, Elbow
and Sports Medicine Fellowship
Louis U. Bigliani, MD,
William N. Levine, MD
NYU Hospital for Joint Diseases
Sports Medicine Fellowship
Orrin Sherman, MD
McGaw Medical Center of
Northwestern University
Sports Medicine Fellowship
Michael A. Terry, MD
The Staten Island Sports Medicine/
Arthroscopic Fellowship
Mark F. Sherman, MD
Inside AANA
13
Transit
I
Teaching
by Abdul Foad, MD
have to echo the sentiments of the previous years’ AANA
Traveling Fellows when they say it was an experience of a
lifetime. From observing the calculated finesse of arthroscopically repairing a massive chronic retracted rotator cuff tear with the
Graft Jacket by both Dr. Snyder and Dr. Getelman to dining out
like rock stars and experiencing exclusive outdoor sporting activities, the 2013 AANA Traveling Fellowship was an experience we
will cherish forever.
Our trip began Sunday, April 14 where we met in the Denver
Airport. The four Fellows: Kevin Willits, MD from the University
of Western Ontario in London, Ontario, Canada; Kevin Farmer,
MD from the University of Florida, Gainesville; Matthew Bollier,
MD from the University of Iowa, Iowa City and Abdullah Foad, Above: Ready to learn; Stephen Burkhart, MD, Kevin
MD from the Quality Surgicenter, Clinton, Iowa became quickly Willits, MD, Matthew Bollier, MD, Peter Millett, MD
acquainted. We all met up with our Godfather, Stephen Burkhart, (Steadman-Philippon Institute), Abdul Foad, MD, and
MD from the San Antonio Orthopaedic Group in Vail, Colorado. Kevin Farmer, MD.
After a restful night at the plush Sebastian Hotel, we were greeted by the Steadman-Philippon team of Richard Steadman, MD; John Feagin, MD; Thomas Clanton, MD; Peter Millett, MD; and Robert LaPrade, MD, PhD for a Grand Rounds
session. After we gave our individual presentations to the group of physicians, physical/occupational therapists, and research
scientists, we were given a tour of their world-class research facilities by Coen Wijdicks, PhD and Luke O’Brien, PT. Next,
we had the opportunity to observe Dr. Millett perform a flawless double-row rotator cuff repair of a delaminated chronic
cuff, a reconstruction of a symptomatic unstable sternoclavicular joint with a gracilus autograft, an MDI arthroscopic stabilization procedure, and a total shoulder. We also had the privilege to watch Dr. Thomas Hackett perform a CRIM pinning
of a midshaft clavicular fracture using the Sonoma flexible nail, a revision ACL reconstruction, a Laterjet procedure, and
an elbow arthroscopy. After a full day’s worth of great cases, we were treated to some fine dining and enjoyed getting
to know the Steadman Clinic Surgeons and their Sports Fellows. We continued the observation of these world-class surgeons the next day with more exciting cases with Dr. LaPrade performing a PCL revision reconstruction and a beautiful
patellofemoral stabilization for a not so uncommon iatrogenic medial patellar dislocation. We were all impressed with Dr.
Philippon performing a hip arthroscopy with labral reconstruction without fluoroscopy!
The flow of events at the Steadman Clinic went so smooth
thanks to the gracious hospitality of Dr. LaPrade, Dr. Steadman, and
Kelly Stoycheff who is the Fellowship and Education Coordinator.
While she was making arrangements for us to go snowmobiling due
to the unexpected snow, she introduced us to the TED sandwich
(stands for Thanksgiving Every Day) which put us all into a “postprandial snoozagenesis”, but we managed to make it out to the Vail
mountains for a fun and friendly day. We topped the visit off with
a wonderful dinner at the Steadman’s home. They were the most
gracious hosts and wow, what a beautiful jaw-dropping view of the
mountains from the back deck of the Steadman’s. It was first class
hospitality all the way! Because of the heavy snowfall (almost 2
feet in three days), our travel plans out of Vail were thwarted. But
having a Godfather like Dr. Burkhart saved the day. He was truly
amazing to watch how he handled all of our travel arrangements. Above: Snowmobiling in Vail; Stephen Burkhart, MD,
We decided to spend the day together driving to Denver and really Abdul Foad, MD, Matthew Bollier, MD, Kevin Farmer,
MD, and Kevin Willits, MD.
getting some “quality time”.
After a late night arrival into LAX, we visited our second site the very next morning: The Southern California Orthopedic Institute in Van Nuys. We observed a revision arthroscopic rotator cuff repair with the aide of the GraftJacket by
Stephen Snyder, MD and a very nice arthroscopic subscapularis repair and suprapectoral biceps tenodesis by Ronald Karzel,
MD. That evening all five of us (yes, including our Godfather, who by the way, gave a very motivating presentation) gave
Continued on page 15
14
Inside AANA
Transit Teaching
Continued from page 14
our presentations to the SCOI surgeons and Sports Fellows at yet
another place of fine dining. The next day, the case list with Dr.
Snyder included an arthroscopic PASTA repair and with Dr. Mark
Getelman, a re-revision of a massive, retracted cuff tear using the
GraftJacket. Their impeccable arthroscopic surgical skills and perseverance were quite impressive and something to be admired. The
big theme we gathered at SCOI was their commitment to excellence,
giving the best patient care, yet maintaining efficiency and costcontainment. They are truly a fine-tuned institute. Extravagant
dining was another common theme in southern California as we
were invited to Fleming’s for dinner and hosted by DePuy Mitek
Synthes. A big “thank you” to them.
That brought us to Saturday where we had a day to play. We
had the pleasure of meeting William Stetson, MD and Scott Powell,
MD who were our great hosts at a California Angels game. They
provided us with a private suite right behind home plate. The game Above: California Angels game; Kevin Farmer, MD,
was essentially over after the first inning as the Angels scored 9 Matthew Bollier, MD, Kevin Willits, MD, Abdul Foad, MD,
runs against the Detroit Tigers with a final score of 10-1. This and Stephen Burkhart, MD.
gave us lots of time to socialize and enjoy each other’s company.
It was a perfect day!
Our third and final destination was San Antonio, where our “honorary Godmother” Mrs. Nora Burkhart greeted us at
the airport. We went straight to the Alamo Café for some good ‘ole authentic Mexican food. After our stomachs were full
of freshly made tortillas, the Burkhart’s arranged for a private tour of the Alamo. This was a shrine for Texas liberty where
one could not help but feel proud to be an American, let alone, a Texan. Afterwards, we enjoyed a casual stroll along the
famous San Antonio River Walk before a busy next day’s schedule.
We spent the last few days at the San Antonio Orthopaedic
Group where we watched the Godfather in his element. We saw
cutting-edge arthroscopic shoulder surgery case after case. We
observed an arthroscopic capsular release with decompression; arthroscopic repair of a massive cuff tear including the supraspinatus/
infraspinatus/subscapularis and intraosseous suprapectoral biceps
tenodesis where Dr. Burkhart demonstrated his technique of an
anterior interval slide “in continuity”. The grand finale was what
we all thought would be an irreparable cuff tear. Thank goodness
we aren’t betting folks as Dr. Burkhart “wowed us” in repairing
yet another difficult shoulder. We were able to see all the tricks
from his Cowboy’s Companion text come out on this very one case.
He is truly the epitomy of the ideals of competency, compassion,
mentoring, and teaching.
While at the San Antonio Orthopaedic Group, we not only
observed premier educational events, but we also were introduced
to the business of orthopaedics. Mr. Usman “Sani” Mirza (the
CEO of the Group) was gracious enough to spend a couple hours Above: Cloud 9 Ranch; Kevin Farmer, MD, Matthew
with us to provide information and allow us to ask questions to Bollier, MD, Kevin Willits, MD, Abdul Foad, MD, and
help maximize our business and professional careers. He was very Stephen Burkhart, MD.
enlightening regarding the business of orthopaedics and learning to
think “outside the box”. The 2013 AANA Traveling Fellowship came to an end after having a great big Texas style down
home dinner at the Burkhart’s Cloud 9 Ranch where we enjoyed close-up observation of various exotic animals from all
over the world, story-telling, and camaraderie.
After eleven days, our Traveling Fellowship ended at the 2013 AANA Annual Meeting at the J.W. Marriott Resort in
San Antonio. The feeling of living like rock stars continued as we had free reign to any of the ICLs and we were invited
to many receptions and the President’s Dinner. Meeting Nicholas A. Sgaglione, MD was an honor. Getting to know him
a little bit on a personal level was heart-warming. This was truly a one-time opportunity and we are very appreciative to
all the hosts and their support staff for making the experience so amazing. All four of us look forward to seeing our new
friends at future meetings and to hosting future traveling fellows.
Inside AANA
15
Scientific Paper
T
by Robert Afra MD
his is a review of the article Koh, et al. Pain management by Periarticular Multimodal Drug Injection
After ACL Reconstruction: a Randomized, Controlled
Study. Arthroscopy 2012. 28(5):649-657.
In a prospective, randomized, controlled study published
in a 2012 issue of Journal of Arthroscopy and Related Research, Koh et al. demonstrate that enhanced pain control
can be obtained with analgesic injection into the periarticular tissues in comparison to intraarticular injection after
arthroscopic ACL reconstruction.
The study design entailed a single center, single blinded
study with two experienced surgeons using a single technique
to perform arthroscopic ACL reconstruction using BTB
autograft (using identical surgical principles including graft
harvest, tunneling, and fixation methods). Patients were randomly distributed into 5 study groups (control, intraarticular
injection using ropivicaine [IA-R], intraarticular injection
using a multimodal drug cocktail [IA-MDC], periarticular
injection using a multimodal drug cocktail [PA-MDC], and
combined intraarticular and periarticular injection using
a multimodal drug cocktail [IA/PA-MDC]). Pain level at
POD 0,1,2, and 14 were assessed using VAS scores. The
patients, the investigator collecting all outcome variables,
and the statistician were blinded to treatment arm. MDC
comprised 150mg of 0.75% ropivacaine (20ml), 5mg of
morphine sulfate (5ml), 30mg of ketorolac (1ml), 200microg
of epinephrine (1:1000) (0.2ml), and 375mg of cefuroxime
in 5ml normal saline (to minimize infection risk of cocktail
preparation). PA injections include medication administration to several specific locations: (1) periosteum around bone
harvest sites (patella, tibial tuberosity);(2) patella tendon
retinaculum; (3) infrapatellar fat pad; (4) tibial tunnel periosteum and fascia; and (5) incision and portal sites. Only
patients undergoing primary ACL reconstruction using BTB
autograft were included. Patients with concomitant meniscus
debridement, repair, or microfracture were included; and
there were no significant differences with respect to proportion of combined procedures with the ACL reconstruction
among the groups. There were no significant demographic
data differences among the study groups. Patients with history of prior ipsilateral ACL reconstruction, allergy, opiate
abuse, or hepatic/renal dysfunction were excluded.
The authors show that periarticular injection into the
soft tissues around the knee (as specified above) produce
statistically significant improvement in pain control when
compared to intraarticular injection within the first 24 hours
after surgery. The groups including PA (PA and PA/IA)
injections had less pain during the night after surgery (POD
0) than patients in the groups without PA injections.
16
No significant differences were observed when comparing intraarticular injections of ropivicaine versus the
multimodal drug cocktail. Pain levels in the Control, IA-R,
and IA-MDC groups were not significantly different during
the entire study period.
Additionally, pain levels in the PA and PA/IA groups
were not significantly different during the entire study period. From POD 1 and onward, the intergroup pain level
differences were not statistically significant among any of
the groups.
The authors of this study are based in Seoul, Korea. It is
important to highlight several technical differences employed
by the surgeons that may deviate from standard practice in
the US, which the authors acknowledge. All patients in the
study were admitted to an inpatient hospital for two days; all
patients received spinal anesthetic; and all patients received
intravenous fentanyl patient controlled analgesia (PCA).
This is the standard regional practice for these authors. All
patients also received celecoxib. To their credit, however,
this facilitated better pain assessment oversight.
The authors state that an IA injection may have no
additional effect on pain relief, as no additional pain level
reduction was observed in the IA-R or IA-MDC groups when
compared with the Control group. Although this statement
is consistent with the data presented, it is feasible that any
IA injection benefit was masked by the spinal anesthetic,
the intravenous patient controlled analgesia, and/or oral
celecoxib administration that all patients undergoing ACL
reconstruction at the authors’ institution received.
Continued on page 17
Inside AANA
Coding
L
Corner
by William R. Beach, MD
ouis McIntyre, MD, the AANA Health Policies Committee chairman, has
updated the membership on Clinical Practice Guidelines in the HP update
section. The new reality of evidence-based medicine (EBM) is upon us.
The reality is that we have a paucity of higher levels of evidence/data and we have
to change that, now! We have to capture the innovative spirit of AANA. How
would the early pioneers of arthroscopy approach this task? Our expectations of
the past and dream plan for the future is to:
1
2
Enlist AANA members and other orthopedic surgeons to collect data and
champion the challenge that lies ahead.
Create innovative data collection tools that will achieve the task, collect
data. This means shorter questionnaires focused on patient centered
outcomes research. As has been said before, “it is better to get 100 patients
to answer one question than to get one patient to answer 100 questions!”
3
4
5
6
7
NOW AVAILABLE
ARTHROSCOPY
SELF ASSESSMENT
PROGRAM
ORDER
NOW!
Create databases that will house the data collected by hundreds of volunteer
surgeons.
Develop optimal data collection timetables that will maximize our effort
and collect data at strategic time intervals.
Support the data collection effort with publication “fast-tracks” that allows
this important information to be shared in a larger forum.
Use the data to leverage our/orthopedics value in the healthcare discussion.
Avoid the limitations of access to care that are currently jeopardizing
patient care. Specifically, sharing data with regulators and insurers
highlighting the procedures we perform.
This is a very brief description of a larger plan that has to occur to maintain
the appropriate level of care for our patients. We do not exist in a vacuum and
we have to recognize and embrace our responsibility in a world of evidence-based
medicine. We will need to lead instead of follow in this most important endeavor.
Scientific Paper
Continued from page 16
The authors state that a ‘pain rebound phenomenon on POD 1’ is
observed in the groups with PA injection. Although, an increase in pain
is seen in the PA groups at POD 1, this may simply be an unmasking
of pain that exists as the chemical effects of the PA analgesia subsides.
Furthermore, the pain level of the PA groups is no higher than the nonPA groups.
In summary, a multimodal drug cocktail injected into the periarticular soft tissues after arthroscopic ACL reconstruction provides better
analgesia within the first 24 hours than does an equivalent intraarticular
injection. This has direct clinical implications.
Inside AANA
The NEW Arthroscopy Self-Assessment
Program (ASAP) exam features 100 clinically
relevant, peer reviewed questions and
discussions on Sports Medicine and Arthroscopy
topics providing the opportunity for orthopaedic
professionals to review and enhance their
knowledge. Developed by the Arthroscopy
Association of North America as a
comprehensive self-assessment product,
ASAP can be used to fulfill Component 2 of MOC
and assist in preparation for examinations.
asap offers:
Flexibility to complete the program
in an online format
Electronic format offers ability to see
missed questions and to pick up
where you left off
Ease of claiming credit electronically
ORDER YOUR PROGRAM ONLINE at
http://selfassessment.aana.org
This enduring activity has been approved for
AMA PRA Category 1 Credit™.
17
2013-2014
AANALive
Chairman
Paul E. Caldwell, MD
Joseph P. Burns, MD
Julie A. Dodds, MD
Benjamin Domb, MD
Christopher P. Dougherty, DO
Mark H. Getelman, MD
Mark A. Glazebrook, MD
Jeffrey L. Halbrecht, MD
Victor M. Ilizaliturri Jr., MD
Ronald P. Karzel, MD
Marc R. Labbe, MD
Louis F. McIntyre, MD
Patrick H. Noud, MD
John P. Peden, MD
Kevin D. Plancher, MD
James W. Stone, MD
Richard James Thomas, MD
Stephen C. Weber, MD
Archives
Neil J. Maki, MD
W. Dilworth Cannon Jr., MD
John B. McGinty, MD
John F. Meyers, MD
James R. Ramsey, MD
Howard J. Sweeney, MD
Bylaws
Chairman
J. Kim Meyers, MD
Michael S. Bahk, MD
John G. Costouros, MD
Alexander Golant, MD
John R. Green, III, MD
John D. Toth, DO
Elizabeth Marie Watson, MD
Committee on
Committees
Chairman
William R. Beach, MD
Jeffrey S. Abrams, MD
Richard L. Angelo, MD
J. W. Thomas Byrd, MD
Nicholas A. Sgaglione, MD
18
Committee Members
Health Policy & Practice
Chairman
Louis F. McIntyre, MD
William R. Beach, MD
Kevin F. Bonner, MD
Michael P. Bradley, MD
George C. Branche, III, MD
Christopher P. Dougherty, DO
Kenneth J. Edwards, MD
Robert Y. Garroway, MD
Daniel Mark Hampton, MD
Marston Shaun Holt, MD
W. Bryan Jennings, DO
Richard C. Mather, III, MD
W. Michael Tew, MD
Scott Trenhaile, MD
Jon J.P. Warner, MD
Communications
Chairman
Vipool K. Goradia, MD
Robert Afra, MD
Michael P. Bradley, MD
Paul E. Caldwell, MD
Sherwin S. W. Ho, MD
John D. Kelly, IV, MD
Patricia A. Kolowich, MD
Bryan T. Leek, MD
Mark C. Pinto, MD
Michael E. Pollack, MD
Joshua Port, MD
Steven M. Stoller, MD
Sabrina M. Strickland ,MD
Richard James Thomas, MD
Christopher W. Uggen, MD
Compliance
Chairman
Patrick St. Pierre ,MD
Laura A. Alberton, MD
Robert T. Burks, MD
J. Emory Chapman, MD
Michael D. Feldman, MD
Robert E. Hunter, MD
John D. Kelly, IV, MD
Kurre T. Luber, MD
Sean McMillan, DO
Darius M. Moezzi, MD
Ronald M. Selby, MD
John M. Tokish, MD
Christopher W. Uggen, MD
Noah D. Weiss, MD
Development
Chairman
Jeffrey S. Abrams, MD
Jack M. Bert, MD
Robert T. Burks, MD
James C. Chow, MD
Alan S. Curtis, MD
Marc R. Labbe, MD
James H. Lubowitz, MD
John C. Richmond, MD
Richard K.N. Ryu, MD
Ronald M. Selby, MD
Walter R. Shelton, MD
Denver T. Stanfield, MD
Kenneth R. Zaslav, MD
Education
Chairman
Ben Shaffer, MD
Thomas R. Carter, MD
Alan S. Curtis, MD
Mark C. Drakos, MD
Richard D. Ferkel, MD
Larry D. Field, MD
Jeffrey L. Halbrecht, MD
Laurence D. Higgins, MD
Ronald P. Karzel, MD
John D. Kelly, IV, MD
Jason L Koh, MD
Marc R. Labbe, MD
Christopher M. Larson, MD
Kevin D. Plancher, MD
Matthew T. Provencher, MD
Ricardo J. Rodriguez, MD
Steven E. Rokito, MD
Anthony A. Romeo, MD
Allston J. Stubbs, MD
John M. Tokish, MD
Jeffrey Yao, MD
Education Foundation
Chairman
James C. Y. Chow, MD
Albert A. Andrews, MD
Richard L. Angelo, MD
Leslie S. Matthews, MD
Michael McBreen, MD
Richard K.N. Ryu, MD
Felix H. Savoie, III, MD
Continued on page 19
Inside AANA
Committee Members
Continued from page 18
Executive
Chairman
J. W. Thomas Byrd, MD
Jeffrey S. Abrams, MD
Richard L. Angelo, MD
William R. Beach, MD
Robert T. Burks, MD
Louis F. McIntyre, MD
Nicholas A. Sgaglione, MD
Fellowship
Chairman
Denver T. Stanfield, MD
Brian D. Busconi, MD
Mark H. Getelman, MD
Alexander I. Glogau, MD
Edward Rhett Hobgood, MD
Laith M. Jazrawi, MD
C. Benjamin Ma, MD
John F. Orwin, MD
Anil S. Ranawat, MD
Glen Ross, MD
Finance
Chairman
J. W. Thomas Byrd, MD
Jeffrey S. Abrams, MD
Richard L. Angelo, MD
William R. Beach, MD
Brian J. Cole, MD
Louis F. McIntyre, MD
International
Chairman
Pietro M. Tonino, MD
Jeffrey S. Abrams, MD
James C. Chow, MD
Carlos A. Guanche, MD
Robert E. Hunter, MD
Victor M. Ilizaliturri, Jr., MD
John D. Kelly, IV, MD
C. Benjamin Ma, MD
M. Mike Malek, MD
Anthony A. Romeo, MD
Felix H. Savoie, III, MD
William B. Stetson, MD
Howard J. Sweeney, MD
Inside AANA
Journal Board of
Trustees
Chairman
Walter R. Shelton, MD
Richard L. Angelo, MD
Robert E. Hunter, MD
Peter Jokl, MD
Bruce A. Levy, MD
Richard K.N. Ryu, MD
Felix H. Savoie, III, MD
Nicholas A. Sgaglione, MD
Learning Center
Chairman
Alan S. Curtis, MD
Craig R. Bottoni, MD
Joseph P. Burns, MD
Diane L. Dahm, MD
Carlos A. Guanche, MD
Mark R. Hutchinson, MD
William Ben Kibler, MD
Christopher M. Larson, MD
Bryan T. Leek, MD
Ian K.Y. Lo, MD, FRCSC
Kevin R. Murray, MD
Jonathan Joseph Myer, MD
Shane J. Nho, MD
John A. Randle, MD
Scott P. Steinmann, MD
James W. Stone, MD
Allston J. Stubbs, MD
Howard J. Sweeney, MD
Scott Joshua Szabo, MD
Joseph C. Tauro, MD
Raymond Thal, MD
Nikhil N. Verma, MD
Roberto Vianello, MD
Program
Chairman
Matthew T. Provencher, MD
Brian J. Cole, MD
Louis F. McIntyre, MD
Robert A. Pedowitz, MD
Jonathan B. Ticker, MD
John M. Tokish, MD
Research
Chairman
Jonathan B. Ticker, MD
Asheesh Bedi, MD
Srino Bharam, MD
Struan H. Coleman, MD
Alexis Chiang Colvin, MD
Diane L. Dahm, MD
Darren L. Johnson, MD
Peter J. Millett, MD, MSc
Michael J. O’Brien, MD
John C. Richmond, MD
Kevin P. Shea, MD
Scott P. Steinmann, MD
Ilya Voloshin, MD
Stephen C. Weber, MD
Technology
Chairman
Joseph C. Tauro, MD
Paul E. Caldwell, MD
Jason A. Craft, MD
Samuel R. Goldstein, MD
Alexander Kent Meininger, MD
Eric S. Millstein, MD
Keith Douglas Nord, MD
Michael J. O’Brien, MD
Alexander Pruitt, MD
Allston J. Stubbs, MD
Membership
Chairman
J. Emory Chapman, MD
James L. Chen, MD
Juliet M. DeCampos, MD
Geoffrey F. Dervin, MD
Julie A. Dodds, MD
Christopher D. Hamilton, MD
Victor M. Ilizaliturri, Jr., MD
Eric C. McCarty, MD
William B. Stetson, MD
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Inside AANA