December 5-7, 2013
ARIA, Las Vegas
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Emerging Techniques in Orthopedics (ETO) Previous Meetings Highlights
Emerging Techniques in Orthopedics, Sports Medicine and Arthroscopic Surgery 2012 Meeting Highlights
Thursday, December 6th, 2012
It was an exciting time on day 1 of Emerging Techniques in Orthopedics. Our first day was knee day. We tried to put together a faculty that was both from here, the United States, and internationally. We invited some members from Austria and we found that they do things just a little bit different than us. I found that inviting former presidents of various organizations, whether it'd be American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, or the American Academy of Orthopedic Surgeons, brought together a faculty that really started to debate pro and con on many issues that you face in your operating room and in the office.
One of the highlights of the day was to learn new procedures specifically medial patellar femoral ligament reconstruction arthroscopically from an international point of view. And we had a special section this year on pediatric and adolescent anterior cruciate ligament (ACL) reconstruction where we brought together all the top names to figure out how really do we help our young patients who are ACL deficient.
On day 1 of knee, we were also honored that Russell Warren, MD, back. He was one of our honored faculty in conjunction with John Bergfeld, MD. The two of them sat down and helped us really sort what we are doing with our patients from many procedures of the knee and how do we really help our patients.
Kevin D. Plancher, MD
Emerging Techniques in Orthopedics
Friday, December 7th, 2012
Day 2 of ETO was shoulder day. We had invited Gilles Walch, MD, Department of Shoulder Surgery, Orthopedique Santy, Hospital Prive Jean Mermoz, Lyon, France to help us, as well as James Esch, MD, Assistant Clinical Professor, Department of Orthopaedics, University of California, San Diego School of Medicine. It was a spectacular day where we argued back-and-forth in a debate format what exactly are we doing, is it helping our patients, and what procedure can we do to help them to get better to use their shoulder.
We were excited on day 2 to have the return of Richard Hawkins, MD, he was able to moderate and to help us really sort out how do we treat the biceps, how do we treat how many specific shoulder issues.
Kevin D. Plancher, MD
Emerging Techniques in Orthopedics
Saturday, December 8th, 2012
Saturday was open shoulder day for Emerging Techniques. We learned from Gilles Walch, MD, and his experience in dealing with the reverse total shoulder. His 17-year history was summarized in 20 minutes and really will guide most of us on how and when we use the reverse total shoulder. Saturday was also an exciting time for us to learn about practice management, the do's and don'ts in this challenging time of healthcare crisis.
One of the newest features of Saturday afternoon in Emerging Techniques in Orthopedics was the labs. We sent our participants to 5 different laboratory locations to learn knee, shoulder —whether I'd be arthroscopic, open total shoulder or reverse shoulder, all-inside ACL, all-inside PCL, arthroscopic repairs of the rotator cuff and even endoscopic cubital tunel releases.
Thank you to all the exhibitors and vendors that made this possible.
Kevin D. Plancher, MD
Emerging Techniques in Orthopedics
From The American Journal of Orthopedics® Conference News Update
2nd Annual Emerging Techniques in Orthopedics Meeting—Las Vegas
Arthroscopic Tibial Eminence Fractures Update
The key to diagnosing tibial eminence is a high index of suspicion, according to Carl W. Nissen, MD, Elite Sports Medicine, Connecticut Children's Medical Center. "If you donâ€™t think about it, you will probably not see it in many instances."
While these fractures are uncommon, accounting for less than 2% of fractures, when appropriately diagnosed and treated early, tibial eminence fractures do very well, he explained. Considerations when dealing with these fractures include that intrasubstance injury can occur with bony injury and secondary injuries need to be diagnosed early, Nissen added.
Diagnosis of tibial eminence fractures includes lateral x-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI). "For me, MRIs in these instances are very important, because you can see problems that go along with eminence fractures that are important to be able to treat, and know about them ahead of time, before you go into the operating room," Nissen explained.
Classification system for these fractures include Type I (<3 mm displacement), Type 2 (intact posterior hinge), and Type 3 (avulsed fragment). However, Nissen determines whether a patient should be treated using a more simplified classification system, where Type A fractures are fractures that you can live with and the patient will do fine, while Type B fractures, are bad, and have to be fixed."Although the McKeever classifications I, II, and III, are something that you need to know about, I will tell you that almost all of these eminence fractures that have any displacement, end up in the operating room" Nissen stated.
Two surgical options for the treatment of tibial eminence fractures include sutures and open reduction internal fixation (ORIF). Some of the advantages associated with sutures are the strength of fixation and purchase on small fragments, however, they also require drilling across physis, involve a more complex procedure, and can lead to physeal tethering. ORIF is simple, works well for large fragments, and provides strength of fixation. Some of its disadvantages include potential hardware removal, purchase on fragment, and physis violation.
"Using sutures is the method I have turned to almost exclusively," Nissen explains."I feel much more comfortable as an arthroscopic surgeon, being able to place sutures appropriately at the base of the ACL, drilling 2 tunnels, then tying it down, and holding the fragment down. With the high strength sutures that are available to us, we can really get some fantastic tension on the ACL as well as complete reduction of the fracture fragment."
What Is the Key to Success in RCR Failures?
While rotator cuff repair (RCR) failure have many causes, proper indications are the key to successful revision surgery, Larry D. Field, MD, Mississippi Sports Medicine, Orthopedic Centers, Jackson, at the 2nd Annual ETO meeting. "The failed rotator cuff repair patient is challenging to treat," he stated. "Whether it is your own patient who failed, or the patient has been referred to you"
Field emphasizes the importance of defining failure and finding ways to best treat the patient. Diagnostic and technical errors, as well as surgical complications, failure to heal, and traumatic failure, are some of the different types of rotator cuff failure. "The reality is that RCR failure is often multifactorial," he added.
Taking a closer look at diagnostic errors, Field explained that an incorrect diagnosis (eg, cervical radiculopathy, adhesive capsulitis) will decrease the success of operative outcome, while recognizing the right patient and the right diagnosis will improve these outcomes. In addition, identifying the presence of other conditions such as radiculopathy or adhesive capsulitis will help prevent an incomplete diagnosis.
Technical errors also contribute to RCR failures, including inadequate rotator cuff immobilization, high tension repair, and poor fixation. Surgical complications include infection, deltoid detachment, stiffness, and neurological injury. Failure to heal is another consideration for rotator cuff repair, with factors including poor vascularity, advanced age, and larger tears, have been associated with decreased healing rate, he noted.
"With that said, successful revision of previously failed rotator cuff repairs is possible" Fields stated."The indications really are the key to helping us carry out these operations successfully, and a thorough evaluation is necessary both with a very extensive history and physical review of pertinent medical records, advanced imaging are very important in these situations, and while arthroscopy can be challenging, it does offer us an unparalleled opportunity to evaluate and assess these tears."
Five tips and tricks Field shared, included correcting motion loss, thorough debridement of the shoulder, mobilizing the rotator cuff extensively, to not forget about the subscapularis, and to address concomitant pathology.
In correcting motion loss, capsular release is an important component; it can improve rotator cuff release and lower the humeral head, Field stated. For debridement, adequate visualization is needed as well as removal of sutures and adhesions. Aggressive mobilization can be achieved by maximizing footprint coverage, increasing fixation security, and medialize the rotator cuff on footprint as necessary.
"Don't forget about the subscapularitis," Field emphasized. "I think that subscapularis tears are either underappreciated or underrecognized, or potentially ignored, in primary indexed rotator cuff surgery, but they do contribute to failure" Repairing subscapularis tears improves symptoms and increase healing of supra/infra tears. It is also important to address concomitant pathology, Field concluded. Bicep pathology is common in rotator cuff tears and the AC joint is often overlooked or ignored.
From The American Journal of Orthopedics ® Conference News Update
2nd Annual ETO Meeting—Las Vegas
Lessons Learned From 30 Years of Shoulder Arthroscopy
In an honored professor lecture, James C. Esch, MD, Orthopedic Specialists of North County Inc, Oceanside, California,discussed the he learned lessons from 30 years of shoulder arthroscopy and whether after all this time, he and other surgeons know what they are doing. Esch is Consultant for Smith & Nephew Inc, Endoscopy Division, and has stock options in KFx Medical (Carlsbad, California).
"Together we have been studying shoulder arthroscopy of 30 years," he said. Orthopedic surgeons come to meetings to learn more about shoulder arthroscopy and to become better surgeons. Surgeons trust what they hear and observe, he added, and use the information to become the best possible surgeon to their patients.
"Shoulder arthroscopy was developed by individuals in private practice interested in solving a problem," Esch began, then listed his mentors, including Lanny Johnson, MD, who in 1976, developed the needlescope. At first, arthroscopic shoulder surgery focused on understanding labrum anatomy and repairing labrum to the bone, Esch explained. For instance, Lanny Johnson, MD, developed a staple for fixation, while Eugene Wolf, MD, was a proponent of screw fixation. Other advances included resorbable tack devices, trans-osseous sutures, and the metallic suture punch.
Then came Harvard Ellman, MD, who, according to Esch, was the bridge to traditional shoulder surgeons and suggested that cuff-repair was necessary. To that end, several surgeons developed techniques geared toward cuff repair, such as Lonnie Paulos, MD, who developed subacromial space surgery and mini-open rotator cuff repair, Tom Sampson described co-planning, and Stephen Snyder, developed the use of mini-open tools. "The rapid expansion of shoulder arthroscopy by community surgeons created conflict with most traditional shoulder surgeons," Esch noted.
Taking a closer look at long-term instability recurrences in a young population, Esch cites results from Caspari, who found that his instability surgery had a higher instance of failure 5 years postoperatively (28%). Other surgeons, including O'Driscoll and Walch stopped using this technique in favor of others. Then Castagnia and Wilhelms reported 10-year results with a 21% failure rate for their instability surgery"'So maybe we are not doing as good as we think we are," Esch continued. â€œAnd then we still have rotator cuff repair concerns: single row, double row, partial cuff tear, biceps tear."
In 2008, Jennifer A. Coghlan and colleagues conducted a systematic review on surgery for rotator cuff disease. They searched several different databases, including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE, and included trials that were randomized or quasi-randomized clinical trials with rotator-cuff disease patients and surgical interventions, compared with placebo, no treatment, or any other treatment. Overall, they included 14 randomized controlled trials (N=829), and found that "surgery may not lead to differences in pain, compared with different exercise programs," Esch stated. "Maybe exercise is just as good andit doesn't seem to make any difference."
According to current American Academy of Orthopaedic Surgeons (AAOS) guidelines, rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears (level IV, weak recommendation) and routine arthroscopic subacromial decompression is not required at the time of rotator cuff repair. While some surgeons may resent these guidelines, Esch explained, the AAOS reinforces that their guidelines are based on evidence-based medicine, are transparent, and treatment is based on mutual communication between patient and physician. "We are afraid for our patients and we believe that our patients with cuff repairs do better," Esch stated. "But the patients trust us that we are doing the best for them." Better data is needed, he emphasized.
Esch believes take-down and repair of tears works best in his hands. "So, where do I fit?" Esch's educational background consisted of a classical education, which was followed by a similar education at Notre Dame, where information was very much black and white. However, his philosophical education challenged this concept. "I am challenged by whether our arthroscopic shoulder surgical results are upheld by data or just a belief system," Esch continued.
"The men who championed these procedures were my mentors, which are now referred to in the medical industry as key opinion leaders." Are key opinion leaders true mentors and proponents of the truths, he questioned.
"My challenge in 30 years of presenting shoulder arthroscopic programs is to find the best and most honest teachers, and continue to look at the results," Esch concluded. "We need to continue to look at evidence that may challenge our beliefs in our shoulder results."
2011 Emerging Techniques in Orthopedics, Sports Medicine & Arthroscopic Surgery Meeting Highlights of the Inaugural Event
"Get ready to rumble! In the right corner, the defending champion from New York City, Dr. Russell Warren... in the left corner, Dr. Thomas Branch! Let's box!" announced Mark Miller, MD, Knee Program Chair and opening-day moderator for the first annual Emerging Techniques in Orthopedics: Sports Medicine & Arthroscopic Surgery, held December 8-10, 2011, at the Encore at Wynn in Las Vegas, Nevada. So began a fast-paced, "no holds barred" meeting featuring "star-studded" faculty from leading institutions across the United States. Mixing just the right amount of fun and entertainment with education throughout the 2.5-day inaugural meeting, Conference Chair Kevin Plancher, MD, said in his opening remarks to more than 300 attendees, "I hope this is a meeting in which you say, 'I didn't know that; I am going to change my practice.'"
The American Journal of Orthopedic
s and Orthopaedic Foundation for Active Lifestyles, the meeting offered 20.5 CME credits and covered anterior cruciate ligament reconstruction, shoulder surgery, hip arthroscopy, new surgical devices, and proper coding practices.
Restoring the correct "footprint" in ACL reconstruction
In their debate over which method is superior, double bundle or single bundle, in anterior cruciate ligament reconstruction (ACLR), conference Honored Professor Russell Warren, MD, Professor of Orthopaedics at Weill Cornell Medical College, and surgeon in chief emeritus at Hospital for Special Surgery, New York, NY, and Thomas Branch, Director of University Orthopaedic Clinic, Dekalb Medical Center in Decatur, GA, both stressed the goal of ACLR as elimination of the pivot shift, including translation and rotation. Dr. Warren summarized that, although the mechanical data, as demonstrated in the laboratory setting or with computer-navigated operative systems, demonstrate the double bundle will control rotation better than single bundle, the clinical value of this superiority has yet to be shown well. He did mention to the audience, however, that double bundle may be a consideration in patients with no menisci.
Dr. Branch highlighted studies that show single bundle ACLR using bone-tendon-bone (BTB) autograft results in higher rates of osteoarthritis, compared with single bundle ACLR using hamstring autograft, but single bundle with hamstring autograft does not result in comparable long-term survivorship, compared with single bundle BTB autograft. He discussed his data results with regard to single bundle versus double bundle hamstring ACLR.
This debate moved into Dr. Miller's discussion of choosing a proper tunnel location in ACLR, in which he emphasized that the key end result, whether a surgeon uses single bundle or double bundle for reconstruction, is to restore the patient's anatomy.
Honored Professor Lecture
Moderated by shoulder Program Chair Claude T. Moorman, III, MD, day 2 featured "The Journey: Orthopedics and Life" presented by conference Honored Professor Richard Hawkins, MD, Clinical Professor at the University of South Carolina School of Medicine, Program Director of the Steadman Hawkins Clinic of the Carolinas Fellowship Program, Chairman of the Orthopaedic Research Foundation of the Carolinas, and team physician for the Denver Broncos and Colorado Rockies. A founding member of the American Shoulder and Elbow Surgeons Society and the first fellow of the late Charles Neer, MD, the "father of modern shoulder surgery" Dr. Hawkins said he had been "preparing for this speech for the past 69, almost 70, years." Speaking from the heart, Dr. Hawkins reminded his audience to set goals, and he shared his: communication, attention to detail, being a good person, passion, and curiosity.
As his former teacher, Dr. Hawkins praised Dr. Plancher on his accomplishments in organizing the inaugural Emerging Techniques in Orthopedics: Sports Medicine & Arthroscopic Surgery meeting.
For the 2012 conference, Dr. Plancher looks forward to welcoming Honored Professors John Bergfeld, MD, Director of the Operating Room and Senior Surgeon, Department of Orthopaedic Surgery, Cleveland Clinic Sports Health Center, Cleveland, Ohio; James Esch, MD, Orthopaedic Specialists in North County, San Diego, California; and Gilles Walch, MD, Department of Shoulder Surgery, Centre Orthopedique Santy, Hopital Prive Jean Mermoz, Lyon, France.
Video interviews with 2011 ETO faculty members Brian Cole, MD and Bert Mandelbaum, MD.
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