Non-Arthroplasty Management of Irreparable Rotator Cuff Tears
By: Shariff K. Bishai, D.O., M.S., FAANA; Joseph A. Abboud, M.D. and Guy R.S. Ball, D.O.

Rotator cuff tears are the most common form of shoulder disability in the United States.¹ Current iData research places the number of rotator cuff related surgeries at well over 400,000 each year. However, there are a wide variety of rotator cuff tears. A rotator cuff tear can range from partial thickness, including partial articular-sided supraspinatus tendon avulsion (PASTA) and partial-thickness articular surface intratendinous tear (PAINT), to full-thickness (small, greater than 1 cm, medium 1-3 cm, large 3-5 cm, massive, less than 5 cm) and even irreparable. Within the spectrum of disease also exists a spectrum of treatment. Most people are familiar with initial conservative management consisting of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy plus or minus injections.

If conservative options fail to provide relief, there are also many surgical options available. For most people with rotator cuff disease, a traditional single or double-row repair with scheduled formal physical therapy works well with a success rate exceeding 90% for many small tears. However, as tears grow larger the success rate falls to below 10% in large and massive tears.² As we move to the far end of the spectrum, we begin to see higher failure rates when the traditional surgical approaches are employed. If we look at the work of Gerber et al., we see that fatty infiltration and tendon retraction are significant predictors of outcome. Less than 15 mm of tendon length was correlated with a 92% failure rate, whereas greater than 15 mm tendon length reduced overall failure rate to below 25%.³ Thanks to the work of Chalmers et al., we even have an algorithm-based application that can predict success and possibility of recurrent tear. Several studies have evaluated age as a risk factor and have been able to show that younger people are significantly more likely to heal.^4,5 We also now know that smoking, hyperlipidemia, vitamin D deficiency and osteoporosis all negatively impact rotator cuff healing.⁶ We now have the information to know who is more likely to do well and who is likely to do poorly with traditional rotator cuff repair surgery. The only question left to answer is: What do we do for the patients we know are going to fail traditional repair?

One of the emerging areas of interest in rotator cuff repair is augmenting the repair with biologics. Over the last several years, platelet-rich plasma (PRP) and stem cell augmentation have become increasingly popular. A rotator cuff tear Level 1 2021 randomized clinical trial published in Arthroscopy: The Journal of Arthroscopic and Related Surgery outlines the potential benefits, and superiority to corticosteroids, of PRP for partial-thickness rotator cuff tears.⁷ The enthusiasm that exists around biologic technologies is largely due to their success in vitro. However, when some of the biologics are brought into the operating room, the results remain less than significant. A 2018 Journal of Bone and Joint Surgery analysis neatly lays out the current guidelines in respect to PRP and stem cells.⁸ At this time, there is little evidence to support widespread use of PRP or stem cell therapy; however, the recommendations may change as more studies emerge.

Large, massive and irreparable rotator cuff tears provide a special challenge to Orthopaedic Surgeons. Part of the challenge is providing optimal surgery to your patient, considering the patient’s short- and long-term functional requirements. In select populations, massive rotator cuff tears can be treated with debridement of the cuff tear, tenotomy of the torn tendon and physical therapy. This method has been shown to be a good pain improver but does little to improve overall strength or motion.⁹ Another option is to perform a partial repair with margin convergence. This option can balance forces across the shoulder and attempt to maintain humeral head depression. This method has not been shown to improve function; even worse, this method can have retear rates as high as 52%.¹⁰

Read Drs. Bishai, Abboud and Ball's full article

Full Version of December E-Newsletter

Quadriceps Tendon Grafts for ACL Reconstruction – Hype or Here to Stay?
By: Harris S. Slone, M.D. and W. Michael Pullen, M.D.

Quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction are not new, but certainly a subject of renewed enthusiasm. Marshall et al. first described the use of QT grafts for ACL reconstruction in 1979.¹ Twenty years later, John P. Fulkerson, M.D. subsequently described the use of all soft tissue central quadriceps free tendon grafts,² quite similar to QT grafts commonly used with modern techniques. In the last five-10 years, the number of studies evaluating QT grafts for ACL reconstruction increased exponentially,³ and similar increases were seen with clinical utilization. Yet many questions remain regarding the use of QT grafts for ACL reconstruction: What is fueling the surge in popularity? Are there long-term consequences of harvesting from the QT? Is the enthusiasm for QT autografts all hype, or here to stay?

While long-term results of patella tendon and hamstring autograft ACL reconstruction are generally favorable, concerns exist regarding rerupture rates, donor site morbidity, variable rates of return to sport, graft-tunnel mismatch, cosmesis, graft size predictability and disruption of dynamic medial stabilizers. As a result, surgeons and investigators sought alternative graft options. QT autografts have long been recognized as a viable graft option, primarily utilized in the revision setting before gaining the now more widespread popularity as a primary graft option. Refinements of harvesting techniques, instrumentation and fixation options have allowed for an easier transition for surgeons who have become accustomed to patella tendon or hamstring grafts. As Orthopaedic Residents and Fellows are now more frequently exposed to QT ACL reconstruction during training, familiarity with this graft is only expected to increase.

Utilizing modern techniques, published clinical outcomes have been largely favorable, although long-term comparative results are still lacking. Of particular concern is a large study from the Danish Knee Ligament Registry, which recently demonstrated an increased risk of graft failure with QT grafts.⁴ While the results of this study should give us pause, they should also be interpreted within appropriate context. QT grafts accounted for only around 3% of the total grafts included and were more frequently used in higher risk patients; thus, some authors have raised concerns regarding statistical bias and selection bias.⁵ This study also included reconstructions performed as far back as 2005, long before modern fixation and harvest techniques. A follow-up study performed between 2012-2019 from the same registry showed failure rates similar to alternative autografts when surgery was performed at higher volume centers, and that there may be a “learning curve” effect with QT grafts.⁶ Other studies have demonstrated a greater loss of knee extensor strength with QT grafts as compared to hamstring grafts.^7,8 Risk of patella fracture is likely increased when harvesting a bone plug from the proximal pole of the patella as compared to the distal pole.⁹ As a result, many surgeons favor using an all soft-tissue QT graft, with which the fracture risk associated with bone harvest is negated. Rare complications of impending compartment syndrome and rectus femoris retraction have also been reported.¹⁰

Read Drs. Slone and Pullen's full article

Full Version of November E-Newsletter

Emerging Technologies in Hip Arthroscopy
By: Jorge Chahla, M.D., Ph.D. and Luc M. Fortier, B.A.

In the last two decades, hip arthroscopy has become increasingly popular in treating various hip pathologies.¹ As utilization of technology in different orthopaedic subspecialties continues to gain traction, hip arthroscopy is no different. Recent advancements in hip arthroscopy have focused on the application of technology to teach the next generation of surgeons the skills necessary to perform safe and effective hip arthroscopy as well as improve the accuracy and precision of hip arthroscopy procedures to provide better patient outcomes.^2-6

Even though hip arthroscopy is rapidly expanding, its procedures are not as commonly performed as arthroscopic knee or shoulder procedures. This reality, coupled with decreases in Orthopaedic Resident caseloads and working hours, have made it difficult for some trainees and junior attendings to gain adequate experience in hip arthroscopy.⁶ The complex geometry of the hip joint and its thick soft-tissue envelope also make hip arthroscopy one with a particularly steep learning curve.^{7, 8} In response, a variety of virtual reality (VR) systems have been developed to provide trainees and novice surgeons a way to acquire the necessary skills to safely and effectively perform arthroscopic hip procedures.^{5, 6, 9-12} These developments are extremely promising and have the potential to shift the future of basic hip arthroscopy training. However, future efforts should attempt to introduce more advanced hip arthroscopy skills into VR training such as labral repair techniques and capsular management strategies.

Amid the upheaval of the COVID-19 pandemic, the shift towards virtual platforms born out of necessity has introduced new options for hip arthroscopy learning. Professional societies such as AANA and companies such as Avail Medsystems, Inc. have embraced how COVID-19 has reshaped the world by streaming live hip arthroscopy procedures online. These strategies offer a cost-effective and convenient way to reach a broad audience interested in sharing knowledge about surgical techniques and new products within hip arthroscopy.

Read Drs. Chahla and Fortier's full article

Full Version of October E-Newsletter

Augmentation in Rotator Cuff Repair – Where Are We Now?
By: Chaitu S. Malempati, M.D. and Andrew Croft, M.S.4

To this day, rotator cuff pathology remains a common problem. As our population ages, the number of patients who are affected continues to rise. Rotator cuff tendon tears affect between 30-50% of people older than 50 years of age.^1-2 Despite a comprehensive understanding of rotator cuff and biomechanically advanced surgical repair techniques, there is still a subset of rotator cuff tears that go on to failure.^3-4 The outcomes of rotator cuff repair depend on a multitude of factors including tear size, chronicity, patient age, muscle atrophy and patient comorbidities.^5-6 The inability to obtain high healing rates and optimal outcomes has spurred the advancement of augmentation techniques, biologics and various adjuncts. However, the question remains: Where are we now with these advancements in rotator cuff repair?

Over the past 15 years, there has been a growing scientific interest in using exogenously supplied growth factors or growth factor stimulators to improve surgical outcomes.⁷ This approach augments the healing environment where the reconstructed rotator cuff heals. Platelet-rich plasma (PRP) involves a concentration of platelets that contain growth factors and cytokines and can be locally applied to damaged tissue to improve wound healing.⁸ Even though PRP use has increased, its effectiveness remains controversial. While some studies have concluded that PRP treatment (specifically leukocyte-poor PRP) is effective in healing injured or repaired tendons and ligaments quicker than without PRP treatment,⁹ other studies have found no significant statistical difference when comparing patients treated with PRP and those that are untreated for rotator cuff repair.¹⁰ Matrix metalloproteinase (MMP) inhibitors are the enzymes responsible for extracellular matrix (ECM) degradation. Studies have shown that MMP concentrations increase in degenerative rotator cuff tissues as well as in postsurgical rotator cuff tissue, particularly MMP-13.¹¹ Bedi et al. concluded that modulating MMP-13 activity after rotator cuff repair may offer a novel biologic pathway to augment tendon-to-bone healing;¹² however, further investigative work into MMP inhibition’s role in rotator cuff repair augmentation is needed.

The idea behind using stem cell therapy is to improve surgical rotator cuff repair’s success rate through augmenting the healing environment. Recent studies have applied mesenchymal stem cell (MSC) therapy with varying levels of success to rotator cuff repair.¹³ Studies have investigated MSCs derived from different tissues to varying degrees, and although they all evoke the same general effects, some lineages seem to have a superior capacity for tissue regeneration such as bone marrow-derived MSCs.¹⁴ Using MSCs for rotator cuff surgery is one of the most promising new areas of biologic augmentation; its drawbacks, however, necessitate further research and technological advancement.

Read Drs. Malempati and Croft's full article

Full Version of September E-Newsletter

Opioids in Sports Medicine
By: Niraj V. Kalore, M.D.

As per data from the Centers for Disease Control and Prevention, drug overdose deaths in the U.S. increased by 29.4% from 70,630 in 2019 to 92,183 in 2020. Except for South Dakota and New Hampshire, every state has had an increase in deaths due to drug overdose (Figure 1). This indicates that the opioid crisis in the U.S. is an unresolved problem, despite recent government regulations requiring electronic prescribing and prescription limits.

Athletes and Commonly Used Opioids

An estimated 8.6 million sports injuries occur each year¹. Athletes have a strong desire and significant social and/or economic pressure to “play through the pain,” driving them to seek out opioid pain medications to continue playing without properly recovering. This starts the dangerous cycle of “play-pain-opioid-play.” Additionally, these injured athletes are at a higher risk for serious injuries that may require surgery. Using opioid pain medications for postoperative pain control and unsupervised access to leftover prescription pills further aggravate the problem. Prescription opioids’ high cost on the black market then drives athletes to illicit opioids like heroin, which have a significantly increased risk of addiction, accidental overdose and death. This downward spiral from injury to illicit drug use is accelerated in professional athletes due to the intense pressure of a short career and the need to maximize income through continued sports participation.

According to the National Council on Alcoholism and Drug Dependence, 12% of male athletes and 8% of female athletes used prescription opioids in the 12-month period studied. A recent systematic review from Ekhtiari et al. indicated that the rate of opioid use over an NFL career is 52%, while the lifetime opioid use rates in high school athletes are 28%-46%.² Risk factors associated with opioid use included race (particularly Caucasians), contact sports (hockey, football, wrestling), postretirement unemployment and undiagnosed concussion.

Read Dr. Kalore's full article

Full Version of August 2021 E-Newsletter

AOSSM-AANA Combined 2021 Annual Meeting Review
By: By: Kevin F. Bonner, M.D., FAANA

After months of eager anticipation, the historic AOSSM-AANA Combined 2021 Annual Meeting recently wrapped up. Kudos goes to organizational leaders Drs. Michael Ciccotti and Brian Cole – without their assistance, this meeting would not have come to fruition.

The meeting was full of great content, including 24 instructional courses, nearly 80 paper presentations and 240 posters, in addition to the numerous invited lectures, exciting panels and more. Industry was also present and in full force, revealing their latest technology and devices – it has admittedly been a while since most of us have had the opportunity to see these advances in person.

Pre-Meeting: Wednesday, July 7
The Biologics Association (BA) 2^nd Annual Summit took place prior to the meeting. The BA, through the leadership of Drs. Jason Dragoo, Bert Mandelbaum and numerous others, seeks to foster and collaborate for shared and coordinated efforts to speak with a unified voice in the musculoskeletal biologics environment, advocating for the responsible use of biologics in clinical practice.

Drs. Jorge Chahla, Rachel Frank and Seth Sherman put together a comprehensive program highlighting the current science and controversies surrounding orthobiologics. The day was full of current updates on various biologic agents and their indication(s) for treatment of pathologies of tendon, cartilage, ligament and bone, including subchondral bone lesions. Additionally, there were numerous sessions that addressed potential complications associated with the use of biologics and ways in which to avoid them. Finally, Dr. Scott Bruder reviewed the recent FDA guidance to ensure everyone was clear that stem cells; stromal vascular fraction (fat-derived cells); umbilical cord blood and/or cord blood stem cells; amniotic fluid; Wharton’s jelly; and exosomes are not approved for use. The only exception is if one is part of an FDA clinical trial.

Read Dr. Bonner's full article

Full Version of July 2021 E-Newsletter

Maximize Your AANA Member Benefits
By: Ivan H. Wong, M.D., F.R.C.S.C., FAANA

Colleagues and Fellow AANA Members:

A lot has changed in the last 15 months since the COVID-19 pandemic began, but there’s one thing that has not: AANA’s keen focus on listening and responding to the needs of its members during a time that was clouded with uncertainty.

Throughout 2020 AANA successfully launched several new member benefits that focus on bringing education, resources and connections with colleagues straight to you. The increased benefit offerings adapt to new methods and modes of education we've sought out since March 2020. From interactive webinars to online engagement platforms and organizational partnerships, each benefit aims to better protect our staff, patients and ourselves.

New member benefits AANA has launched since the beginning of 2020 include.

Full Version of June 2021 E-Newsletter

AOSSM-AANA Combined 2021 Annual Meeting Update
By: Nikhil N. Verma, M.D., FAANA

It’s often said that opportunities are born from challenging situations. Despite a generational global pandemic, The American Orthopaedic Society for Sports Medicine (AOSSM) and AANA are successfully joining forces to host the first-ever combined annual meeting this summer. In the faceof an unprecedented challenge to the medical community, our associations have done a heroic job of continuing to provide cutting-edge, online-based educational content. With brighter days ahead, it’s finally time to come together again, in person, for all that the AOSSM-AANA Combined 2021 Annual Meeting has to offer. So, ditch your pajamas and sweatpants, put on some real clothes and join us in Nashville, Tennessee July 7-11, 2021, for what will be our best annual in-person meeting ever!

With the combined efforts between AOSSM and AANA, we have expanded the number of program chairs to include two leaders from each organization. With contributions from Drs. Steven Cohen (AOSSM), Brett Owens (AOSSM), Kevin Bonner (AANA) and myself, the program certainly proves that four heads are better than one. Our vision for this program is to bring together the strengths of each organization by featuring presentations from around the globe. Of course, the task becomes much easier when we can harness the talent and diversity of our organizations’ members to bring you leading experts in all aspects of sports medicine and arthroscopy.

Full Version of May 2021 E-Newsletter

Use of Osteochondral Allograft Transplantation for Patellofemoral Cartilage Injury
By: Kirk A. Campbell, M.D.¹ and Sanjeev Bhatia, M.D.²

1. NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
2. Hip & Knee Joint Preservation Center, Northwestern Medicine West Region, Warrenville, IL

Patellofemoral chondral defects are common and have been reported to account for up to 30-40% of chondral defects in patients undergoing knee arthroscopy.^1-3 A majority of these defects are incidental findings, but a significant amount does become symptomatic, causing anterior-based knee pain and swelling. Common causes of patellofemoral chondral damage include patella instability, trauma, osteochondritis dissecans and generalized degenerative

changes.³ The complex anatomy of the patellofemoral compartment makes treating these defects quite challenging, due to the morphology of the patella and trochlea, as well as the high joint reaction forces (up to 7.8 times the body weight during deep knee bending and squats). ^4,5

There are also a variety of other factors that may add to the complexity of addressing patellofemoral chondral damage, including patellar malalignment; abnormal lateral tilt; instability and maltracking; patella alta or baja; and trochlea dysplasia, to name a few.^3,6 A successful surgical approach to addressing any patellofemoral cartilage damage typically also involves concomitantly addressing any underlying pathology with tibial tubercle osteotomy and/or patellar stabilization procedures as needed.

Read Drs. Bhatia and Campbell's full article

Full Version of April 2021 E-Newsletter

Gluteus Medius Tears – Not Just Trochanteric Bursitis
By: Anil K. Gupta, M.D., M.B.A. and Jacob Maier, M.S.

Greater trochanteric pain syndrome (GTPS), a spectrum of pathology that manifests as lateral hip pain, affects an estimated 1.8 in 1000 patients per year.¹ While typically attributed to trochanteric bursitis, recent research has shown that GTPS, especially cases recalcitrant to conservative treatment, often involves some degree of injury to the gluteus medius (GM) tendon. First described in the late 1990s, GM tears range from low-grade partial-thickness tears to complete tendon avulsion from the greater trochanter. Thus, surgical intervention has evolved over the last decade and has become an effective treatment for trochanteric pain. The similarities in the pathogenic mechanism, presentation, radiographic findings and surgical repair techniques earned GM tears the nickname, “rotator cuff tears of the hip.”² This review aims to explore the presentation, diagnosis, treatment and outcomes for GM tendon pathology, focusing primarily on the surgical management options.

The hallmark of GTPS is lateral hip pain, which often has an insidious onset. However, acute trauma, usually a fall, can also be a cause.^3,4 Other symptoms of gluteal pathology include pain while rising from a seated position or with prolonged standing, pain at night and pain with hip rotation. In the case of full-thickness GM tears, abductor weakness will be prominent. Consequently, these patients will demonstrate gait abnormalities, a positive Trendelenburg sign, and/or an inability to overcome resisted abduction.^3,5 Ortiz-Declet et al. described an exam maneuver that has excellent accuracy in predicting GM tears.⁶ The patient flexes the symptomatic hip to 90 degrees, externally rotates 10 degrees, flexes the knee to 90 degrees and then must attempt to externally rotate against resistance from the examiner. Recreation of pain or weakness indicates a positive test.

Often, symptoms resolve with conservative treatment only. Rest, nonsteroidal anti-inflammatories (NSAIDs) and physical therapy are the first line of treatment. A corticosteroid injection can also be considered in patients with severe pain on initial presentation.⁷ Injections alone provide excellent short-term relief, while physical therapy and home exercise have demonstrated better long-term outcomes.⁸ Shockwave therapy has shown some success in treating lower extremity tendon injuries, with long-term results similar to physical therapy.^8–11 This treatment has the potential to be a great option for patients that fail other conservative therapies, but further studies are necessary.

Read Drs. Chahla and Kunze's full article

Full Version of March 2021 E-Newsletter

Biologics in Sports Medicine
By: Jorge Chahla, M.D., Ph.D. and Kyle Kunze, M.D.

The ways we treat patients have improved thanks to several developments in refining patient selection, enhancing surgical techniques and optimizing recovery, and only continues to evolve. The application of biologics has been observed in all of these domains, though evidence as to the appropriateness and efficacy of their use has remained far behind the frequency of their administration in practice. Indeed, the vast use of biologics has been out of optimism and excitement derived from a paucity of high-quality evidence, and the level of public misinformation is not insignificant.¹ We cannot fall short of continuing to appropriately define the optimal compositions of biologics we choose to administer and the specific indications for their use in order to treat our patients appropriately and optimize patient outcomes.

Read Drs. Chahla and Kunze's full article

Full Version of February 2021 E-Newsletter

Simulation in Arthroscopy Training: Where We Are At, Where We Are Going
By: Niraj V. Kalore, M.D.

Arthroscopic surgery has always included complexities that require substantial hand-eye coordination, manual dexterity and knowledge of anatomy. The learning curve for arthroscopic proficiency can be daunting for the trainee. In an era of cost containment, high volume and added focus on operating room efficiency, time in the operating room is highly constrained. The traditional model of learning in the operating room may not provide enough opportunity to gain the necessary skills. Additionally, the foundational skills of arthroscopy like triangulation and knot tying may not develop sufficiently in the high pressure/high throughput environment the operating room often creates.

Arthroscopy and Simulation: Where Do We Currently Stand?
Since the Accreditation Council for Graduate Medical Education (ACGME) implemented an 80-hour work week rule for residents in 2003, substantial research has focused on simulation to improve arthroscopy training. In a simulated environment, the trainee can focus on perfecting arthroscopic skills without having the added pressure of time or consequences for patient safety. It’s possible to deconstruct complex procedures into specific steps and focus on repeating each step until sufficient proficiency is attained. This strategy can help trainees move up the learning curve more efficiently; supplement traditional teaching; and improve surgeon performance and patient safety.

Read Dr. Kalore's full article

Full Version of January 2021 E-Newsletter

Choosing the Right Job: Use Financial Modeling to Critically Assess Compensation in Differing Job Opportunities

By: Sanjeev Bhatia, M.D. and Kirk A. Campbell, M.D.
Members, Communications/Technology Committee

One of the most common reasons newly minted Orthopaedic Surgeons change jobs after the first few years is having dissatisfaction with actual compensation vs. perceived compensation. After years of hard work, possible relocation and delayed gratification, it is only natural that new surgeons and their spouses would seek something perfect and permanent in an employment situation. Unfortunately, many Orthopaedic Surgeons do not have the time, tools or experience when critically evaluating the compensation model within their first employment opportunities and are frequently disappointed by their circumstances when it is different from what they envisioned. Sadly but more common than not, this situation often leads to significant personal and familial stress, professional insecurity and financial hardship.

Here we will present a simple method Orthopaedic Surgeons can utilize in financially modeling their net worth across various job opportunities they may be exploring. At its core, the technique employs a simple sensitivity analysis, similar to what professional analysts on Wall Street use, to simulate various "what if" scenarios financially. The purpose of financial modeling is to simplify complex compensation arrangements typically seen in orthopaedic surgery employment, and identify large discrepancies in compensation and risk to the young surgeon early on in the job search process.

Don’t Just Think About the Money
Although we are focusing our discussion on financial compensation, it is critical to note that earning potential is not the only factor to consider when evaluating employment opportunities. Other factors including practice quality (i.e. reputation, growth potential, ancillaries and financial strength, etc.), academic opportunities, partners, location and spouse happiness should be heavily weighted. That being said, compensation is often cited as one of the top two causes Orthopaedic Surgeons change employers. It is very common for young surgeons to leave a certain practice because their compensation expectations are vastly different than what they were actually paid. This situation is often exacerbated by the incredibly complex compensation arrangements, overhead cost formulas and partnership costs seen in various orthopaedic practice environments in our health care system.

What is Financial Modeling?
Financial modeling, in the finance world, is the process of creating a summary of a company's expenses and earnings, in the form of a spreadsheet, that can be used to calculate the impact of a future event or decision. Company executives frequently use these tools to guide decisions and estimate stock prices. Despite its seemingly complex uses, the process is relatively straightforward and may be of value to young physicians—chief executives, of sort, for their own careers—in their job decision-making process.

Read Drs. Bhatia and Campbell's full article

Full Version of December 2020 E-Newsletter

Orthopaedic Practice Management: Pearls & Pitfalls

A Q&A with Jack M. Bert, M.D., by Christopher J. Tucker, M.D.
Member, Communications/Technology Committee

Jack M. Bert, M.D., AANA Past President, is a world-renowned thought leader on orthopaedic practice management, an avid clinician, founder of the Minnesota Cartilage Restoration Center and CEO of MDDirect. In this conversation, we discuss the business of orthopaedics and, specifically, his practice management pearls and pitfalls. This conversation flows chronologically, much like a surgeon evolves through his or her career, to ensure we hit all the highlights and have a little bit of something for everyone. We discuss the early career surgeon; the established surgeon; ancillary and alternative income streams; nonclinical opportunities; and transitioning out of practice.

Chris Tucker, M.D. (CT): Jack, can you share with us your pearls and pitfalls for the surgeon looking for a job either right out of residency or someone looking to transition practices? What should they be looking for (and looking out for)?

Jack Bert, M.D. (JB): Great question. There are several important concepts to think about when you're looking for a job:

1. The contract. The contract should be relatively simplistic language and you should be able to understand 99% of it. Utilize a good contract attorney if there are parts of it that you don't understand. There are two important clauses that are absolutely critical to ensure that they are appropriately written: termination with cause and termination without cause. If an employer simply wants to terminate your employment without cause, it can be for (literally) any reason whatsoever and in my opinion, should be eliminated from a contract, which is extremely difficult. "With cause" requires egregious behavior such as inappropriate care, proven sexual harassment, etc. Remember that contracts written with a 90-day termination clause for either party without cause are just 90-day contracts! Noncompete clauses can be written so that you will be unable to practice anywhere near the community in which you live IF the health care system or private group has multiple offices. For example, if you have a 10-mile radius noncompete from the office in which you practice and leave the group or hospital system, the contract may be written to include ALL the clinic sites owned by the group or hospital. IF there are multiple clinic sites or offices 15 to 20 miles away, the "10-mile radius" may end up being 50 miles from where you are living since the 10-mile radius applies to ALL sites. A recent Medscape survey noted that only 8% of respondents were successful in negotiating out of a noncompete agreement and 12% were unsuccessful. The remainder simply didn’t try.
2. Type of employment opportunity. When you consider the current number of Orthopaedic Residents and/or Fellows who are looking at employment opportunities, whether it’s through a hospital, health care system or private practice, there's no question that the number of Orthopaedic Surgeons that are joining groups and being employed by hospitals or health care systems is rising. There are two reasons for this: orthopaedics is one of the top two revenue sources for hospitals; thus, they want to control the surgeons and obtain as much downstream revenue as they can get. "Downstream revenue" is the money that you earn for the hospital, including your professional fees in the clinic and surgery, MRI referrals, facility fees when you do surgery, physical therapy (PT) referrals, durable medical equipment (DME) referrals and any lab referrals. According to the Merrit-Hawkins 2019 Physician Revenue survey, Orthopaedic Surgeons earned an average net revenue for the hospital of $3.29 million/year. Note that health care systems and equity investment groups are slowly purchasing group practices with lucrative buyouts. These equity buyouts are becoming very common, and if you are seeking a private practice job, you’ve got to consider the likelihood of the practice undergoing an equity purchase. As soon as there's a buyout of a group, the salaries for the remainder of the partners that are in the group commonly drop by roughly 30%. It’s important to know up front if this is a consideration and how long it will be before you will attain partnership.
   
   If you decide to work for a hospital or health care system, make sure that you have a reasonable employment contract. Remember, you're going to be paid based upon your productivity which depends upon hitting your target work relative value unit (RVU) numbers. Before you sign the contract with a hospital system, you want to confirm that there is a strong referral source for you as a new surgeon or it can be very difficult to reach these numbers. Furthermore, make sure there is no "clawback provision" in your contract so that if you don’t reach a minimum RVU value during the first year or two of a fixed salary contract, they can’t terminate you "without cause" and demand you pay back the amount that you didn’t technically earn because you didn’t reach a preassigned work RVU value.
3. Understand your worth. When it comes to negotiating reimbursement with your potential employer, you’ve got to understand what you’re worth and what you’re generating for the hospital system. They use something called the Medical Group Management Association (MGMA) to determine average salaries for specialists. For example, the average salary for an Orthopaedic Surgeon is approximately $400-450,000 in year one. The administrators argue that they need to use the 50^th percentile as your salary. My response to that when meeting with administrators on behalf of a surgeon group is this: "So, are these Orthopaedic Surgeons the best of the worst or the worst of the best, since they are in the 50^th percentile?" The bottom line is you want to know what you are generating for the hospital or system yourself and negotiate from there. You won’t be able to do this initially, but when it comes time to renegotiate your contract after several years in practice, you will hopefully have some data that estimates the amount you have earned for the hospital. Remember that the data noted above confirms that the average Orthopaedic Surgeon produces about $3.29 million, net, for the hospital on an annualized basis. In salary negotiations, you want transparency and fairness, which is extremely difficult to achieve since hospital administrators rarely share earnings data with physicians. Get an explanation of benefits (EOBs) from patients and keep them. Try to get ones representing every payer in your area. That way you will at least have an idea what the hospital or your group practice is getting paid for your services based upon the charges.
4. Finally, carefully read your initial contractual agreements. This will be the only time you're going to be able to successfully negotiate your contract. Once you put pen to paper, remember, there's no turning back.

Read the Full Q&A with Drs. Bert and Tucker

Full Version of November 2020 E-Newsletter

Measuring Success: Implementing Patient-Reported Outcome Measures Into Your Practice

By: Kevin W. Wilson, M.D.
Member, Communications/Technology Committee

The concept of the patient-reported outcome measures (PROMs) has migrated from the background, based in research, to common discussion in everyday clinical practice. Rather than relying on imaging, simple exam measurements and the surgeon’s assessment of return of strength and function, PROMs give the patient a stake in how we evaluate the results of any intervention.

The growth and development of incorporating PROMs in orthopaedic practice has mirrored the use of big data and other industries, including professional sports. Larger corporations are leveraging their resources to incorporate these techniques, while smaller entities are taking more measured approaches. While most surgeons can agree that an accurate measurement of the patient's perception of their success in treatment is vital, how we collect and utilize this data remains highly controversial. Furthermore, the push for pay-for-performance in health care creates many concerns for the frontline surgeon wondering how to implement meaningful PROMs in a variety of clinical settings. The experiences of AANA members from large academic centers, military institutions and group practices have recurring themes. Most agree that there is tremendous promise and importance in measuring patient-reported outcomes. There is equal consensus that several barriers exist to implementation including cost, integration, compliance and utilization.

Louis McIntyre, M.D., past president of AANA and Chief Quality Officer at U.S. Orthopedic Partners, works to implement patient-reported outcome programs across partner practices. He advocates that PROMs are useful in quality control, compliance (merit-based incentive payment system), negotiating, marketing, patient engagement, research and alternative payment methodologies like bundled payment programs. He states that these measures can identify or confirm clinical deficiencies and trends across practices, as well as demonstrate safety quality and efficacy. He does note that there are barriers, including the cost of outcome platforms; difficulties with integrating into existing electronic medical records and practice management platforms; patient compliance; and disruption of office workflow.

Read more on Dr. Wilson's full article on Measuring Success

Full Version of October 2020 E-Newsletter

Measuring Success: Implementing Patient-Reported Outcome Measures Into Your Practice

By: Kevin W. Wilson, M.D.
Member, Communications/Technology Committee

The concept of the patient-reported outcome measures (PROMs) has migrated from the background, based in research, to common discussion in everyday clinical practice. Rather than relying on imaging, simple exam measurements and the surgeon’s assessment of return of strength and function, PROMs give the patient a stake in how we evaluate the results of any intervention.

The growth and development of incorporating PROMs in orthopaedic practice has mirrored the use of big data and other industries, including professional sports. Larger corporations are leveraging their resources to incorporate these techniques, while smaller entities are taking more measured approaches. While most surgeons can agree that an accurate measurement of the patient's perception of their success in treatment is vital, how we collect and utilize this data remains highly controversial. Furthermore, the push for pay-for-performance in health care creates many concerns for the frontline surgeon wondering how to implement meaningful PROMs in a variety of clinical settings. The experiences of AANA members from large academic centers, military institutions and group practices have recurring themes. Most agree that there is tremendous promise and importance in measuring patient-reported outcomes. There is equal consensus that several barriers exist to implementation including cost, integration, compliance and utilization.

Louis McIntyre, M.D., past president of AANA and Chief Quality Officer at U.S. Orthopedic Partners, works to implement patient-reported outcome programs across partner practices. He advocates that PROMs are useful in quality control, compliance (merit-based incentive payment system), negotiating, marketing, patient engagement, research and alternative payment methodologies like bundled payment programs. He states that these measures can identify or confirm clinical deficiencies and trends across practices, as well as demonstrate safety quality and efficacy. He does note that there are barriers, including the cost of outcome platforms; difficulties with integrating into existing electronic medical records and practice management platforms; patient compliance; and disruption of office workflow.

Read more on Dr. Wilson's full article on Measuring Success

Full Version of October 2020 E-Newsletter

Ultrasound-Guided Shoulder Injections Help Fortify Medical Decision-Making

By: Gregory C. Mallo, M.D.
Member, Communications/Technology Committee

In 1977, Charles S. Neer II, M.D. first identified suspected rotator cuff disease by eliciting pain with passive abduction in the scapula plane and holding the arm in internal rotation. This became known as the “Neer sign.” Years later, temporary relief of a painful Neer sign with an injection of local anesthetic into the subacromial space indicated a positive "Neer test," which increased diagnostic utility.

In today’s modern medicine, practitioners consider the subacromial injection a diagnostic staple for identifying shoulder pathology. More recently, the ubiquity of portable ultrasound technology has improved injection accuracy, further solidifying its use as a powerful diagnostic tool.

There have been several excellent articles in the literature discussing a myriad of diagnostic shoulder injections that many of us are familiar with. These include injections into the subacromial space, the acromioclavicular (AC) joint, the long head biceps tendon (LHBT), glenohumeral joint and suprascapular notch.

Thus, the purpose of this article is not to review these various indications and techniques, but instead to share how ultrasound-guided diagnostic injections dramatically impact some unique situations.

Read Dr. Mallo's full article

Full Version of August 2020 E-Newsletter

In-Office Needle Arthroscopy is Ready for Prime Time
Why Needle-Based Arthroscopy Platforms Offer Surgeons and Patients an Alternative

Sean McMillan, D.O., DAL
Member, Communications/Technology Committee

In-office needle arthroscopy has seen a renewed interest over the past several years among Orthopaedic Surgeons. Advances in platform optics, cost reduction and portability have fostered this growth. Furthermore, the opportunity for immediate answers to plan or enact treatment, usually resulting in avoiding additional diagnostic imaging and its follow-up appointments, has enhanced the prospects for this modality.

A review of the literature defines diagnostic arthroscopy as the gold standard for intra-articular knee pathology.^1,2 There are many written works that address the similar benefits seen in using needle arthroscopy in this endeavor.^3-10 In addition to the efficacy of diagnosis for intra-articular pathology, the safety profile associated with needle arthroscopy was reported to be equivalent to standard in-office injection.^5,11 So where does the resistance to a more universal adoption lie? No singular answer can be provided; however, an understanding of the Rogers Innovation Curve reminds us that Orthopaedic Surgeons are often creatures of habit. Surgical arthroscopy ultimately gained recognition for superiority over open arthrotomy in the mid-1980s due to the enhanced ability to diagnose and treat intra-articular pathology. Nevertheless, history often forgets that the innovation of arthroscopy originated almost 70 years earlier in 1912. Change in habit is often born out of necessity, gaining acceptance gradually when an appropriate treatment algorithm is blended with a need.

Size Matters: Why In-Office Needle Arthroscopy Isn’t Ready for Prime Time

J. Martin Leland III, M.D.
Member, Communications/Technology Committee

Since its creation in the early 1990s,¹ in-office needle arthroscopy has gone through at least four different iterations with countless technological improvements.² Systems have gone from expensive towers of equipment yielding poor image quality to a hand-held, iPad-style monitor that can easily attach to a needle scope and syringe. Needle arthroscopy has seen significant advances in improving visualization, decreasing cost, decreasing size of equipment and increasing portability. However, numerous problems with in-office needle arthroscopy remain, which leads to the conclusion that it just isn’t ready for prime time.

Full Version of July 2020 E-Newsletter

2020 AANA Advocacy Updates: What You Need to Know Now

Eric C. Stiefel, M.D.
Chair, Advocacy Committee

Members of the AANA Advocacy Committee continue to support AANA members’ interest in advocacy and reimbursement. We would like to highlight a few of the initiatives AANA representatives have been working on in 2020.

COVID-19 Impact Analysis and Business Update

AANA leadership was first to market when it came to providing members with accurate and timely updates on compliance and government programs; these programs are aimed at minimizing the negative impacts of the cover pandemic on physicians and small business owners. Over 300 members took advantage of webinars that contained education programming ranging from optimal management of elective surgery patients to the Paycheck Protection Program and COVID-19 stimulus payments.

Single Anatomic Location
Removal of "shoulder is a single anatomic location" from the National Council on Compensation Insurance (NCCI) introductory language
One big win came earlier this year when the statement, "the shoulder is a single anatomic location" was removed from the introductory language of the NCCI edits. This change marked the conclusion of work that started in 2016 with the unbundling of shoulder code 29823. It was our belief that this language was the central argument supporting bundling of many of the secondary codes in the family of arthroscopic shoulder surgery. AANA leadership partnered with the AAOS Advisory Circle to request revision/removal of this language from the 2019 NCCI edits. We were successful in removing this inaccurate language in the 2020 NCCI edits.

Battle Over Superior Capsular Reconstruction (SCR)
The AANA Advocacy Committee formed a task force of specialty societies that includes AANA, the American Shoulder and Elbow Surgeons (ASES), The American Orthopaedic Society for Sports Medicine (AOSSM) and the American Academy of Orthopaedic Surgeons (AAOS) to advocate our request for changing the American Medical Association (AMA)’s recommendation to report superior capsular reconstruction (SCR) as an unlisted surgical procedure (29999). Significant historical president supported alternative coding options and was presented to the AMA CPT^® Advisor with a request to revise their 2017 recommendation to report this procedure using an unlisted code. At the level of CPT^® Editorial Panel, we were forced to abandon efforts to achieve this revised recommendation due to risk of re survey (and revaluation) of the family of shoulder arthroscopy codes. Currently, AANA recognizes code 29999 as the appropriate code to use for isolated SCR procedures; however, we would note that in cases where a humeral-based repair of native rotor cuff tissue (for example: subscapularis or infraspinatus tendons) is performed, code 29827 can be reported as a base code in addition to code 29999 for the SCR repair. We encourage members to seek precertification when reporting SCR as an unlisted surgical procedure, with reference to code 29806.

Read More

Full Version of June 2020 E-Newsletter

Massive Cuff Tear Repair - You Mean We Don’t Need a Graft?

Wesley M. Nottage, M.D.
Member, Communications/Technology Committee

The definition of a massive tear varies between authors, but the general criteria for a massive rotator cuff is based on either the number of tendons involved (two or three), a direct measurement greater than 5 cm^(1,11) or a combination of these criteria.^(3,8,9)

The treatment options include: nonoperative treatment with injections and physical therapy; bursal debridement and biceps tenotomy or tenodesis; a partial cuff repair; a complete rotator cuff repair, a complete rotator cuff repair with augmentation; tendon transfers; a superior capsular reconstruction; a subacromial balloon; or a reverse shoulder arthroplasty.

The clinical presentation is important. The ability to go overhead (with pain, or better after a bursal anesthetic) despite the tear suggests an arthroscopic partial or complete repair may do well. The morbidity of the treatment options and the surgeon experience significantly play a role in the selected treatment option. Remember that most of these tears are usually acute on chronic, and the patients were functioning without enough problems to seek help prior to the latest symptoms that bring them to you for treatment. One goal of treatment can be considered to return the patient to their status prior to the last event that brought them to you for care.

"Massive" and "irreparable" are two different concepts. Despite a preoperative MR imaging and exam suggesting a massive tear, the literature reports in this group 50-80% of these tears are completely repairable. A complete repair of the massive rotator cuff is associated with good results and improvement in functional scores over nontreatment, a partial repair or debridement. However, a complete rotator cuff repair requiring aggressive soft-tissue releases is not superior to a partial repair. Double-row and transosseous repairs result in lower retear rates than single-row techniques. The clinical judgment as to how far to go to get a repair plays a major role in the outcomes.

Eliminating excessive rotator cuff tension is the key principle to respect when attempting a complete repair. Utilization of the principles of margin convergence; multiple-double or tripleloaded anchors to decrease the load per suture; and the use of transosseous-equivalent techniques when possible will favor a durable repair. Certainly, after starting, a number of complete repairs will end up as partial repairs, which, although not as good as a complete repair, can still offer significant pain relief.

There are several systemic reviews of the complete repairs of massive rotator cuff tears.

Read More

Full Version of May 2020 E-Newsletter

A Closer Look at the Second AANA-Exclusive, COVID-19 Webinar
Q&A with Louis F. McIntyre, M.D.

Towards the beginning of April, AANA launched its first live webinar on strategies to implement in order to keep practices alive and well during the acute stage of the COVID-19 pandemic. To follow its high success, AANA released a second live webinar in late April focusing on strategies to carry out once practices reopen.

We asked webinar moderator Louis F. McIntyre, M.D., AANA Immediate Past President, questions regarding the webinar and how viewers will be better prepared for reopening their practices.

Full Version of April 2020 E-Newsletter

COVID-19: How is Your Practice Changing as a Result of the Coronavirus Pandemic?

In response to the COVID-19 (coronavirus) pandemic, orthopaedic practices across the globe are changing their processes, guidelines and the way they see patients in order to protect their staff, patients and ultimately themselves.

AANA Leaders and Committee Members provided insight into how their practices have changed due to COVID-19 as well as their advice for creating a safer work environment. Their answers are compiled into 10 helpful tips for you to incorporate into your own practice (if you haven’t done so already).

1. Screen all staff and patients with temperature checks, travel history, known contact with an individual who has tested positive for COVID-19, symptoms of fever, cough, etc. Brian J. Cole, M.D., M.B.A., Orthopaedic Surgeon and Managing Partner at Midwest Orthopaedics at Rush; AANA First Vice President, states that his team currently wears surgical masks only for those interfacing with patients who clear the initial screening process.
2. Embrace telehealth initiatives. Dr. Cole explains that maintaining the core of the business is essential so that when it’s safe to evaluate and treat elective conditions, those involved will be better prepared to do so – meaning the ability to evaluate both new and existing patients through telehealth practices is a current and future must.
3. Shift surgeries performed. Mark H. Getelman, M.D., Orthopaedic Surgeon at Southern California Orthopedic Institute; AANA Second Vice President, notes that, from a surgical viewpoint, only surgeries that are urgent and emergent are being performed, which would be defined as cases where a delay of 45-60 days would result in a negative impact to overall recovery, including but not limited to: fractures; unstable joints; and certain critical hand, elbow, ankle, foot, knee and shoulder tendon and ligament ruptures needing acute repair
4. Practice commonly used hygiene initiatives. Dr. Getelman says this includes what has become routine for many: washing hands before and after a visit; using hand sanitizer; and wearing protective gloves before, during and after a patient examination. In addition, advanced screening has become routine in the clinic now as well as with patient questionnaires and temperature checks, maintaining social distancing and considering mask use for all clinical personnel at this time.
5. Implement a "terminal clean policy” for each patient room. Paul E. Caldwell, M.D., Orthopaedic Surgeon at Tuckahoe Orthopaedics Associates; AANA Board of Directors Member-at-Large and Membership Committee Chair, advises, in addition to personal hygiene initiatives, implementing a policy where a nurse wipes down each room with disinfectant wipes after the patient is seen. He also encourages "elbow bumps" versus handshakes and carrying out patient conversations at a six-foot distance.
6. Develop a long-term financial plan. Dr. Caldwell says that this is key from a business standpoint. In addition, he suggests budgeting your resources wisely.
7. Utilize Physician Assistants (PAs). Jonathan B. Ticker, M.D., Orthopaedic Surgeon and Shoulder Specialist at Orlin & Cohen Orthopaedic Group; AANA Communications/Technology Committee Chair, explains how PAs at his office are filling a critical screening role and assisting with patient triage for virtual or in-person consultations.
8. Consider an “on-call” practice as an option. Dr. Ticker echoes Dr. Cole’s advice on utilizing telehealth initiatives, and notes how his office has temporarily become an “on-call” practice in order to balance the need to be there for patients with the health and safety of staff and the community, offering a mixture of in-person (for urgent and emergent patient needs) and telehealth visits.
9. Maintain strict distancing between all staff. Michael E. Pollack, M.D., Orthopaedic Surgeon at MidJersey Orthopaedics; AANA Communications/Technology Committee Member, says that, for those in-person visits, in addition to the appropriate and compulsive hygiene his staff displays, everyone is also maintaining strict distancing – even going down to "A" and "B" shifts in order to have fewer employees in the office at a given time and help decrease overhead to a more sustainable level.
10. Educate staff and patients to the best of your ability. Additionally, Dr. Pollack encourages his colleagues to use their platform as trusted providers to educate patients, despite their lack of critical care and pulmonary expertise. Another tip? Continue to communicate with staff daily and in real time so they understand that their safety and the health of society is paramount.

Finally, during these difficult and stressful times, it’s important to be flexible and persevere. Louis F. McIntyre, M.D., Orthopaedic Surgeon for Northwell Health; AANA Immediate Past President, notes that even when state lockdowns end and lives return to normal, the normalcy everyone is used to seeing might not exist for some time, long after hospitals and practices have better control of the situation. One important plus, though: long-term trends for the specialty are still good for doctors and patients alike.

Full Version of March 2020 E-Newsletter

Telemedicine: A Primer for Arthroscopists

"Telemedicine" is a term we are all starting to hear more frequently. Most of us know that it’s out there and being used by some providers. We often hear about its use in specialties where access is a problem, such as psychiatry or neurology in rural areas.

But how will telemedicine affect the arthroscopic surgeon? Will it be used simply as a marketing tool to garner more patients, or will it truly be transformational and change the way that we deliver patient care? The answer to this remains to be seen and will be affected by the ease of use, adoption by patients, regulatory issues and whether it will be adequately reimbursed.

Firstly, what is telemedicine or telehealth? Sometimes these terms are used interchangeably and there is considerable debate about their exact definitions. Most consider telemedicine to be the delivery of traditional health care between a provider and a patient using technology, while telehealth is more encompassing and includes the administration and educational aspects of health care. In this article, we will be using the term "telemedicine" and focusing on the interaction between you (the physician) and a patient. I will not be covering the growing field of remote patient monitoring, which is worthy of its own discussion.

With all the administrative and technology burdens already placed on us, why should we even consider incorporating telemedicine into our practice?

Vishal Mehta, M.D.
Member, AANA Communications/Technology Committee

Full Version of February 2020 E-Newsletter

Microfracture: Is It Officially a Thing of the Past?

Marrow stimulation procedures, specifically microfractures, have historically been the "gold standard" in the initial treatment of full thickness (Grade IV) articular cartilage defects. While various marrow stimulation techniques have existed for many decades, the term "microfracture" and the corresponding technique was originally introduced by Steadman et al. The purpose of a microfracture procedure is to open channels in the subchondral bone at the base of a chondral defect using an awl or a chondral pick to stimulate blood flow and the release of bone marrow elements to the surface of the defect area.

The procedure is straightforward and technically easy to perform during a routine arthroscopy but is wrought with potential issues and concerns. First, the typical postoperative protocol after a microfracture procedure requires a significant period of restricted weight bearing (four-eight weeks), whereas a type of debridement procedure alone allows for early weight bearing with assistive devices and full-weight bearing within one-two weeks.

Second, the resulting cellular base that forms as a result of the procedure is primarily fibrocartilage, as opposed to true hyaline cartilage. Fibrocartilage lacks Type II collagen and therefore lacks the tensile strength of healthy, native hyaline cartilage.

Third, the standard microfracture technique with an awl has been shown to create substantial injury to the subchondral bone itself, often resulting in edema, subchondral cyst formation and even intralesional osteophyte formation over time.

Fourth, multiple systematic reviews and meta-analyses have shown patient-reported outcomes to significantly decrease at two years after a microfracture. This is in stark contrast to the results of various cartilage restoration type-procedures, such as autologous osteochondral transfer, allograft osteochondral transplantation (OCA) and autologous chondrocyte implantation (ACI), each of which have reported success rates from 70-80% or more at five- and 10-year follow-up.

Finally, other studies have shown the success rates of these cartilage restoration procedures to be significantly less after a microfracture procedure has previously been performed first.

So, should microfracture be officially deemed a thing of the past?

Clayton Nuelle, M.D.
Member, AANA Communications/Technology Committee

Full Version of January 2020 E-Newsletter