November 2022
Transitioning from traditional arthroscopy using nanotechnology in awake patient meniscectomies
By: Vonda J. Wright, M.D., M.S. and Jonathan D. Schwartzman
The pivot from open sports procedures 40 years ago to minimally invasive arthroscopic techniques represents a profound paradigm shift for sports medicine, allowing smaller incision sizes, decreased soft tissue trauma/postoperative pain, faster healing times, lower infection rates and optimized recovery. Minimally invasive sports surgery has been the standard. Now, newer and even smaller diameter visualization scopes are available to achieve these goals while reducing the risk of iatrogenic joint damage during procedures and set the stage for in-office procedures.
Nanotechnology, or needle scopes, allow an incisionless approach with decreased fluid requirements and can be set up in awake patients under local anesthesia. This approach results in rapid recovery for diagnosing and treating meniscus derangements. The 2 mm diameter needle scopes have demonstrated diagnostic and therapeutic efficacy in cases ranging from diagnostic arthroscopy, staging for cartilage procedures, meniscal surgery and elbow/ankle arthroscopy. Like any new approach, transitioning to a new technique creates a learning curve for both the surgeon and operating room staff. The following article outlines transitioning surgical technique from standard arthroscopy to using nanotechnology for awake patient meniscal procedures in an outpatient setting.
Our evolution from standard arthroscopy to NanoScopeTM (Arthrex, Inc.) arthroscopy occurred over four consecutive weeks utilizing a stepwise approach with significant weekly transitions, allowing technical comfort for surgeons and their operating room staff.
Read Dr. Wright and Schwartzman's full article
Full Version of November 2022 E-Newsletter
August 2022
Meniscal Repair: To Infinity and Beyond?
By: Steven DeFroda, M.D., M.E. and Clayton W. Nuelle, M.D., FAANA
The most common orthopaedic procedure performed is a partial meniscectomy, with most meniscal tears treated using a mere debridement or partial resection instead of a formal repair. Reasons such as severity of the tear(s), patient age or poor blood supply are justifications given for going straight to a meniscectomy; we trim and move on. Twenty minutes later it’s high fives all around and on to the next case, but is this always the answer?
When doing fracture work, we do not just dispose the comminuted fragments, so why do we do this in knee arthroscopy? We all understand the importance of the meniscus to the knee joint’s health, but that doesn’t make it technically easier to repair a significant tear. COVID-19 changed a lot, but with regards to orthopaedic education, the rise of Zoom and webinars became increasingly evident, both for trainees and attendings alike. One of the most common topics? Meniscal repair. These webinars broke down barriers and geographic constraints, allowing us to see experts in the field weigh in on how they tackle complex meniscal pathology, ultimately opening new horizons and treatment options. Bucket, root, horizontal, flap and the dreaded radial tear can be repairable! Ever since the seminal article in 1982 by Arnoczky and Warren taught us about the meniscus’s blood supply, there has been a certain dogma that the meniscus has a poor vascular supply, and thus may not heal. This study states that only 10-25% of the meniscus had blood supply. It’s important to remember that this, and most other studies looking at meniscal perfusion, involve adult meniscal tissue. A recent 2020 study that examined meniscal perfusion in neonatal meniscus found a six-fold greater meniscal perfusion in all zones of the meniscus, including centrally, compared to adult meniscus.
Read Dr. DeFroda and Nuelle's full article
Full Version of August 2022 E-Newsletter
July 2022
Blood Flow Restriction Therapy: Q&A
By: Christopher J. Tucker, M.D.
Blood Flow Restriction Therapy (BFRT) is currently one of the hottest topics of interest in the field of musculoskeletal rehabilitation. BFRT is a controlled form of vascular occlusion in which a tourniquet is used to reduce arterial inflow and occlude venous outflow to an extremity, often combined with resistance training or other forms of exercise. Initially developed in the rehabilitation of wounded military service members with volumetric muscle loss and/or limb-salvage situations, its principles have now been adapted and applied to an expanding host of applications to include regular strength training, post-operative rehabilitation and postoperative atrophy prevention. BFRT represents a technique in which stresses across joints can be decreased without compromising strength conditioning, thereby safely accelerating recovery in load-compromised individuals. In addition to “traditional” forms of BFRT with resistance strength training, newer applications have emerged and are being developed such as its use with aerobic exercise, passive applications and neuromuscular stimulation. As applications expand, research also continues to yield better insight into the action mechanisms of BFRT. Multiple additional physiologic benefits beyond muscle strength are being discovered: improvements in muscular endurance, cardiovascular fitness, pain relief and bone density.
The following Q&A has been adapted from a recent Arthroscopy Journal Podcast conducted by Podcast Editor and AANA Communications & Technology Committee Chair Christopher J. Tucker, M.D. and Johnny Owens, M.P.T., one of the world’s leading experts in BFRT. It explores and reviews various aspects of BFRT to include its physiology, various applications, guidelines for safe implementation and considerations for the future of the science.
Christopher Tucker, M.D.:
What are the principles of BFRT, and its mechanism of action, as best as we currently understand it now in 2022?
Johnny Owens, M.P.T.:
I think we're dialing in our understanding of the mechanism of action of BFRT’s action mechanism a little bit better. Currently, we believe that the metabolic stress from vascular occlusion and mechanical tension from resistance training or other exercise lead to increases in muscle hypertrophy and strength. Metabolites at the cellular level, as well as hormonal differences, cell-to-cell signaling, cellular swelling and intracellular signaling pathways, are all involved. Metabolites, which are known mediators of muscle hypertrophy, are amplified by the relative ischemic and hypoxic conditions generated with BFRT.
Read Dr. Tucker's full article
Full Version of July 2022 E-Newsletter
June 2022
AANA22: A Day-By-Day Recap
By: Todd C. Battaglia, M.D., M.S., FAANA
Greetings all! We have just wrapped up AANA22, May 19-21 at the San Francisco Marriott Marquis. The meeting corresponded with the organization’s 40th Anniversary. AANA Immediate Past President Mark H. Getelman, M.D., FAANA and Program Chair Kevin F. Bonner, M.D., FAANA put together an outstanding conference. This was our first "solo" annual meeting since the start of the COVID-19 pandemic and included over 100 e-poster presentations and 16 Instructional Course Lectures (ICLs). In addition, we welcomed faculty from our guest nations in the Pan-Asian region, including Thailand, Hong Kong and Korea.
Special programs, including the Residents and Fellows Program and Emerging Leaders Program, offered members early in practice expert advice in practice management, research activities, engagement with Arthroscopy, AANA’s peer-reviewed journal, and advancement within AANA. In addition, social relief and networking opportunities were provided through events including the AANA Golf Tournament, receptions, wine tours and dinners.
Day One (Thursday) was largely a "shoulder" day. Early sessions, including those led by John M. Tokish, M.D., FAANA and Ivan H. Wong, M.D., FAANA focused on the importance of bony involvement in shoulder stability. Several talks reiterated the significance of bone loss, both humeral and glenoid, in determining outcomes – even if the patient does not have frank recurrent instability! Strategies for calculation and management of bone loss, including Remplissage, Latarjet (open and arthroscopic) and distal tibial allograft (DTA), were all highlighted and made very clear that any surgeon treating shoulder instability must be prepared to address bony deficiencies with both arthroscopic and open approaches. Later, the focus shifted to rotator cuff and biceps/superior labrum. Particularly interesting were the various strategies for addressing massive and/or irreparable cuff tears. These included in situ biceps tenodesis, balloon spacer and superior capsular reconstruction (SCR) with autograft biceps versus hamstring allograft versus iliotibial band (ITB) versus dermal graft. It quickly became evident that there remains no consensus on a "best" strategy; even more interestingly, we remain unsure what factors are necessary for a successful outcome (does the SCR graft need to heal for a good result?). Similar debate surrounds management of the long head biceps – determination of which biceps and superior labral pathologies require treatment can be difficult, and no tenodesis technique (subpectoral, suprapectoral, top of groove) has been established as a gold standard. Concurrently in the afternoon, a session on hip femoroacetabular impingement (FAI) included discussion and demonstrations on labral augmentation and reconstruction, including a live surgical demonstration by esteemed Amherst College alum Andrew B. Wolff, M.D., FAANA.
Read Dr. Battaglia's full article
Full Version of June 2022 E-Newsletter
April 2022
Traumatic Anterior Shoulder Instability
By: Chaitu S. Malempati, D.O. and Connor Donley, M.S.-IV
Anterior shoulder instability is currently the most common form of shoulder instability. It usually occurs after a traumatic event such as a motor vehicle accident, a contact event/collision or a fall with an outstretched arm with the shoulder in abduction and external rotation.1,2 These events are becoming more common in high-level contact sports as well. The inherent minimal bony restriction of the glenohumeral joint gives the shoulder maximum mobility, but stability relies on the comprehensive integrity between the static and dynamic bony and soft-tissue stabilizers. This brief synopsis will serve as a general overview of the present diagnosis and management of these injuries.
Traumatic anterior shoulder dislocations, a common culprit of anterior shoulder instability requiring closed reduction, has an incidence of 23 in 100,000 person-years, and an incidence of 98 in 100,000 person-years in the greater than 20 years age group.3,4 Furthermore, these injuries are almost three times more frequent in men. Nonsurgical treatment of anterior shoulder dislocations can have recurrent instability rates as high as 75%.3,4 While there appears to be various ideas and paradigms on managing anterior shoulder instability, how can we as an orthopaedic community identify patients with a high risk of recurrence who will benefit the most from operative stabilization?
Due to the traumatic etiology that occurs in collisions and high-level contact sports presenting with anterior shoulder instability, the identification of concomitant injuries through a detailed history and physical exam, along with X-ray, CT and MRI findings, will allow the correct intervention to be chosen. While the most observed injury following anterior shoulder dislocation is a Bankart lesion,4 Mohtadi et al. showed no difference in recurrence rates following an open or arthroscopic approach to repairing a Bankart lesion.5 Regarding return to sport, a systemic review by Abdul-Rassoul et al. found arthroscopic Bankart repair to have the highest return to sport rate at 97.5% among surgical intervention for anterior shoulder stabilization.6 Also, a Bankart fracture or glenoid bony disruption is seen in 33% of first-time anterior shoulder dislocations and if left untreated, can result in an increased rate of instability recurrence and a greater amount of glenoid bone loss (GBL).7 Furthermore, Hill-Sachs lesions (HSLs) are seen in 90% of first-time anterior shoulder dislocations and become significant in patients who present with recurrent instability.7 A three-dimensional CT scan is the most useful diagnostic method to define the percent of GBL present and determine if the HSL is on track or off track.8 These distinctions will allow surgeons to determine which operative treatment option will be the most beneficial.
Read Drs. Malempati and Donley's full article
Full Version of April 2022 E-Newsletter
March 2022
Women in Sports Medicine
By: Andrea M. Spiker, M.D. and Cassandra A. Lee, M.D.
March is Women’s History Month, which recognizes and honors women’s contributions in the United States. What began as Women’s History Week (the week of March 8) by presidential proclamation in 1980 subsequently became a Women’s History Month in 1987.1 In the spirit of Women’s History Month, we would like to highlight in this month’s Inside AANA E-Newsletter the women in orthopaedic sports medicine.
As Orthopaedic Surgeons, we are in the absolute least diverse specialty in all of medicine by both sex and race. Despite women making up greater than 50% of all graduating medical students, less than 6% of all practicing Orthopaedic Surgeons are women.2 While increased diversity in our field is perhaps on the horizon, with 16% of orthopaedic trainees now being women, this growth in gender diversity is the lowest in medicine and of all the surgical subspecialties.3 Between 2005 and 2016, other historically underrepresented surgical subspecialties have made impressive strides to increase the number of women in their ranks (neurosurgery 11.1% women in 2005, with a 56.8% increase in female Orthopaedic Residents by 2016; thoracic surgery 10.7% women in 2005 with a 111.2% increase in female Orthopaedic Residents by 2016); meanwhile, orthopaedic surgery has only moved forward at a snail’s pace (11.5% female Orthopaedic Residents in 2005, to 14.5% in 2016 and 16% in 2021).3 So why are women choosing not to enter the field of orthopaedic surgery? It is not because they are less qualified than males; female and male trainees achieve similar scores on the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery examinations. In fact, females have a higher fellowship match rate than their male counterparts (96% vs. 81%, P, 0.001).4,5 The answer to this question of why we cannot attract and retain females in the field of orthopaedics, and orthopaedic sports medicine surgery, is multifaceted.
Women are underrepresented in orthopaedic surgery leadership positions, and women more than men are influenced in their decision to enter orthopaedic surgery based on exposure to a same sex or ethnicity role model.6 Only 18% of full-time orthopaedic surgery faculty are women, and of those, women hold disproportionately lower academic titles than men.3 Women are also underrepresented in academic sports medicine publishing, and when they publish, are less likely to be a senior author, which affects their academic mobility.7 When women are given titles within departments, they are more often education-based positions, such as program director. These positions take a substantial amount of time away from academic pursuits, and are not considered in the same elevated category as leadership positions such as chair, vice chair or division chief. 8 Additionally, this status quo is perpetuated by undertones of phenomena such as implicit bias, imposter syndrome and stereotype threat. Implicit bias is present in everyone and is defined as the existence of cultural stereotypes that lead to preformed mental associations. These associations affect what we say and do, unwittingly and unintentionally, possibly contradicting our conscious beliefs.9 Stereotype-based assumptions also influence our decisions of who to mentor, admit or hire.
Read Drs. Spiker and Lee's full article
Full Version of March 2022 E-Newsletter
February 2022
2022 AANA Annual Meeting Update
By: Kevin F. Bonner, M.D., FAANA
Our goal from the onset of preparation and planning for the 2022 AANA Annual Meeting (AANA22) in San Francisco was to make this meeting one of the most memorable educational events of your career, all while commemorating AANA’s 40th Anniversary. Being involved in several meetings for different organizations over the years, this is easier said than done.
This meeting combines what we feel is the optimal blend of debates addressing current controversies, innovative technical pearls, on-point lectures from leaders revealing their contemporary decision-making and case panels with opinions guaranteed to surprise you. You will get the opportunity to hear over 75 high-level scientific paper presentations as well as review over 100 e-posters to see what’s to come in future issues of Arthroscopy and its journal companions. Furthermore, key opinion leaders will reveal their latest innovative techniques they’re using now in their practices. We will also have collaborative sessions with the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) and the Society of Military Orthopaedic Surgeons (SOMOS). We have prioritized delivering high-level educational content that is immediately applicable to your practices back home.
Full Version of February 2022 E-Newsletter
January 2022
The Issue of Surprise Billing Rules in Plain English
By: Douglas W. Lundy, M.D., M.B.A.
At the 2020 AAOS Annual Meeting, I began my tenure as advocacy council chair. The ongoing overlay of the pandemic along with the hyper-partisan climate in Washington, D.C. has drastically changed the atmosphere in advocacy when it comes to protecting the practice of orthopaedic surgery and our ability to care for the patients we have been entrusted. I can assure you that the role is much different than I had anticipated!
Medicine was assaulted with two gloomy issues in 2021: the proposed severe cuts to Medicare payments to physicians and the implementation of the regulations for the No Surprises Act. Our aggressive lobbying efforts have mitigated the Medicare cuts for the time being, but even so, we will face a decrease in Medicare payments in 2022. We will certainly continue to fight this terrible trend which further threatens the viability of medical practices already damaged by the economic effects of the COVID-19 pandemic.
Since the Medicare issue is relatively at bay for the moment, I would like to focus this article on the flawed rulemaking process in the No Surprises Act and why these issues are of such vital concern to Orthopaedic Surgeons. On December 27, 2020, the No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions). This bipartisan law was intended to protect patients from surprise medical bills as well as other issues concerning patients.
Read Dr. Lundy's full article
Full Version of January 2022 E-Newsletter