2016 Final Program

Transcription

2016 Final Program

THE KNEE SOCIETY
The 2016 Specialty Day Meeting of
The Knee Society

In association with the
American Association of Hip and Knee Surgeons
(AAHKS)
Final Scientific Program
Saturday, March 5, 2016
Orange County Convention Center, West Bldg., Valencia Room B
Orlando, Florida
ANNOUNCEMENTS
AAOS Annual Meetings
March 14-18, 2017
San Diego, California
March 6-10, 2018
New Orleans, Louisiana
AAHKS 26th Annual Meeting
Save the Date - New Location!
November 10-13, 2016
Hilton Anatole, Dallas, Texas
AAHKS 26th Annual Meeting Call for Symposia
Submit proposals by May 2, 2016
covering all aspects of arthroplasty and health policy.
AAHKS 26th Annual Meeting Call for Abstracts
Submit abstracts by June 1, 2016 for consideration
as podium or poster presentations.
Submit symposia and abstracts online at www.AAHKS.org.
AAHKS 27th Annual Meeting
November 2-5, 2017
Hilton Anatole, Dallas, Texas
Digital Archives Are Yours For 1 Year!
On-site participants of the 2016 Specialty Day Meeting of The Knee Society and AAHKS
will receive complimentary access to video archives for one year beginning April 15, 2016.
This program is streaming LIVE via the Internet to participants around the world.
Live-streaming and recording services are provided by:
© 2016 The Knee Society
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WELCOME TO THE 2016 SPECIALTY
DAY MEETING OF THE KNEE SOCIETY
AND AAHKS
GENERAL INFORMATION
The Mission of The Knee Society:
The mission of The Knee Society is to promote outstanding care to patients with knee disorders through
innovative research and education.
Meeting Objectives:
The Knee Society/AAHKS Specialty Day Meeting is designed to update clinical skills and basic knowledge
through research findings and biomechanical studies; to discuss the various surgical and non-surgical
treatments and management of conditions related to the knee joint; to determine indications and
complications in total knee arthroplasty; to critique presentations of surgical techniques and demonstrations
of treatment options; and to evaluate the efficacy of new treatment options through evidence-based data.
CME Accreditation:
This activity has been planned and implemented in accordance with the accreditation requirements and
policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership
of the American Academy of Orthopaedic Surgeons and the Knee Society. The American Academy of
Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
The American Academy of Orthopaedic Surgeons designates this live activity for a maximum of 7.75 AMA
PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
IMPORTANT
Please complete evaluation online at:
https://www.surveymonkey.com/r/KSSD16 or use the QR code
to access.
Please silence all electronic devices while inside the session
room.
Please refrain from unauthorized photography and video
recording of presentations.
Your registration for, and attendance of, this session gives The
Knee Society permission to capture images of session attendees
and to use these images for internal and marketing purposes.
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ACKNOWLEDGMENTS
PAST PRESIDENTS OF THE KNEE SOCIETY
PAST PRESIDENTS OF AAHKS
1983
Chitranjan S. Ranawat, MD
1991
J. Phillip Nelson, MD
1984
1992-1993
1985
Richard S. Bryan, MD (Deceased)
1994
Richard C. Johnston, MD, MS
1986
John N. Insall, MD (Deceased)
1995
Lawrence D. Dorr, MD
1987
Charles O. Townley, MD (Deceased)
1996
Hugh S. Tullos, MD (Deceased)
1988
David G. Murray, MD
1997
Merrill A. Ritter, MD
1989
Frederick C. Ewald, MD
1998
Richard H. Rothman, MD, PhD
1990
Lawrence D. Dorr, MD
1999
James A. Rand, MD
1991
Herbert Kaufer, MD
2000
Richard B. Welch, MD
1992
Paul A. Lotke, MD
2001
John J. Callaghan, MD
1993
Leonard Marmor, MD (Deceased)
2002
Douglas A. Dennis, MD
1994
David S. Hungerford, MD
2003
Clifford W. Colwell, Jr., MD
1995
Richard D. Scott, MD
2004
Richard F. Santore, MD
1996
Victor M. Goldberg, MD (Deceased)
2005
Joseph C. McCarthy, MD
1997
W. Norman Scott, MD
2006
William J. Hozack, MD
1998
James A. Rand, MD
2007
Daniel J. Berry, MD
1999
Kenneth A. Krackow, MD
2008
David G. Lewallen, MD
2000
Thomas S. Thornhill, MD
2009
William J. Robb, III, MD
2001
Clifford W. Colwell, Jr., MD
2010
Mary I. O’Connor, MD
2002
Robert E. Booth, Jr., MD
2011
Carlos J. Lavernia, MD
2003
Cecil H. Rorabeck, MD
2012
Thomas P. Vail, MD
2004
Merrill A. Ritter, MD
2013
Thomas K. Fehring, MD
2005
Russell E. Windsor, MD
2014
Brian S. Parsley, MD
2006
Gerard A. Engh, MD
2007
Michael A. Kelly, MD
2008
2009
William L. Healy, MD
2010
Arlen D. Hanssen, MD
2011
Robert B. Bourne, MD, FRCSC
2012
Giles R. Scuderi, MD
2013
Steven J. MacDonald, MD, FRCSC
2014
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ACKNOWLEDGMENTS
THE KNEE SOCIETY EXECUTIVE BOARD 2015-2016
AAHKS BOARD OF DIRECTORS 2015-2016
Thomas P. Vail, MD – President
Jay R. Lieberman, MD - President
Thomas P. Sculco, MD – 1st Vice President
William A. Jiranek, MD - 1st Vice President
Adolph V. Lombardi, Jr., MD –
Robert L. Barrack, MD –
3rd
2nd
Vice President
David A. Halsey, MD - 2nd Vice President
Vice President
Mark I. Froimson, MD - 3rd Vice President
Thomas K. Fehring, MD – Immediate Past President
Brian S. Parsley, MD - Immediate Past President
Steven J. MacDonald, MD – Past President
Michael P. Bolognesi, MD - Secretary
Michael E. Berend, MD – Secretary, Chair, Tech. Cmte.
C. Lowry Barnes, MD - Treasurer
Mark W. Pagnano, MD – Treasurer
Joseph T. Moskal, MD – Member-at-Large
Mark P. Figgie, MD – Chair, Membership Committee
Ryan M. Nunley, MD – Member–at - Large
Christopher L. Peters, MD – Chair-Elect, Membership Cmte.
Audrey K. Tsao, MD – Member-at-Large
Kevin J. Bozic, MD, MBA – Chair, Education Committee
Bryan D. Springer, MD – Chair, Research Committee
AAHKS EDUCATION AND
COMMUNICATIONS COUNCIL
Fred D. Cushner, MD – Member-At-Large
Craig J. Della Valle, MD – Member-At-Large
Craig J. Della Valle, MD -- Chair
Bryan D. Springer, MD – Vice Chair
Stephen J. Incavo, MD – Chair-Elect, Education Committee
John C. Clohisy, MD
THE KNEE SOCIETY EDUCATION
COMMITTEE 2015-2016
Gregory G. Polkowski, II, MD
Kevin J. Bozic, MD, MBA – Chair
Keith R. Berend, MD
Stephen J. Incavo, MD – Chair-Elect
David F. Dalury, MD
Keith R. Berend, MD
William P. Barrett, MD
R. Michael Meneghini, MD
William A. Jiranek, MD
Jeffrey A. Geller, MD
Timothy M. Wright, PhD
AAHKS EDUCATION COMMITTEE 2015-2016
William L. Griffin, MD – Past Chair
William P. Barrett, MD - Chair
Michael R. O’Rourke, MD
Douglas E. Padgett, MD
Gregory J. Golladay, MD
Jay J. Patel, MD
David A. Halsey, MD
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THE 2016 KNEE SOCIETY SCIENTIFIC AWARDS
The Scientific Awards will be presented from 1:01 pm – 1:33 pm
In October 1993, The Knee Society’s Executive Board established an award program to recognize
meritorious presentations at the annual Specialty Day meetings. The Board designated three
awards to be presented annually, in honor of The Knee Society members: Mark Coventry, MD,
Chitranjan S. Ranawat, MD, and John N. Insall, MD.
This year’s award recipients are:
The John N. Insall, MD, Award
Do Injections Increase the Risk of Infection Following TKA?
Presenter:
Nicholas A. Bedard, MD
Co-Authors: Andrew J. Pugely, MD; Jacob M. Elkins, MD, PhD; Kyle R. Duchman, MD; Robert W.
Westermann, MD; Steve S. Liu, MD; Yubo Gao, PhD; John J. Callaghan, MD
The Chitranjan S. Ranawat, MD, Award
No Difference in Two-Year Functional Outcomes Using
Kinematic Versus Mechanical Alignment in TKA
Presenter:
Simon W. Young, FRACS
Co-Authors: Matthew L. Walker, FRACS; Ali Bayan, FRACS; Toby Briant-Evans, FRCS;
Paul Pavlou, FRCS; Bill Farrington, FRCS, FRACS
The Mark Coventry, MD, Award
Oral Antibiotics Reduce Reinfection Following 2-Stage Exchange:
A Multi-Center, Randomized Controlled Trial
Presenter:
Craig J. Della Valle, MD
Co-Authors: Jonathan M. Frank, MD; Erdan Kayupov, MSE; Mario Moric, MA; John Segreti, MD;
Erik Hansen, MD; Curtis Hartman, MD; Kamil Okroj
Congratulations to presenting authors and their co-authors!
The Knee Society Scientific Awards
Manuscripts in consideration for the 2017 Knee Society Scientific Awards
may be submitted beginning in September 2016 through Clinical
Orthopaedic and Related Research (CORR).
The deadline to submit is December 1, 2016.
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THE 2016 YOUNG INVESTIGATOR SYMPOSIUM
The Young Investigator Symposium will be presented from 4:06 pm – 4:35 pm
Closed Incision Negative Pressure Therapy Versus Antimicrobial Dressings
Following Revision Hip and Knee Surgery: A Comparative Study
Presenter:
H. John Cooper, MD
Co-Author:
Marcel A. Bas, MD
Discharge Destination after Total Knee Arthroplasty: An Analysis of
Post-Discharge Outcomes and Risk Factors
Presenter:
Calin S. Moucha, MD
Co-Author:
Aakash Keswani
Thrombogenic Risk of Unicompartmental Knee Versus Total Knee Replacement
Presenter:
Edwin P. Su, MD
Co-Authors: Lauren E. Mount, MD; Allina Nocon, MPH; Thomas P. Sculco, MD; George Go, BS;
Nigel E. Sharrock, BMedSci, MB, ChB
IN THIS BOOK
PAGE
16
Detailed Schedule
Abstracts
27
Disclosures
80
The Hip Society’s Program
On reverse side
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THE KNEE SOCIETY’S
RESEARCH & EDUCATION FUND
The Knee Society thanks the following
donors to the Fund for their generosity
Mentor Level
($250,000 - $499,999)
Leadership Level
($2,500-$9,999)
Dr. & Mrs. Adolph V. Lombardi, Jr.*
Zimmer Biomet, Inc.*
Stephanie & Chad Alvarez*
David Eichler*
Derek Fox & Aaron Gatten / Apex Surgical*
Leo Fusilli*
Dan Kelley*
Joey Matt*
Jason Olejniczak / Midwest Biomet*
Rick Page & Marc Vreede / Biomet Detroit*
Brett Parkin / Biomet West, Inc.*
Lance & Lisa Perry*
Jim Reiff / Northwest Biomet*
Steven L. Rohlf*
Mike & Lori Schmitt*
Stallings Orthopedics, Inc.*
Thomas P. Vail, MD
John White / Biomet Corp.*
David Whitman & David Burke/Select Orthopedics*
Dan Williamson*
Shane Zeringue*
Partner Level
($100,000 - $249,999)
Biomet, Inc.*
Dr. & Mrs. Keith R. Berend*
Michael E. Berend, MD*
Advisor Level
($25,000 - $99,999)
Mason Jones*
Jeffrey R. McLaughlin, MD*
Visionary Level
($10,000 - $24,999)
Loyalty Level
($500 - $2,499)
Gary Barnett*
Biomet MidOhio, Inc.*
Case Medical, Inc. *
Craig J. Della Valle, MD*
Christopher Dodd, MD*
Jeff Grover / Greater Michigan Biomet*
Jeff Hibbard / Biomet-Hibbard*
David W. Murray, MD*
Patrick Riccione*
Timothy E. Green*
William L. Griffin, MD
Matt Harper / Biomet So. Texas*
William L. Healy, MD
Brian & Jennifer May*
John Merageas*
* Contribution given in memory of Dane A. Miller, PhD
The Knee Society is a tax-exempt 501(c)(3) organization.
Donations made to the The Knee Society may be tax-deductible to the extent permitted by law.
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CONGRATULATIONS TO THE 2016
JOHN N. INSALL TRAVELLING FELLOWS
Davide E. Bonasia, MD
AO Mauriziano Hospital
University of Torino
Torino, Italy
Michael J. Taunton, MD
Mayo Clinic
Dept. of Orthopedic Surgery
Rochester, Minnesota
Jonathan Vigdorchik, MD
NYU Langone/Hospital for Joint Disease
Dept. of Orthopedic Surgery
New York, New York
Chun Hoi Yan, MD
University of Hong Kong
Queen Mary Hospital
Dept. of Orthopedics & Traumatology
Hong Kong
Visit The Knee Society website at www.kneesociety.org
for more information and to download the application.
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PROGRAM
15
KNEE
Valencia Room B
Page
8:00 am – 8:02 am
WELCOME
Thomas P. Vail, MD (San Francisco, CA)
President, The Knee Society
8:02 am – 8:04 am
Kevin J. Bozic, MD, MBA (Austin, TX)
Chair, Education Committee, The Knee Society
8:05 am – 8:52 am
Session I: Minimizing TKA Complications
Moderator: John J. Callaghan, MD (Iowa City, IA)
8:05 am – 8:12 am
27
Periprosthetic Joint Infection: Controversies and Areas in Need of Research
Javad Parvizi, MD (Philadelphia, PA)
8:13 am – 8:20 am
28
Prevention and Management of Instability in TKA
Thomas K. Fehring (Charlotte, NC)
8:21 am – 8:28 am
30
Optimizing Risk Factors
Richard Iorio (New Rochelle, NY)
8:29 am – 8:36 am
33
Venous Thromboembolism
Jay R. Lieberman, MD (Los Angeles, CA)
8:37 am – 8:52 am
DISCUSSION
8:53 am – 10:04 am
Session II: TKA Alignment: Mechanical, Anatomic, or Kinematic
Moderator: Thomas P. Schmalzried, MD (Los Angeles, CA)
8:53 am – 9:00 am
34
Mechanical Alignment
Douglas A. Dennis (Denver, CO)
9:01 am – 9:08 am
35
Anatomic Alignment
Michael A. Mont, MD (Baltimore, MD)
9:09 am – 9:16 am
36
Kinematic Alignment
Stephen M. Howell, MD (Sacramento, CA)
9:17 am – 9:24 am
38
Custom Cutting Guides
Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)
9:25 am – 9:32 am
39
Robotics for UKA and Potential Role in TKA
Jess H. Lonner, MD (Bryn Mawr, PA)
9:33 am – 9:40 am
41
Computer Navigation: Past, Present, Future
S. David Stulberg, MD (Chicago, IL)
9:41 am – 9:48 am
43
Mechanical Guides
Robert E. Booth, MD (Philadelphia, PA)
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Valencia Room A
Page
HIP
8:00 am – 8:04 am
WELCOME
Daniel J. Berry, MD (Rochester, MN)
President of The Hip Society
8:05 am – 8:49 am
Session I: Direct Anterior THA: Controversies, Data,
Techniques in 2016
Moderator: Steven J. MacDonald, MD, FRCSC (London, ON, Canada)
8:05 am – 8:10 am
26
Perspective of a Convert: Why I Changed to Direct
Anterior Approach and the Associated Learning Curve
Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)
8:11 am – 8:16 am
28
The Direct Anterior Approach in a Risk Factor for Early Failure
in Cementless Total Hip Arthroplasty: A Multi-Center Study
R. Michael Meneghini, MD (Fishers, IN)
8:17 am – 8:22 am
29
Surgical Tips and Pearls to Maximize Success of Direct Anterior THA
Done with an Orthopedic Table
Joel M. Matta, MD (Santa Monica, CA)
8:23 am – 8:28 am
31
Surgical Tips and Pearls to Maximize Success of Direct Anterior THA
Done without a Fracture Table
William J. Hozack, MD (Philadelphia, PA)
8:29 am – 8:34 am
33
The Accumulated Evidence Supports Posterior Approach THA
as the Gold Standard in 2016
Bryan D. Springer, MD (Charlotte, NC)
8:34 am – 8:49 am
Discussion
8:50 am – 9:40 am
Session II: Contemporary Insights into Unsolved Problems in THA
Moderator: Clive P. Duncan, MD, FRCSC (Vancouver, BC, Canada)
8:50 am – 8:55 am
35
Abductor Deficiency and THA: Diagnosis and Management
Richard W. McCalden, MD, FRCSC (London, ON, Canada)
8:56 am – 9:01 am
36
Psoas Impingement & Tendinopathies after THA: Diagnosis and Management
William A. Jiranek, MD (Richmond, VA)
9:02 am – 9:07 am
38
THA for the Patient with a BMI over 40: Risk and Reward
David G. Lewallen, MD (Rochester, MN)
9:08 am – 9:13 am
40
Recurrent Dislocation in the Patient with a Constrained Liner or
Dual-Mobility Implant: What Now?
John J. Callaghan, MD (Iowa City, IA)
17
KNEE
Valencia Room B
Page
9:49 am – 10:04 am
DISCUSSION
10:05 am – 10:15 am
BREAK
10:16 am – 11:03 am
Session III: The Painful TKA: Prevention, Evaluation,
and Management
Moderator: Aaron G. Rosenberg, MD, FACS (Chicago, IL)
10:16 am – 10:23 am
45
Managing Expectations
Michael J. Dunbar, MD, FRCSC, PhD (Halifax, NS, Canada)
10:24 am – 10:31 am
47
Optimizing Emotional Health
David C. Ayers, MD (Worcester, MA)
10:32 am – 10:39 am
48
Pre- and Post-Operative Opioid Management
Thomas P. Vail, MD (San Francisco, CA)
10:40 am – 10:47 am
49
The Role of “Pain Management”
Craig J. Della Valle, MD (Chicago, IL)
10:48 am – 11:03 am
DISCUSSION
11:04 am – 12:00 pm
Session IV: Transitioning to Value-Based Healthcare
Moderator: Kevin J. Bozic, MD, MBA (Austin, TX)
11:04 am – 11:11 am
50
Bundled Payments and Other Value-Based Payment Strategies
11:12 am – 11:19 am
51
The Role of the EMR in Improving Value
Wael K. Barsoum, MD (Cleveland, OH)
11:20 am – 11:27 am
53
The Role of Registries in Improving Value
Colin Howie, ChB, FRCS, FRCS (Ortho) (Edinburgh, United Kingdom)
11:28 am – 11:35 am
54
Integrated Delivery Systems are Key to Value Creation
Mark I. Froimson, MD (Hunting Valley, OH)
11:36 am – 11:43 am
56
Private Practice Models are More Nimble
Daniel B. Murrey, MD, MPP (Charlotte, NC)
11:44 am – 12:00 pm
DISCUSSION
12:00 pm – 1:00 pm
LUNCH
18
Valencia Room A
Page
HIP
9:14 am – 9:19 am
41
Pelvic Discontinuity: Newest Knowledge and Technical Tips in Management
Wayne G. Paprosky, MD, FACS (Winfield, IL)
9:20 am – 9:25 am
42
Failed 2-Stage THR
Arlen D. Hanssen, MD (Rochester, MN)
9:25 am – 9:40 am
DISCUSSION
9:40 am – 9:55 am
BREAK
9:56 am – 10:34 am
Session III: Strategies to Speed Recovery and
Decrease Complications after THA
Moderator: Mark W. Pagnano, MD (Rochester, MN)
9:56 am – 10:01 am
43
Perioperative Management: Get Ahead and Stay Ahead
Mark W. Pagnano, MD (Rochester, MN)
10:02 am – 10:07 am
44
Role of Staphylococcal Screening and Treatment Prior to THA
Scott M. Sporer, MD (Winfield, IL)
10:08 am – 10:13 am
46
Risk Stratified VTE Prophylaxis after THA
Jay R. Lieberman, MD (Los Angeles, CA)
10:14 am – 10:19 am
47
Outpatient Joint Replacement
Michael E. Berend, MD (Indianapolis, IN)
10:19 am – 10:34 am
DISCUSSION
10:35 am – 11:10 am
Session IV: Complex Primary THA: Case-Based Discussion on
the State of the Art
Moderator: Daniel J. Berry, MD (Rochester, MN)
10:35 am – 10:55 am
Panel: Richard Iorio, MD (New Rochelle, NY); Michael E. Berend, MD (Indianapolis,
IN); Greg G. Polkowski, II, MD (Nashville, TN); Prof. Fares S. Haddad, FRCS
(London, United Kingdom); Miguel E. Cabanela, MD (Rochester, MN)
10:55 pm – 11:10 am
DISCUSSION
11:11 am – 11:33 am
Session V: Taper Corrosion in Orthopaedic Devices – Newest Knowledge
Moderator: Joshua J. Jacobs, MD (Chicago, IL)
11:11 am – 11:16 am
48
Dual Modular Necks in THA: How Big is the Problem? What Caused the Problem?
What Have we Learned?
Michael A. Mont, MD (Baltimore, MD)
11:17 am – 11:22 am
49
When to Revise and What to Revise if Trunionosis is Suspected?
Joshua J. Jacobs, MD (Chicago, IL)
11:23 pm – 11:33 am
DISCUSSION
19
KNEE
Valencia Room B
Page
1:01 PM – 1:33 PM
Session Va: The Knee Society’s Scientific Awards
Moderator: Lawrence D. Dorr, MD (Los Angeles, CA)
1:01 pm – 1:11 pm
57
The John N. Insall, MD Award
“Do Injections Increase the Risk of Infection Following TKA?”:
Presenter: Nicholas Bedard, MD (Iowa City, IA)
1:12 pm – 1:22 pm
58
The Chitranjan S. Ranawat, MD Award
“No Difference in Two-Year Functional Outcomes Using
Kinematic Versus Mechanical Alignment in TKA”
Presenter: Simon W. Young, FRACS (Auckland, New Zealand)
1:23 pm – 1:33 pm
59
The Mark Coventry, MD Award
“Oral Antibiotics Reduce Reinfection Following 2-Stage Exchange:
A Multi-Center, Randomized Controlled Trial”
Presenter: Craig J. Della Valle, MD (Chicago, IL)
1:34 pm – 1:45 pm
Session Vb: Highlights
1:34 pm – 1:39 pm
AAHKS 2015 Annual Meeting
Gregory G. Polkowski, II, MD (Nashville, TN)
1:40 pm – 1:45 pm
The John N. Insall, MD Traveling Fellowship
W. Norman Scott, MD (New York, NY)
1:46 pm – 2:31 pm
Session VI: Peri-Operative Management—How Do I Do It?
Moderator: Daniel J. Berry, MD (Rochester, MN)
Prof. Fares S. Haddad, BSc MD (Res) FRCS (Orth) (London, United Kingdom);
Steven J. MacDonald, MD, FRCSC (London, ON, Canada);
R. Michael Meneghini, MD (Fishers, IN); Michael P. Bolognesi, MD, MS (Durham,
NC); C. Lowry Barnes, MD (Little Rock, AK); Mark W. Pagnano, MD (Rochester, MN)
2:31 pm – 2:50 pm
BREAK
2:51 pm – 4:05 pm
Session VII: Case Presentations
Moderator: Thomas P. Vail, MD (San Francisco, CA)
2:51 pm – 2:58 pm
60
When is TKA Appropriate?
Ryan M. Nunley, MD (St. Louis, MO)
2:59 pm – 3:06 pm
61
When Enough is Enough?
Michael Ries, MD (Carson City, NV)
3:07 pm – 3:14 pm
62
Peri-Prosthetic Fractures – What to Do?
Bassam A. Masri, MD, FRCSC (Vancouver, BC, Canada)
20
Valencia Room A
Page
11:34 am – 11:50 am
50
HIP
Program Highlight: Presidential Guest Speaker
Introduction: Daniel J. Berry, MD (Rochester, MN)
Taper Corrosion in THA: What Causes it and Why are We Seeing it Now?
Michael M. Morlock, PhD (Hamburg, Germany)
11:54 am – 12:50 pm
LUNCH
12:50 pm – 1:28 pm
Session VI: Top 3 New and Impactful Findings from Joint Registries
Around the Globe
Moderator: Kevin J. Bozic, MD, MBA (Austin, TX)
12:50 pm – 12:55 pm
52
Top Findings from Australian National Joint Registry
Richard N. de Steiger, MD (Richmond, Australia)
12:56 pm – 1:01 pm
54
Top Findings from British National Joint Registry
Martyn Porter, MD (Wigan, United Kingdom)
1:02 pm – 1:07 pm
55
Top Findings from Scandinavian Joint Registries
Henrik Malchau, MD, PhD (Boston, MA)
1:08 pm – 1:13 pm
56
American Joint Replacement Registry: High Level Update
1:13 pm – 1:28 pm
DISCUSSION
1:29 pm – 2:19 pm
Session VII: Is Cross-Linked Poly Now the Bearing of Choice?
Moderator: William J. Maloney, III, MD (Redwood City, CA)
1:29 pm – 1:34 pm
58
Results of Cross-Linked Poly at 10 Years or More
Harry E. Rubash, MD (Boston, MA)
1:35 pm – 1:40 pm
59
Highly Cross-Linked Polyethylene Provides Decreased Osteolysis
and Reoperation
Paul F. Lachiewicz, MD (Chapel Hill, NC)
1:41 pm – 1:46 pm
60
Ceramic vs. Metal Femoral Heads: What is the Role for Each in 2016?
Thomas P. Schmalzried, MD (Los Angeles, CA)
1:47 pm – 1:52 pm
62
Ceramic-on-Ceramic Bearings in 2016: A Perspective from Outside
the United States
Carsten Perka, MD (Berlin, Germany)
1:53 pm – 1:58 pm
63
Dual Mobility Implants: What is Their Role in Primary THA?
Jean-Noël Argenson, MD (Marseille, France)
1:59 pm – 2:04 pm
66
Failed Metal-on-Metal Current Diagnostic Algorithms and Guidellines
Thomas K. Fehring, MD (Charlotte, NC)
21
KNEE
Valencia Room B
Page
3:15 pm – 3:22 pm
65
Dealing with Extensor Mechanism Deficiency
Matthew S. Austin, MD (Philadelphia, PA)
3:23 pm – 3:30 pm
67
Treatment of the Unstable TKA
Robert T. Trousdale, MD (Rochester, MN)
3:31 pm – 3:38 pm
68
Is This Knee Infected?
Kevin L. Garvin, MD (Omaha, NE)
3:39 pm – 3:46 pm
71
Patient is Unhappy, but I Don’t Know Why
Robert L. Barrack, MD (St. Louis, MO)
3:46 pm – 4:05 pm
DISCUSSION
4:06 pm – 4:35 pm
Session VIII: Young Investigator Symposium
Moderator: Mary I. O’Connor, MD (New Haven, CT)
4:07 pm – 4:12 pm
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Paper I
“Closed Incision Negative Pressure Therapy Versus Antimicrobial Dressings
Following Revision Hip and Knee Surgery: A Comparative Study”
H. John Cooper, MD (New York, NY)
4:13 pm – 4:18 pm
73
Paper 2
“Discharge Destination after Total Knee Arthroplasty: An Analysis of Post-Discharge
Outcomes and Risk Factors”
Calin S. Moucha, MD (New York, NY)
4:19 pm – 4:24 pm
75
Paper 3
“Thrombogenic Risk of Unicompartmental Knee versus Total Knee Replacement”
Edwin Philip Su, MD (New York, NY)
4:25 pm – 4:35 pm
DISCUSSION
4:36 pm – 5:00 pm
Session IX: Transitioning to Outpatient TKA
Moderator: Michael E. Berend, MD (Indianapolis, IN)
4:36 pm – 4:43 pm
77
Building an Outpatient TKA Program
Keith R. Berend, MD (New Albany, OH)
4:44 pm – 4:51 pm
78
Outpatient TKA is a Triumph of Knowledge over Reason
Bryan D. Springer, MD (Charlotte, NC)
4:51 pm – 5:00 pm
DISCUSSION
5:00 pm
ADJOURN
22
Valencia Room A
Page
HIP
2:04 pm – 2:19 pm
DISCUSSION
2:20 pm – 2:52 pm
Session VIII: How Do We Ideally Position the Acetabular Component?
Moderator: Robert T. Trousdale, MD (Rochester, MN)
2:20 pm – 2:25 pm
69
Newest Knowledge on Ideal Component Position
Lawrence D. Dorr, MD (Pasadena, CA)
2:26 pm – 2:31 pm
71
The Impact of Lumbar Spine Pathology on Functional Hip Position
Douglas E. Padgett, MD (New York, NY)
2:32 pm – 2:37 pm
72
Socket Position and the Risk of Dislocation after Revision THA
Robert L. Barrack, MD (St. Louis, MO)
2:37 pm – 2:52 pm
DISCUSSION
2:53 pm – 2:57 pm
6
2:58 pm – 3:15 pm
Program Highlight:
The Hip Society’s 2016 Lifetime Achievement Award
Introduction: Daniel J. Berry, MD (Rochester, MN)
Recipient: Clive P. Duncan, MD, FRCSC (Vancouver, BC, Canada)
Session IX: The Hip Society Scientific Awards
Moderators: Thomas P. Vail, MD (San Francisco, CA)
A. Seth Greenwald, D.Phil (Oxon) (Cleveland, OH)
2:58 pm – 3:03pm
74
The John Charnley Award
The Missing Link: Re-Defining the Natural Progression of Osteoarthritis in Patients
with Hip Dysplasia and Impingement
Rafael J. Sierra, MD (Rochester, MN)
3:04 pm – 3:09 pm
76
The Otto AuFranc Award
A Multi-Center, Prospective, Randomized Study of Outpatient
Versus Inpatient Total Hip Arthroplasty
Nitin Goyal, MD (Alexandria, VA)
3:10 pm – 3:15 pm
78
The Frank Stinchfield Award
Total Hip Arthroplasty For Femoral Neck Fracture Is Not A Typical DRG 470:
A Propensity-Matched Cohort Study
Alexander S. McLawhorn, MD, MBA (New York, NY)
3:16 pm – 3:26 pm
BREAK
3:27 pm – 4:15 pm
Session X: Revision THA Video Technical Tips to Improve Results
Moderator: C. Anderson Engh, MD (Alexandria, VA)
3:27 pm – 3:32 pm
80
Revision THA for Periprosthetic Fracture
George J. Haidukewych, MD (Orlando, FL)
23
24
Valencia Room A
Page
3:33 pm – 3:38 pm
81
Extended Trochanteric Osteomy Tips and Tricks
Craig J. Della Valle, MD (Chicago, IL)
3:39 pm – 3:44 pm
82
Fluted Tapered Stems in Revision THA
Scott M. Sporer, MD (Winfield, IL)
3:45 pm – 3:50 pm
84
Custom Triflange Cup: Planning and Execution
Douglas A. Dennis, MD (Denver, CO)
3:51 pm – 3:56 pm
86
The Cup-Cage Construct
Allen E. Gross, MD, FRCSC (Toronto, ON, Canada)
3:57 pm – 4:02 pm
89
High-Dose Antibiotic Containing Spacers for Infected THA
Kevin L. Garvin, MD (Omaha, NE)
4:02 pm – 4:15 pm
DISCUSSION
4:16 pm – 4:23 pm
Session XIa: Young Investigator Presentation
Timothy M. Wright, PhD (New York, NY)
4:16 pm – 4:21pm
92
HIP
Removal of an Infected Hip Arthroplasty is High-Risk Surgery: Putting Morbidity
into Context with other Major Non-Orthopaedic Operations
James A. Browne, MD (Charlottsville, VA)
4:21 pm – 4:23 pm
DISCUSSION
4:24 pm – 4:32 pm
Session Xlb: The Hip Society Rothman-Ranawat Traveling Fellowship
Moderator: Chitranjan S. Ranawat, MD (New York, NY)
4:24 pm – 4:29 pm
Highlights of the 2015 Experience
Brian M. Curtin, MD (Charlotte, NC) and Eoin C. Sheehan, MD (Tullamore, Ireland)
4:30 pm – 4:32 pm
Introduction of the 2016 Hip Society Rothman-Ranawat Traveling Fellows
Chitranjan S. Ranawat, MD (New York, NY)
4:33 pm – 5:10 pm
Session XII: Impingement and Dysplasia
Moderator: Michael B. Millis, MD (Boston, MA)
4:33 pm – 4:38 pm
93
Complications after Hip Arthroscopy: A Prospective Multicenter Trial
Utilizing a Validated Grading Scheme
Christopher M. Larson, MD (Edina, MN)
4:39 pm – 4:44 pm
94
Risks for Conversion to THA after Primary Hip Arthroscopy in a
Healthcare System
Christopher L. Peters, MD (Salt Lake City, UT)
25
HIP
Valencia Room A
Page
4:45 pm – 4:50 pm
97
Average 10-Year Clinical Outcomes of the Bernese PAO for the Treatment
of Classic Acetabular Dysplasia
John C. Clohisy, MD (St. Louis, MO)
4:51 pm – 4:56 pm
99
Predictors of Success for Joint Preserving Surgery of the Hip
Paul E. Beaulé, MD, FRCSC (Ottawa, ON, Canada)
4:57 pm – 5:10 pm
Discussion
5:10 pm
ADJOURN
26
ABSTRACTS AND MEETING MATERIALS
Session I: Minimizing TKA Complications
8:05 am – 8:12 am
Preventing Periprosthetic Joint Infection: Strategies that Work
Javad Parvizi, MD
Periprosthetic joint infection (PJI) is becoming the leading cause of failure following total joint
arthroplasty (TJA) and several studies have identified independent risk factors for the development
of PJI. Despite the debates revolving around some of the identified risk factors, several preventative
perioperative strategies are currently commonly in use.
Detailed evaluation of our institutional data and published reports have been performed to identify
perioperative strategies that can be used to minimize the risk of developing a PJI.
Strong evidence was found to support preoperative health and nutritional status optimization, the
use of prophylactic antibiotics and antibiotic impregnated cement, preoperative skin preparation
and the use of disposable draping, shorter operative time, cautious use of anticoagulants and the
avoidance of allogeneic blood transfusion. Little or no evidence was found to support the use of
laminar flow operating rooms or use of personalized protection suit, double gloving, hair removal,
changing blades after skin incision, or addition of antibiotic to the irrigation solution.
Many of the commonly used practices to lower PJI lack strong data to support their use highlighting
the need for larger randomized controlled studies. There is, on the other hand, strong support for
implementation of simple strategies that could minimize risk of PJI.
27
8:13 am – 8:20 am
Prevention and Treatment of Knee Instability
OrthoCarolina Hip and Knee Center
Introduction
Early failure of TKA is discouraging to patient and surgeon alike. Prosthetic knee instability has been shown
to be the leading cause of reoperation in a series of knees revised within the first five years (2).
Symptoms
Gross collateral instability is easily diagnosed, however most instability patterns are subtle requiring a careful
history and physical. Symptoms include catching, giving way, anterior knee pain, pain over the pes bursa, or
a feeling that the knee can’t be trusted especially descending stairs (1). Recurrent effusions due to chronic
micromotion with a predominance of red blood cells on aspirate can be helpful in making the diagnosis (3).
Classification
The OrthoCarolina Knee Instability Classification System can be helpful to guide diagnosis and treatment.
Symptoms
Subtle-giving
way, lack of
trust, anterior
knee pain
Type
1A
Coronal instability
with competent
collateral
ligaments
Type
1B
Coronal instability
with incompetent
collateral
ligaments
Gross instability,
difficulty
ambulating
Type 2
Flexion and
extension gap
mismatch
Can be subtle or
severe, giving
way, catching,
lack of trust,
anterior knee
pain
Physical Exam
Perform sitting
with leg hanging
off table,stable
to stress in one
direction, loose
in opposite
direction
Gross instability
without an end
point to varus or
valgus stress
2 presentations:
1. Stable in full
extension, AP
instability at 90
of flexion.
Cause
Under-released
concave structures
Treatment
If well-aligned, rebalance
the collaberal ligaments
by releasing the tight
concave side to catch up
with the loose convex
side, then increase the
polyethylene thickness
Incompetent
collateral
ligaments not
substituted for at
primary surgery,
trauma or
iatrogenic injury
Failure to equalize
the flexion and
extension gaps at
primary surgery
Revision to
constrained condylar
implant or hinge
2. Flexion
contracture
where extension
gaps is too tight
and knee is
stable in flexion
Type 3 Global instability
Can be subtle or
severe-catching,
giving way, lack
of trust, anterior
knee pain
Knee goes into
recurvatum and
is also loose at
90 of flexion to
AP stress,
effusion
common
28
Inadequate
polyethylene
thickness used at
primary surgery to
promote early
range of motion
Usually requires femoral
component removal
Step 1: Release posterior
capsule by stripping up
back of the distal femur
to increase the extension
gap If adequate either
resect more distal femur
to increase extension gap
until gaps equal or
increase the size of the
femoral component
adding posterior condylar
augments to decrease
flexion gap
If well-aligned, increase
thickness of polyethylene
until stable in all planes
Type 4
Posterior cruciate
insufficiency
Type 5
Combined
instability pattern
Symptoms
Usually subtle,
catching, giving
way, lack of trust
Physical Exam
Knee is stable in
extension,
positive Drawer
tests at 90 of
flexion
Cause
Rupture or
incompetence of
posterior cruciate
ligament
Treatment
Use of ultra-congruent
anterior constrained poly
if available or revision to
a posterior stabilized
femoral component
The key to prosthetic knee instability is prevention at the time of primary surgery. A successful
stable knee arthroplasty requires proper mechanical alignment, a complete concave release of the
coronal deformity, and equalization of the flexion and extension gaps.
References
1.
Fehring TK, Valadie A: Knee Instability after Total Knee Arthroplasty: Clin Orthop Relat Res
299; 1994, 157-162.
2.
Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M: Early Failures in Total Knee
Arthroplasty, Clin Orthop Relat Res 392; 2001, 315-318.
3.
Raab GE, Fehring TK, Odum SM, Mason JB, Griffin WL: Aspiration as an Aid to the Diagnosis
of Prosthetic Knee Stability, Orthopedics 32 (5); May 2009, 318.
4.
Brooks DH, Fehring TK, Griffin WL, Mason JB, McCoy TH: Polyethylene Exchange Only for
Prosthetic Knee Instability, Clin Orthop Relat Res 405; 2002, 182-188.
5.
Fehring TK, Odum S, Griffin WL, Mason JB: Outcome Comparison of Partial and Full
Component Revision TKA, Clin Orthop Relat Res 440; 2005, 131-134.
6.
Fehring TK: Rotational Malalignment of the Femoral Component in Total Knee Arthroplasty,
Clin Orthop Relat Res 380; 2000, 72-79.
29
8:21 am – 8:28 am
Optimizing Risk Factors
Richard Iorio, MD
While TKA generally has favorable clinical outcomes in patients with advanced OA, there remains
a risk of unfavorable outcomes. This includes operative and post-operative complications
potentially leading to readmissions or revision surgery. Often these suboptimal outcomes are tied
to comorbidities or complications associated with their TKA. Modifiable risk factors for poor clinical
outcomes following TKA include: 1. morbid obesity, 2. poorly controlled diabetes and nutrition, 3.
Staphylococcus aureus (S. aureus) colonization and Hepatitis C infection, 4. cardiovascular
disease, 5. venous thromboembolic disease (VTED), 6. tobacco use, 7. neurocognitive,
psychological and behavioral problems (including drug or alcohol dependency) and 8. physical
deconditioning and fall risk. Together, these eight modifiable risk factors significantly account for
avoidable complications and poor clinical outcomes following TKA. Identifying and modifying
these risk factors prior to surgery presents an opportunity to decrease avoidable complications,
improve clinical outcomes, and decrease costs associated with unnecessary health services
utilization following these procedures.
Although some of these modifiable risk factors may be longstanding and recalcitrant to change,
patients may express a renewed interest in addressing them if they stand in the way of obtaining
TKA, a procedure they hope will result in dramatic changes in pain, physical function and quality of
life. The prospect of undergoing TKA may therefore provide an opportunity (i.e. “teachable
moment”) to identify and manage such modifiable risk factors through shared decision making.
By implementing risk factor optimization programs, we have lowered our complications and
readmission rates after TKA. Our concept of a Perioperative Orthopaedic Surgical Home (POSH) to
optimize patients preoperatively is the NYULMC plan to deal with these difficult patients. We have
validated a POSH Readmission Scoring Tool which quantifies modifiable risk factors and predicts
readmission risk, thus identifying patients who would benefit from surgery delay and risk factor
optimization. Patients with a POSH Score of 3 had a 1.94 times higher risk of readmission, and
with a score of 4 had a 4.21 times higher risk of readmission. This represents an overwhelming
opportunity for cost savings, improvement in care and improvement in quality of life for our TKA
patients.
Optimization interventions based on modifiable risk factors
• MRSA Screening and Decolonization, weight based antibiotic dosing, and use of Vancomycin
and Gentamycin in high risk patients, Hepatitis C screening
• Smoking cessation (hard stop)
• Cardiovascular Optimization and Stroke Prevention (using PT, High dose Statins, and ACE
inhibitors perioperatively)
• Aggressive weight control (hard stop at a BMI of 40)
• Catastrophizing avoidance
• Drug and alcohol interventions
• Fall education prevention
• Physical deconditioning physical improvement interventions
• Diabetes control and nutritional interventions
• Screening for high risk VTED patients with thrombophyllia testing and risk stratification in
order to avoid aggressive anticoagulation
30
POSH Risk Factor Scoring Tool
31
Summary
Although improved care coordination can assist in increasing efficiency of care and controlling
costs, it does not prevent all complications and readmissions. Patient selection and risk
optimization is the key to decreasing readmissions and complications associated with patient
related factors.
References








Boraiah, Sreevathsa; Joo, LiJin; Inneh, Ifeoma; Rathod, Parthiv; Meftah, Morteza; Band,
Philip; Bosco, Joseph A. III; and Iorio, Richard: A Readmission Risk Assessment Tool to
Manage Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty. Journal of
Bone and Joint Surgery, December, 2015, EPUB on line ahead of print.
Bronson, Wesley; Lindsay, David; Lajam, Claudette; Iorio, Richard; Caplan, Arthur; Bosco,
Joseph A: Ethics of Provider Risk Factor Modification in Total Joint Arthroplasty. Journal
of Bone and Joint Surgery Am, 2015 Oct 07; 97(19):1635-1639.
http://dx.doi.org/10.2106/JBJS.O.00564
Garvin, Kevin L.; Yu, Stephen; Healy, William L.; Pellegrini, Vincent D. Jr.; Iorio, Richard. ICL
65: Preventing Hospital Readmissions and Limiting the Complications Associated with
Total Joint Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, J Am
Acad Orthop Surg 2015;23: e60-e71.
Iorio, Richard. Strategies and Tactics for Successful Implementation of Bundled
Payments: Bundled Payment for Care Improvement at a Large, Urban, Academic Medical
Center. Journal of Arthroplasty, Vol. 30, Issue 3, 349-50, 2015.
Iorio, Richard; Clair, Andrew J.; Slover, James; and Zuckerman, Joseph D.: Early Results of
CMS Bundled Payment Initiative for a 90 day Total Joint Replacement Episode of Care.
Journal of Arthroplasty, 2015 Sep 9. pii: S0883-5403(15)00804-9. doi:
10.1016/j.arth.2015.09.004. [Epub ahead of print]PMID:26427938
Bronson WH; Fewer M; Godlewski K; Slover JD; Iorio, Richard; Bosco J; Caplan, A. The
Ethics of Risk Modification Prior to Elective Joint Replacement Surgery. Journal of Bone
and Joint Surgery, 96-A, 1143-50, 2014.
Kiridly, DN; Karkenny, A; Hutzler, L; Slover, J; Iorio, Richard; Bosco, JA. The Effect of
Severity of Disease on Cost Burden of 30-day Readmissions following Total Joint
Arthroplasty (TJA). Journal of Arthroplasty, 2014, May, Vol. 29, No. 5. Pages 903-905.
Guy Maoz, MD; Michael Phillips, MD; Joseph Bosco, MD; James Slover, MD, MS; Anna
Stachel, MPH; Ifeoma Inneh, MPH; and Richard Iorio, MD. Modifiable vs. Non-Modifiable
Risk Factors for Infection after Hip Arthroplasty. Clinical Orthopaedics and Related
Research, Accepted for publication, Epub ahead of print July, 2014.
32
8:29 am – 8:36 am
Risk Stratified VTE Prophylaxis after Total Knee Arthroplasty
Jay R. Lieberman, MD
Professor and Chairman
Department of Orthopaedic Surgery
Keck School of Medicine of USC
The selection of a prophylaxis agent is a balance between efficacy and safety. Total knee
arthroplasty patients receive DVT prophylaxis because orthopaedic surgeons want to prevent the
morbidity and mortality associated with pulmonary embolism. The selection of a prophylaxis agent
is a balance between efficacy and bleeding. The prophylaxis must prevent symptomatic pulmonary
embolism and DVT but at the same time avoid over anticoagulation which may lead to bleeding and
other wound problems. Risk stratification is the key to effective prophylaxis.
Although there is great interest in using risk stratification to select a prophylaxis regimen to use for
a specific patient, there is no validated risk stratification strategy available today. There is general
agreement at this time that patients who have had a prior PE or symptomatic DVT are at higher risk
for development of a pulmonary embolism. In addition, there is a general belief that patients who
have coagulation abnormalities (i.e. Factor V Leiden, Protein C and S deficiency) and higher body
mass index are probably at increased risk of developing a VTE. The selection of a prophylaxis
regimen should also be influenced by the ability to mobilize the patient after surgery. Further
research on effective risk stratification strategies is needed.
References
1.
Lieberman, J.R., Pensak, M.J. Prevention of Venous Thromboembolic Disease After Total
Hip and Knee Arthroplasty. J Bone Joint Surgery Am. 2013; 95(19):1801-1811.
2. Bohl, D.D., Maltenfort, M.G., Huang, R., Parvizi, J., Lieberman, J.R., DellaValle, C.J.
Development and Validation of a Risk Stratification System for Pulmonary Embolism
Following Elective Primary Total Joint Arthroplasty. Presented at the Annual Meeting of the
American Association of Hip and Knee Surgeons. Dallas, TX. November 7, 2015.
3. Parvizi, J., Huang, R., Raphael, I.J., Arnold, W.V., Rothman, R.H. Symptomatic Pulmonary
Embolus After Total Joint Arthroplasty: Stratification of Risk Factors. Clin Orthop Related Res.
2014 Mar; 472(3):903-12.
33
Session II: TKA Alignment: Mechanical, Anatomic, or Kinematic
8:53 am – 9:00 am
Mechanical Alignment
Adjunct Professor of Bioengineering, University of Denver
Adjunct Professor, Dept. of Biomedical Engineering, University of Tennessee
Asst. Clin. Professor, Dept. of Orthopaedics, University of Colorado School of Medicine
Historically, poor mechanical alignment has been associated with premature failure of total knee
arthroplasty (TKA) due to prosthetic loosening, polyethylene wear, and instability. Classic
mechanical alignment as described by Insall requires placement of both the femoral and tibial
components perpendicular to the mechanical axis (center of femoral head to center of the body of
the talus). This has been the primary chosen method of alignment historically. Due to the normal
adduction moment on the knee during single leg stance, varus placement of the tibial component
increases this adduction moment, risking medial bone collapse and subsequent loosening.
Numerous reports have confirmed that varus tibial component alignment is associated with
accelerated wear and loosening, often associated with medial tibial osseous collapse. The
combination of obesity and tibial component varus can dramatically increase failure. One analysis
found that tibial component varus in subjects with a body mass index of > 33.7 kg/m2 had a 168X
greater risk of TKA failure. The choice of mechanical alignment is supported by numerous clinical
reports demonstrating implant survival greater than 90% at follow-up intervals greater than 15
years.
Advocates of kinematic alignment report this method results in a more naturally feeling TKA with
better patient satisfaction. Clinical reports have been favorable with this technique although followup duration is limited. Published data utilizing this method demonstrates tibial component varus is
common (as high as 9) with 33% of knees positioned in less than 3 of femoral- tibial valgus which
is worrisome for future failure. A recent computer simulation of TKA with kinematic alignment
demonstrated increased medial tibial loads when compared to mechanical alignment. This method
also risks placing the femoral component internally rotated relative to the transepicondylar axis
which may increase patellar component loads and affect patellar tracking. Detailed published
fluoroscopic kinematic studies of this technique to verify the reported advantages are lacking. Many
unanswered questions remain with use of kinematic alignment. Is it safe to use in all subjects (varus
and valgus knees, posterior cruciate retaining and substituting TKAs, etc) or is it best to use in only
a selective group of subjects?
Bibliography
1. Liu HX, Shang P, Ying XZ, Zhang Y. Shorter survival rate in varus-aligned knees after total
knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015.
2. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how
important is it? J Arthroplasty. 24(6 Suppl):39-43 2009.
3. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML. Does a kinematically aligned total knee
arthroplasty restore function without failure regardless of alignment category? Clin Orthop
Relat Res. 471(3):1000-7, 2013.
34
9:01 am – 9:08 am
Total Knee Arthroplasty-Anatomic Alignment
Michael A. Mont, MD
Restoration of the knee to neutral alignment is essential for a successful total knee arthroplasty
(TKA), as malalignment has been linked with poor functional outcomes, accelerated implant wear,
and early failure [1]. However, numerous studies suggest that up to 20% of patients may be
dissatisfied following TKA, including those with well-aligned components [2, 3]. Various principles
and surgical techniques have been developed in order to attain proper alignment, including
advancements such as customized cutting guides and robot-assisted navigation [4]. Regardless of
the modality used for implantation, anatomic alignment of the femur and tibia must be considered
during preoperative planning to ensure optimal component placement. Using a long-leg standing
radiograph, the anatomic axes can be defined by drawing a line proximal to distal in the
intramedullary canals bisecting the femur and tibia, respectively. In order to restore anatomic
alignment, the distal femur should be cut at 9 degrees valgus to its mechanical axis and the tibia
should be cut at 3 degrees varus to its mechanical axis. The resultant 6 degrees of valgus
approaches the normal tibiofemoral angle and creates a joint line that is parallel to the ground
during normal gait [5]. This talk will focus on the pros and cons of using anatomic alignment and
how the schema differs from other methods of assessing alignment for total knee arthroplasty.
1.
2.
3.
4.
5.
Cherian, J.J., et al., Mechanical, Anatomical, and Kinematic Axis in TKA: Concepts and
Practical Applications. Curr Rev Musculoskelet Med, 2014. 7(2): p. 89-95.
Bourne, R.B., et al., Patient satisfaction after total knee arthroplasty: who is satisfied and
who is not? Clin Orthop Relat Res, 2010. 468(1): p. 57-63.
Noble, P.C., et al., The John Insall Award: Patient expectations affect satisfaction with total
knee arthroplasty. Clin Orthop Relat Res, 2006. 452: p. 35-43.
Kim, S.M., et al., Robot-assisted implantation improves the precision of component position
in minimally invasive TKA. Orthopedics, 2012. 35(9): p. e1334-9.
Hungerford, D.S. and K.A. Krackow, Total joint arthroplasty of the knee. Clin Orthop Relat
Res, 1985(192): p. 23-33.
35
9:09 am – 9:16 am
Is Kinematically Aligned TKA a Good Alignment Option?
Stephen M. Howell, MD
Professor of Biomedical Engineering at UC Davis
Sacramento, CA
Kinematically aligned (KA) TKA has high outcome measures
KA TKA balances the knee without release of the collateral ligaments and with retention of the PCL
[1, 2]. KA TKA resulted in higher Oxford Knee and WOMAC scores and greater flexion than
mechanically aligned (MA) TKA at 2 years in a randomized control trial [3]. KA TKA provided a 23and 20-point improvement in Oxford Knee Score, which is comparable if not greater than the 16
point improvement provided by unicompartmental arthroplasty [3-5]. Use of a KA TKA showed a
trend towards more patients reporting a ‘normal’ feeling knee when compared to MA TKA in a
national multicenter study [6]. A higher Oxford Knee Score predicts higher implant survival rates at
2, 5, 10, and 15 years according to New Zealand Arthroplasty Registry [7].
KA TKA minimizes tibial loosening and promotes implant survival
The patient reported incidence of tibial loosening is 0.2% (5/2310) at 2-9 year after KA TKA
(unpublished). All tibial loosening’s were from
posterior subsidence which caused anterior lift off of
the tibial component and was not associated with a
Feb 2015
Oct 2011
varus mechanism of failure. Tibial loosening was
minimal even though the KA tibial components were
set in ‘varus’, undersized, and extended stems were
not used even in obese patients. The 0.2% incidence
of KA tibial loosening is comparable if not less than
the 0.9% incidence tibial implant failure reported for
MA TKA [8]. KA TKA has the same revision rate as MA
TKA at 3 and 6 years[4, 8, 9]. The concern that
kinematic alignment compromises function and
places the components at a high risk for catastrophic failure is unfounded and should be of interest
to surgeons committed to cutting the tibia perpendicular to the mechanical axis of the tibia [4, 9].
KA TKA is cost-effective in terms of readmission rate, length of stay, & discharge disposition
For 2328 consecutive patients treated with a unilateral KA TKA between 2009 and 2014, the
average length of hospital stay per year shortened from 2.0 to 1.3 days. The rate of discharge per
year to a rehabilitation facility decreased from 41% to 1% and increased from 9% to 53% to home
with outpatient physical therapy. The rate of readmission within 30 days per year did not change
and averaged 1.1%. This all results to a cost savings averaged of $3245 per patient. In summary,
the use of KA TKA enables a shorter length of hospital stay, an increased rate of discharge to home
therapy, and low rate of readmission within 30 days and was cost effective [10].
References
1. Gu Y, Roth JD, Howell SM, et al.: How frequently do four methods for mechanically aligning a total
knee arthroplasty cause collateral ligament imbalance and change alignment from normal in white
patients? The Journal of Bone & Joint Surgery 96(12): e101, 2014.
36
2. Roth JD, Howell SM, Hull ML: Native knee laxities at 0 degrees , 45 degrees , and 90 degrees of
flexion and their relationship to the goal of the gap-balancing alignment method of total knee
arthroplasty. J Bone Joint Surg Am 97(20): 1678, 2015.
3. Dossett HG, Estrada NA, Swartz GJ, et al.: A randomised controlled trial of kinematically and
mechanically aligned total knee replacements: Two-year clinical results. Bone Joint J 96-B(7): 907,
2014.
4. Howell SM, Papadopoulos S, Kuznik K, et al.: Does varus alignment adversely affect implant
survival and function six years after kinematically aligned total knee arthroplasty? Int Orthop: 1,
2015.
5. Pandit H, Jenkins C, Gill HS, et al.: Minimally invasive oxford phase 3 unicompartmental knee
replacement: Results of 1000 cases. J Bone Joint Surg Br 93(2): 198, 2011.
6. Nam D, Nunley RM, Barrack RL: Patient dissatisfaction following total knee replacement: A
growing concern? Bone Joint J 96-B(11 Supple A): 96, 2014.
7. The new zealand joint registry 14 year report: January 1999 to December 2012.
(www.nzoa.org.nz/nz-joint-registry)
8. Ritter MA, Davis KE, Meding JB, et al.: The effect of alignment and bmi on failure of total knee
replacement. J Bone Joint Surg Am 93(17): 1588, 2011.
9. Howell SM, Howell SJ, Kuznik KT, et al.: Does a kinematically aligned total knee arthroplasty
restore function without failure regardless of alignment category? Clin Orthop Relat Res 471(3):
1000, 2013.
10. Barad SJ, Howell SM, Tom J: Is a shortened length of stay and increased rate of discharge to
home associated with a low readmission rate and cost-effectiveness after primary total knee
arthroplasty? Arthroplasty Today, In Press.
37
9:17 am – 9:24 am
Custom Cutting Guides
Adolph V. Lombardi, Jr., MD, FACS
Patient specific instruments have been developed in response to the conundrum of limited accuracy
of intramedullary and extramedullary alignment guides and chaos caused by computer assisted
orthopaedic surgery. This technology facilitates preoperative planning by providing the surgeon with
a three dimensional (3-D) anatomical reconstruction of the knee, thereby improving the surgeon’s
understanding of the preoperative pathology. Intramedullary canal penetration of the femur and
tibia is unnecessary, and consequently, any potential for fat emboli is eliminated. Component
position and alignment are improved with a decrease in the number of outliers. Patient specific
instruments utilize detailed magnetic residence imaging (MRI) or computed tomography (CT) scans
of the patient’s knee with additional images from the hip and ankle for determination of critical
landmarks. From these studies a 3-D model of the patient’s knee is created and with integration
of rapid prototyping technology, guides are created to apply to the patient’s native anatomy to direct
the placement of the cutting jigs and ultimately the placement of the components.
The steps in considering utilization of patient specific guides are as follows: 1) the surgeon
determines that the patient is a candidate for TKA, 2) an MRI or CT scan is obtained at an approved
facility in accordance with a specific protocol, 3) the MRI or CT is forwarded to the manufacturer, 4)
the manufacturer creates the 3-D reconstructions, anatomical landmarks are identified, implant
size is determined, and ultimately femoral and tibial component implant placement is determined
via an algorithm, 4) the surgical plan is executed, 5) the physician reviews and modifies or approves
the plan, 6) the guides are then produced via rapid prototyping technology and delivered to the
hospital for the surgical procedure.
Guides generated from MRIs are designed to uniquely register on cartilage surface whereas guides
produced from CT scans must register on bony anatomy. There are currently two types of guides
produced: those which register on the femur and tibia and allow for the placement of pins to
accommodate the standard resection blocks; and those produced by some manufacturers which
accommodate the saw blade and therefore are a combination of resection and pin guides.
The utilization of patient-specific positioning guides in TKA has several benefits. They facilitate
preoperative planning, obviate the need for violation of the intramedullary canals, reduce operating
times and improve OR efficiency, decrease instrumentation requirements and thereby reduce
potential for perioperative contamination. They are easier to use than computer navigation with no
capital equipment purchase and no significant learning curve. Most importantly, patient-specific
guides facilitate accurate component position and alignment, which ultimately has been shown to
enhance long-term survivorship in total knee arthroplasty.
1. Lombardi AV Jr, Berend KR, Ng VY. Neutral mechanical alignment: a requirement for successful
TKA: affirms. Orthopedics. 2011 Sep 9;34(9):e504-6. doi: 10.3928/01477447-20110714-40.
2. Lombardi AV Jr, Frye BM. Customization of cutting blocks: Can this address the problem? Curr
Rev Musculoskelet Med. 2012 Dec;5(4):309-14.
3. Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AV Jr. Improved accuracy of alignment with
patient-specific positioning guides compared with manual instrumentation in TKA. Clin Orthop
Relat Res. 2012 Jan;470(1):99-107.
38
9:25 am – 9:32 am
Robotically-Assisted Knee Arthroplasty
Jess H. Lonner, MD
Attending Orthopaedic Surgeon, Rothman Institute
Associate Professor of Orthopaedic Surgery, Thomas Jefferson University
Philadelphia, PA
Semi-autonomous robotic technology has been introduced to optimize accuracy of implant positioning
and soft tissue balance in UKA, with the expectation of resultant improvement in durability and implant
survivorship. Currently, nearly 20% of UKA’s in the U.S. are being performed with robotic assistance. It
is anticipated that there will be substantial growth in market penetration over the next decade,
projecting that nearly 37% of UKA’s and 23% of TKA’s will be performed with robotics in 10 years
(Medical Device and Diagnostic Industry, March 5, 2015 [http://www.mddionline.com]). First generation
robotic technology improved substantially implant position compared to conventional methods;
however, high capital costs, uncertainty regarding the value of advanced technologies, and the need for
preoperative CT scans were barriers to broader adoption. Newer image-free semi-autonomous robotic
technology both optimizes implant position and soft tissue balance without the need for preoperative
CT scans and with price points and portability that make it suitable for use in an ASC, where 40% of
systems are being utilized.
Two semi-autonomous robotic systems are available in the U.S. currently – one safeguards against
inadvertent bone preparation by haptic constraint and requires preoperative CT imaging for the planning
algorithm; the other modulates the exposure or speed of the handheld robotic bur to provide accuracy
and does not require a preoperative CT scan. Both are utilized for UKA and PFA and are developing
applications for TKA. Compared to conventional methods, both robotic systems have improved
significantly the precision of bone preparation and reduced variance in implant position. Similarly,
autonomous robotics have shown improved alignment in TKA.
Unlike autonomous robotic technology in which inadvertent soft tissue injury occurred in 5% of cases,
there have been no soft tissue injuries from either of the two semi-autonomous robotic sculpting tools
in 800 consecutive cases performed by this author. Further study is needed to determine if the improved
alignment and quantified soft tissue balance will lead to optimized functional outcomes or improved
durability after knee arthroplasty.
References
1. Lonner JH, John TK, Conditt MA. Robotic arm-assisted UKA improves tibial component alignment: a
pilot study. Clinical Orthopaedics and Related Research 468(1):141-6, 2010.
2. Lonner JH, Smith JR, Picard F, Hamlin B, Rowe PJ, Riches PE. High Degree of Accuracy of a Novel
Image-free Handheld Robot for Unicondylar Knee Arthroplasty in a Cadaveric Study. Clinical
Orthopaedics and Related Research. 473:206-212, 2015
3. Conditt MA, Bargar WL, Cobb JP, Dorr LD, Lonner JH. Current concepts in robotics for the treatment
of joint disease. Adv Orthop. Epub Dec 201
4. Dunbar NJ, Roche MW, Park BH, Branch SH, Conditt MA, Banks SA. Accuracy of dynamic tactile-guided
unicompartmental knee arthroplasty. J Arthroplasty. 2012;27:803-808.e1.
5. Swank ML, Alkire M, Conditt M, Lonner JH. Technology and cost effectiveness in knee Arthroplasty:
39
Computer navigation and robotics. Am J Orthop. 38 (2 suppl):32-36, 2009
6. Lonner JH. Robotically-Assisted Unicompartmental Knee Arthroplasty with a Hand-Held Image-Free
Sculpting Tool. Orthop Clin N Am. 47:29-40, 2016
7. Song EK, Seon JK, Yim JH, Netravali NA, Bargar WL. Robotic-assisted TKA reduces postoperative
alignment outliers and improves gap balance compared to conventional TKA. Clin Orthop. 471: 118126, 2013
40
9:33 am – 9:40 am
Computer Navigation in Total Knee Arthroplasty: Past, Present, Future
S. David Stulberg, MD
The rationale for using computer technology to assist in the precise re-alignment of the leg and
correct positioning of total knee implants is based upon evidence indicating that inferior functional
performance, accelerated polyethylene wear and aseptic loosening of TKA implants is associated
with limb and implant mal-alignment. At the time that the first total knee replacement procedure
utilizing computer navigation was performed by Saragaglia, Picard and co-workers in Grenoble,
France in 1997, the use of conventional surgical techniques, even in the hands of experienced knee
arthroplasty surgeons, was associated with frequent limb and implant mal-alignment. It was also
widely believed that less post-operative pain, better knee function, faster rehabilitation and an
improved quality of life was related to appropriate limb and implant alignment ( 3 degrees of a
mechanical axis of zero).
Computer assisted navigation uses infrared technology to track the spatial position of the patient’s
limb anatomy and the surgical instrumentation. It provides real-time information to guide bone cuts
and allows measurement of the accuracy of these cuts. Systems can be classified into two, broad
categories: closed (systems compatible with specific TKA components) and open (systems that are
not specific to a single manufacturer, component type or instrumentation). The anatomic
information upon which the intra-operative navigation is performed can be acquired either preoperatively from CT scans or intra-operatively using fluoroscopy (image-based CAS) or surfaceregistration techniques (image-free CAS). This information allows the system to construct a threedimensional model of the bony anatomy. The computer navigation software triangulates the
location of registration markers placed in the femur and tibia. The system is then able to provide
information regarding location of anatomic landmarks, limb axes, component position and centers
of hip, knee and ankle joint rotation. The accuracy with which CAS systems can acquire and use this
information has been extensively documented. Moreover, CAS techniques have become the basis
for the use of a number of other computer based total knee technologies (e.g. robotic TKA). CAS
technologies use instrumentation that is not a routine part of the surgeon’s total knee
armamentarium. As a result, the learning curve to become proficient in the use of CAS-TKA is
relatively long.
The clinical reports of the alignment outcomes of CAS-TKA systems has not demonstrated a
consistent improvement in coronal limb or implant alignment relative to alignment results with
manual techniques. There is a suggestion in a number of reports that femoral component rotational
alignment may be more accurate when CAS techniques are used. Moreover, meta-analyses indicate
that the use of CAS-TKA is associated with a reduction in positioning outliers.
In spite of possible improvements in implant and limb alignment, the use of CAS-TKA has not been
associated with a consistent improvement in functional outcomes. Some reports have noted a
decrease in revision rates at 5 years and a decreased revision rate in patients younger than 65.
41
The developers of CAS-TKA technologies had hoped their utilization would be particularly helpful to
inexperienced surgeons and useful for surgeons who did relatively few TKA’s. However, the lack of
reported clear improvements in functional outcomes or consistent reductions in radiographic
alignment outliers and the substantial cost of CAS units has resulted in a relatively low acceptance
rate by surgeons doing TKA surgery. However, CAS is the basis for a number of emerging computer
based TKA technologies. It is likely that the coming generation of TKA surgeons will need to become
familiar with and proficient in CAS-TKA techniques.
1) Burnett, SJ, Barrack RL. Computer-assisted Total Knee Arthroplasty is Currently of No Proven
Clinical Benefit: A Systematic Review. Clin Orthop Relat Res (2013) 471: 264-76.
2) Cheng T, Zhao S, Peng X, Zhang X. Does computer-assisted surgery improve postoperative
leg alignment and implant positioning following total knee arthroplasty? A meta-analysis of
randomized controlled trials. Knee Surg Sports Traumatol Arthrosc (2012) 20: 1307-22.
3) Leone WA, Elson LC, Anderson CR, A systematic Literature Review of Three Moalities in
Technologically Assisted TKA. Adv Orthop. 2015: 719091
4) Ontario Health Technology Assessment Series 2004. Computer-Assisted Hip and Knee
Arthroplasty. Navigation and Active Robotic Systems. An Evidence-Based Analysis. Vol 4, No
2.
5) Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does Computer Assisted Navigation
Improve Function Outcomes and Implant Survivability after Total Knee Arthroplasty? The
Journal of Arthroplasty 30 Supl.1 (2015) 59-63.
42
9:41 am – 9:48 am
Mechanical Guides
Robert E. Booth, Jr., MD
Philadelphia, Pennsylvania
Like it or not, the overwhelming majority of joint replacements around the world are implanted with
manual instruments. They are our history, and for the foreseeable time, they remain our future.
There is no question that even the present generation of manual instruments is being improved
steadily as this abstract is written. We have yet to combine the lessons of ergonomics, of readability,
of texture and surfacing, of shapes that speak to their task so that form and function become
obvious and intuitive, etc. Most current instruments violate such common industrial principles as
being sure the guide is sturdier and more secure than the tool it directs, that it serves multiple
functions and minimizes the absolute number of steps in the procedure, that the attempt to make
it shiny and attractive does not simultaneously make it slippery and droppable, and – perhaps most
common of all – it can stand the inevitable blow from a mallet when its surgeon is frustrated.
More and more expensive tools certainly exist, from patient specific pre-fabricated instruments,
small “smart” devices to facilitate such surgeon failings as rotational alignment, disposable
instruments, and “main frames” ranging from analogs of kinematic testing devices to Haptic robots
to restrict the errant surgical hand. Unfortunately, none of these more expensive options has been
shown to alter the clinical outcome from the functional standpoint even though the number of
“outriders” is often reduced.
In truth, the greatest economy at present is a combination of improved manual tools and the
ergonomic study of their implementation by the operating surgeon. If equivalent long term
functional results can and are being achieved with conventional instruments, perhaps attention
should be equally directed to the efficient handling of these tools rather than blaming the
instrument itself.
Bibliography
1. Abane L, Anract P, Boisgard S, Descamps S, Courpied JP, Hamadouche M.: Patient-Specific
Cutting Guides Were Not Better Than Conventional Instrumentation for Total Knee Arthroplasty.
Evidenced-Based Orthopaedics Commentary by William M. Mihalko, M.D., PhD. JBJS 2015 Nov 18;
97-A (22)1891.
2. Denis Nam MD, Andrew Park MD, Jeffrey B. Stambough MD, Staci R. Johnson Med, Ryan M.
Nunley MD, Robert L. Barrack MD: Custom Cutting Guides Do Not Improve Total Knee Arthroplasty
Clinical Outcomes at Two Year Follow-up. Symposium 2015 Knee Society Proceedings. The Mark
Coventry Award, Clinical Orthopaedics & Related Research e-pub February 25, 2015, 1-7.
43
3. Xie C, Liu K, Xiao L. Tang R: Clinical Outcomes After Computer-Assisted vs. Conventional TKA.
Orthopaedics 2012 May 35(5)e647-e653.
4. Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K: “Meta Analysis of Alignment Outcomes in
Computer-Assisted Total Knee Arthroplasty Surgery”. Journal of Arthroplasty 2007 22(8)10971105.
5. Brin YS, Nikolaou VS, Joseph L, Zukor DJ, Antoniou J: Imageless Computer vs. Conventional Total
Knee Replacement. International Orthopaedics (SICOT) 2011 (35)331-339.
44
Session III: The Painful TKA: Prevention, Evaluation, and Management
10:16 am – 10:23 am
Managing Expectations
Michael J. Dunbar, MD, FRCSC, PhD
Dalhousie University
Halifax, Nova Scotia, Canada
“I did really cry in good earnest when I went to bed, to think that my expectations had done some
good to somebody” Pip, Great Expectations.
Unmet expectations after TKA have been shown to be the largest determinant of dissastisfaction.
Subsequently, managing patient expectations regarding their TKA is vital to optimize postoperative
outcomes, especially in terms of satisfaction. Patient’s expectations should obviously be addressed
prior to surgery and efforts should be made in the patient interview to understand specifically what
the patients expectation’s are.
Satisfaction after TKA correlates with relief of pain, followed by improvement in physical function.
As such, it is important to understand the nature of the patient’s pain and any features of chronicity,
such as opioid use or catastrophizing that may result in chronic postoperative pain. Patients should
be cautioned that it is normal to have some residual pain after TKA, especially with activity, and that
some functions such as kneeling, climbing stairs, and walking on uneven ground can be difficult.
Patients may not be able to return to levels of sporting activity that they are anticipating. It is vitally
important that your patient understands that these limitations can be associated with TKA
outcomes. Understanding and resetting patient’s expectation’s is an important part of the informed
consent process.
Satisfaction is a function of the chronicity of disease process leading to TKA, with patients with long
standing disease states reporting higher rates of satisfaction than those with acute onset
pathologies, such as avascular necrosis. Because TKA has been offered to younger patients, often
earlier in the disease process, the younger patient’s expectations are particularly problematic in
obtaining reliable rates of high satisfaction. Ultimately, TKA is a salvage procedure utilizing metal
and plastic, and it is sometimes prudent to advise patients of that fact.
Selected Readings
Baker PN, van der Meulen JH, Lewsey J, Gregg PJ, National Joint Registry for E, Wales. The role of
pain and function in determining patient satisfaction after total knee replacement. Data from the
National Joint Registry for England and Wales. J Bone Joint Surg Br 2007;89-7:893-900.
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total
knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010;468-1:57-63.
45
Dunbar MJ, Richardson G, Robertsson O. I can't get no satisfaction after my total knee replacement:
rhymes and reasons. Bone Joint J. 2013 Nov;95-B(11 Suppl A):148-52
Husain, A. and G. C. Lee (2015). "Establishing Realistic Patient Expectations Following Total Knee
Arthroplasty." J Am Acad Orthop Surg 23(12): 707-713.
Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee
arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta
Orthop Scand 2000;71-3:262-7.
Robertsson O, Dunbar MJ. Patient satisfaction compared with general health and disease-specific
questionnaires in knee arthroplasty patients. J Arthroplasty 16-4:476-82.
Sullivan, M., et al. (2011). "The role of presurgical expectancies in predicting pain and function one
year following total knee arthroplasty." Pain 152(10): 2287-229
46
10:24 am – 10:31 am
Optimizing Emotional Health in TKR Patients
David C. Ayers, MD
Franklin P, Li W, Ayers D. The Chitranjan Ranawat Award: Functional Outcomes after TKR Varies
with Patient Attributes. Clin Orthop Related Res, Nov 2008, 466(11) p2597-2604.
The analysis of this national primary TKR cohort demonstrates two post-TKR outcome distributions;
one for high pre-TKR emotional health (MCS>50) and one for low pre-TKR emotional health
(MCS<50). The majority of post-TKR patients with stronger emotional health reported improvement
in function. However, the low emotional health group (MCS < 50) distribution was almost flat with
large numbers of patients reporting no improvement in PCS at 12 months. While it is accepted that
emotional health influences functional gain after TKR, the relationship is not clearly understood.
This analysis supports the importance of addressing emotional health issues in the perioperative
TKR process.
Ayers D, Franklin P, Trief P, et al. The Psychological Attributes of Preoperative Total Joint
Replacement Patients: Implications for Optimal Outcome. J. Arthroplasty, Oct 2004, 19 (7): p125130.
What characterizes patients with a low pre-op MCS? Patients with preoperative MCS <50 had
significantly higher trait anxiety, subclinical depression, poor coping skills, lower social support and
reported more catastrophizing and poorer pain control than patients with high pre-op MCS.
Franklin P, Karbassi J, Ayers D. Reduction in Narcotic Use after Primary TKR and Association with
Pain Relief and Satisfaction. J Arthroplasty Sept 2010, 25 (6)
Examined the prevalence of narcotic use before and after TKA and it association with post-TKR
pain relief and patient satisfaction. Patient who used narcotics before TKR were more likely to have
a narcotic prescription at 12 months post-op, reported greater pain at 12 months post-op, and
were more likely to be dissatisfied with TKR outcome.
Franklin P, McLaughlin J, Ayers D. Methods to Document Quantity and Variation of Independent
Patient Exercise after TKA. J Arthroplasty Sept. 2006, 21 (6): p 157-163
Rosal M, Ayers D, Franklin P. A randomized Clinical Trial of a periopertive behavioral intervention
to improve physical activity adherence and functional outcomes following TKR. BMC
Musculoskeletal Disorders. Oct 2011.
Post-operative outcomes following TKR in patients with low pre-op emotional health may benefit
from a peri-operative pathway that provides additional peri-op counseling, coping strategies, social
support. Patients with emotional comorbid conditions may be best managed by a tailored pathway
designed to address patient specific issues; approach is similar to how medical comorbidites are
managed perioperatively.
Ayers D, Franklin P, Ring D. The role of Emotional Health in Functional Outcomes after Orthopaedic
Surgery. J Bone Joint Surg Am, Nov 2013, 95 (21), pe 165
Low pre-op MCS negatively affects patient post-operative outcome following many different types
of orthopedic surgery.
47
10:32 am – 10:39 am
Pre- and Post-Operative Opioid Management
Thomas Parker Vail, MD
James L. Young Professor and Chairman
Department of Orthopaedic Surgery
University of California, San Francisco
While narcotic pain medication remains a helpful adjunct in the care of patients undergoing total
knee replacement, the misuse and overuse of narcotic pain medication in the perioperative period
can adversely affect the outcome of total knee replacement patients. The prevalence of
prescription drug, reportedly extending to more than half of the US population, naturally is reflected
in orthopaedic patients. Astoundingly, the US consumes more than three quarters of the world
supply of opiate analgesics. In a 2014 Senate caucus on International narcotics control, it was
reported that “between 26.4 million and 36 million people abuse opioids worldwide, with an
estimated 2.1 million people in the United States suffering from substance use disorders related to
prescription opioid pain relievers in 2012.” In a recent study conducted by Sing at UCSF, we found
the prevalence of preoperative opioid use for patients undergoing primary TJA for OA to be 35%
overall with 5% of all TJA candidates using long-acting formulations for pain control.
The role for preoperative opioid use and the optimal management of opioid-dependent patients in
the perioperative setting remains unclear. While the proposed AAOS clinical practice guideline on
surgical management of osteoarthritis of the knee (SMOAK) does not specifically address the
treatment of OA with opioid medications, recommendations from the American College of
Rheumatology, American Geriatrics Society, and American Pain Society guidelines support
prescribing opioids for chronic relief of OA.
Results of the UCSF Sing study demonstrated that preoperative opioid use was associated with
significantly worse early postoperative outcome, including longer length of stay, higher rates of
discharge to facility, and increased complications within 90 days. Furthermore, this detrimental
association was more severe with the use of long-acting opioid formulations. Additional work by
Nguyen at UCSF suggests that the preoperative use of narcotic pain medication is a potentially
modifiable risk factor. Specifically, the prospective work by Nguyen and others suggests that
decreasing narcotic consumption prior to surgery and converting from longer acting narcotic
medication to shorter acting medication may positively impact length of stay, success of postoperative pain management, and risk for perioperative complications.
As a result of these observations, pain management protocols at UCSF continue to employ a
comprehensive approach to pain management utilizing elements of shared decision making, multimodal non-narcotic drug (acetaminophen, gabapentin, and celecoxib) protocols, adductor canal
femoral nerve blocks, non-pharmacologic strategies such as PT and cryotherapy, optimization of
preoperative narcotic use to the shortest acting and lowest dose that is clinically effective,
avoidance of parenteral narcotic usage entirely, and careful post-operative monitoring with rapid
tapering narcotic usage after surgery.
48
10:40 am – 10:47 am
The Role of “Pain Management”
Craig J. Della Valle, MD; Adam Young MD; Asokumar Buvanendran, MD
Rush University Medical Center, Chicago, IL
Unfortunately, a substantial number of patients report persistent pain after total knee arthroplasty.
Once mechanical and septic causes of failure have been ruled out, the clinician should consider
Chronic Post-Surgical Pain Syndrome. This syndrome often features neuropathic pain as a
component, which is different than the typical pain experienced following surgery. While our training
as orthopaedic surgeons does not make us optimal providers of treatment, some understanding of
the clinical signs of this entity can assist the clinician in making appropriate referrals to a pain
management specialist to better manage these patients.
While the etiology of chronic post-surgical pain syndrome is not entirely clear, several pre- and postoperative risk factors have been elucidated. Such factors include severe preoperative pain,
preoperative narcotic use, anxiety/depression, and psychological traits such as catastrophisizing. A
genetic predispotision has also been suggested. Poorly controlled pain in the immediate
postoperative period has a strong correlation to chronic post-surgical pain syndrome.
Prevention of any adverse outcome is always desired, and the use of mulit-modal analgesia and
avoiding severe pain in the early postoperative period may reduce the risk of this complication.
Similarly, there is evidence that the perioperative use of pregabalin (Lyrica®) and gabapentin
(Neurontin®) may reduce the risk of chronic post surgical pain. These medications were origially
used as anticonvulsants, but have recently been shown to be effective in treating neuropathic pain.
These disorders are typically characterized by pain that endures for more than 2 months
postoperatively and is associated with cutaneous hypersensitivity (allodynia), burning type
sensations, color changes of the overlying skin, swelling of the leg, and in some cases contractures
of the joint. The presence of multiple symptoms can suggest a more serious pain condition
developing, such as complex regional pain syndrome (CRPS).
Once a patient develops chronic post-surgical pain syndrome, treatment can be challenging. A
multimodal approach to treatment includes not only narcotic pain medication, but nerve stabilizing
drugs such as pregabalin, topical anesthetics, anti-inflammatory medications, non-narcotic
analgesics and anti-depressants. Other options include sympathetic nerve blocks and spinal cord
stimulation.
References
Buvanendran A, Kroin JS, Della Valle CJ, et. Al. Perioperative oral pregabalin reduces chronic pain
after total knee arthroplasty. Anesth Analg. 2010 Jan 1;110(1):199-207.
Elmofty DH, Anitescu M, Buvanendran A. Best practices in the treatment of neuropathic pain. Pain
Manag. 2013 Nov;3(6):475-83.
Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: Prevalence,
sensory qualities, and postoperative determinants. Pain 2011;152:566–72
49
Session IV: Transitioning to Value-Based Healthcare
11:04 am – 11:11 am
Bundled Payments and Other Value-Based Payment Strategies
Kevin J. Bozic, MD, MBA
Healthcare delivery is extremely fragmented in the current landscape, with poor coordination among
providers, minimal transparency around outcomes and costs, and a system that rewards high-cost,
intensive medical interventions over higher-value, patient-centered care. In this context, payers,
providers and policymakers are increasingly focused on identifying delivery payment models to align
incentives among stakeholders to improve the value (outcomes and patient experience divided by
cost) of care 1,2. One such model is bundled payments in which the care team and hospital are
accountable for outcomes, care utilization, and costs up to 90 days post-discharge 3. In order to
succeed in this model, the bundle team must first identify clinical and administrative champions to
lead care redesign efforts, and engage relevant stakeholders. The team must map the episode
pathway in detail, assess episode outcomes and cost data, and identify the most impactful areas
for care redesign and cost reduction. Through multidisciplinary stakeholder input, evidence-based
approaches, and group consensus, the care team will implement and continuously iterate on
interventions to improve quality and cost performance. Several total joint replacement bundle
demonstrations improved outcomes (e.g., lower 90-day readmissions) while reducing resource
utilization and achieving operational efficiencies 3-6. Medicare recently finalized the Comprehensive
Care for Joint (CJR) Replacement model which mandates bundled payments for primary TJR in 67
geographic areas 7. In CJR, hospitals are incentivized to collect patient-reported outcomes such as
change in pain and functional status, with the ultimate goal of determining how PROs can be used
to assess TJR appropriateness and value.
References
1.
Porter ME. What is value in health care? The New England journal of medicine. Dec 23
2010;363(26):2477-2481. 10.1056/NEJMp1011024
2.
Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by
organizing around patients' needs. Health affairs. Mar 2013;32(3):516-525.
10.1377/hlthaff.2012.0961
3.
Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting
opportunities for quality improvement and cost reduction. Clinical orthopaedics and related
research. Jan 2014;472(1):188-193. 10.1007/s11999-013-3034-3
4.
Iorio R. Strategies and tactics for successful implementation of bundled payments: bundled
payment for care improvement at a large, urban, academic medical center. The Journal of
arthroplasty. Mar 2015;30(3):349-350. 10.1016/j.arth.2014.12.031
5.
Bosco J, Shah PC, Slover JD, Torrance A. Optimizing the OR for bundled payments: a case
study. Bulletin of the American College of Surgeons. Nov 2014;99(11):29-36
6.
Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP. Medicare's bundled payment
pilot for acute and postacute care: analysis and recommendations on where to begin. Health
affairs. Sep 2011;30(9):1708-1717. 10.1377/hlthaff.2010.0394
7.
Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement
Model Ruling Proposal. August 25 2015
50
11:12 am – 11:19 am
The Role of the EMR in Improving Value
Wael K. Barsoum, MD
The Health Information Technology for Economic and Clinical Health Act authorized $27 billion over
a period of 10 years to promote meaningful use of electronic health records (EHR). Promises of the
implementation of EHRs in our hospitals included improvements in health care quality, prevention
of medical errors, reductions in health care costs, increased administrative efficiency, and national
remote access to patient records1. This change was accompanied by healthcare reform and the
shift from a volume-driven system to a value-based payment structure. The early promises of EHR
implementation appear to easily align with the goals of a value-based system, but there is debate
as to whether or not EHRs have lived up to this potential.
Studies have focused on addressing the question as to whether hospitals with EHR actually provide
a higher quality of care compared with those that do not2,3. Kazley et al2. reported on 10 quality
process indicators and concluded that there was a positive significant relationship between EHR
use and 4 of the 10 indicators. A systematic review of the literature included 53 review studies to
assess the impact of EHR on the quality of care, and reported a weak impact on efficiency, both
increased and decrease workload, and a change in behavior which did not translate into higher
quality of care in terms of improved patient outcomes3. At the Cleveland Clinic, we implemented a
CarePath using our EHR in 2013, which utilizes standardized admission orders, optimized presurgical orders, a documentation checklist, relatively standardized postoperative care, SCIP
measure optimization, and standardized discharge summaries. This effort has resulted in improved
communication, decrease average length of hospital stay (0.5 days less for THA, 0.2 days less for
TKA), and decreased blood utilization (130 cc less for THA, 30 cc less for TKA).
A second key promise of EHR is the reduction in health care cost by improvements in efficiency.
Reed et al4. studied staggered EHR implementation across outpatient clinics from 2005-2008 on
a population of 169,711 patients, and compared emergency department (ED) visits,
hospitalizations, and office visits use between those with and without EHR use. Multivariable
analysis showed a significant reduction in ED visits (28.80 fewer visits per 1,000 patients annually)
and fewer hospitalizations (13.10 fewer per 1,000 patients annually). There was no significant
association between EHR use and office visits. Kazley et al5. used the National Inpatients Sample
and Health Information Management Systems Society from 2009 to analyze 5,047,089 cases,
1,509,610 (29.9%) of which were cared for in hospitals with advanced EHRs. The study showed
that patient costs were on average 0.0966% (or $731) lower than that of patients treated in
hospitals without advanced EHR. However, whether this is due to efficiency improvements is
questionable in the eyes of the end uses, as Black Book’s Q3 2014 Loyalty Poll surveyed 14,000
nurses, of which 94% said communication did not improve and that dissatisfaction had “reached
an all-time high”.
51
To date, there is little evidence available that investments in EHR quickly translate into direct
benefits to patients and/or providers. The direct and indirect costs are not being offset by
measureable improvements. However, improvements in documentation are noticeable benefits,
and patience may be required to realize the full benefit of EHR implementation. Improvements to
EHRs are constantly evolving, with the potential to raise realized benefits.
1.
2.
3.
4.
5.
US Department of Health& Human Services. 2014;
http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov_home/1204.
Kazley AS, Ozcan YA. Do hospitals with electronic medical records (EMRs) provide higher
quality care?: an examination of three clinical conditions. Med Care Res Rev. Aug
2008;65(4):496-513.
Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health
care: a systematic overview. PLoS Med. 2011;8(1):e1000387.
Reed M, Huang J, Brand R, et al. Implementation of an outpatient electronic health record
and emergency department visits, hospitalizations, and office visits among patients with
diabetes. JAMA. Sep 11 2013;310(10):1060-1065.
Kazley AS, Simpson AN, Simpson KN, Teufel R. Association of electronic health records with
cost savings in a national sample. Am J Manag Care. Jun 2014;20(6):e183-190.
52
11:20 am – 11:27 am
The Role of Registries in Improving Value
Colin Howie MB ChB, FRCS, FRCS(Orth) Ed UK
Registries are often used to identify the benefits of specific implants or techniques. However
perhaps their most important role is to highlight what is doing well in our service. While bundled
payments and private healthcare systems will act to control cost at the most expensive point of
delivery; the operating theatre; perhaps the bigger long term costs to our patients and society are
the costs of complication, infection, stiffness and instability resulting in early revision.
Variation in healthcare has been used to look at rates of interventions per head of population. We
have looked at the rates of complication variation and reported the results back to surgeons as part
of an ongoing quality improvement strategy. Using standards achieved in other hospitals in similar
healthcare settings rather than top down mandated targets the rates of complication have been
reduced and significant savings achieved for the healthcare system in general. Our patients have
benefitted from better outcomes.
53
11:28 am – 11:35 am
Integrated Delivery Systems are Key to Value Creation
Mark Froimson, MD, MBA
Trinity Health
Healthcare in general, and joint replacement in particular, has come under fire for being of uneven
quality and cost, without a direct correlation between the two. As a result, payers and regulators
are attempting to correct this perceived deficiency by incentivizing providers, that is physicians and
health systems, to focus on the value of the care provided. While there is general agreement that
both quality improvement and cost reduction are tandem paths to value creation, there is less
agreement on the best models for achieving one or both of these. Waste and unnecessary
interventions are commonly cited reasons for excess cost and lack of quality. Duplication of
services occurs when there is lack of communication and coordination and when practitioners
attempt to ply their craft in traditional silos. The move to alternative payment models has begun to
shed light on the importance of care coordination and transitions of care, in eliminating redundancy
and ensuring compliance with prescribed treatments. Such seamless care requires that providers
know one another, that there are common and accepted pathways across the continuum, that
communication is fostered, that follow up is assured and that complications and deviations from
the expected course are managed by those with the most knowledge of the patient. Although such
care can occur in a virtual network of providers who are well known to each other, there is increasing
evidence that the most reliable way to ensure such quality and efficiency is through the creation of
integrated delivery systems. Such systems can take the form of a unified entity with a single
business model, but can also exist in the form of a clinically integrated network that is linked by
shared agreements between independent entities. It is the degree of integration that matters more
than the financial ties of the parties delivering the care.
References
Bhatt, Purvi B., Forster Kevin, Walter Terri L., Survive or Thrive? Healthcare Financial Management,
July 2015, p62-67.
Carlin Caroline S., Dowd Bryan, Feldman Roger, Changes in Quality of Health Care Delivery after
Vertical Integration, Health Services Research, August 2015, p. 1043-1069.
Hwang Wenke, PhD, Chang Jongwha, PhD, LaClair Michelle, MPH, Paz Harold, MD, MS, Effects of
Integrated Delivery System on Cost and Quality, The American Journal of Managed Care, May 2013,
Vol 19, No. 5, e175-e184.
54
Jacquin Laura, A Strategic Approach to Healthcare Transformation, Healthcare Financial
Management, April 2014, p.74-79.
May, Ellen Lanser, Achieving Physician-Led Clinical Integration, Healthcare Executive, Jan/Feb
2015, p11-17.
Moore, Keith D., Eyestone, Katherine M., Coddington Dean C., The Integration Aspiration,
Healthcare Financial Management, June 2014, p56-59.
Redding John, Achieving Clinical Integration, Healthcare Financial Management, November 2013,
p. 56-61.
Sharan Alok D., MD, MHCDS, Schroeder Gregory D., MD, West, Michael E., MBA, CPA, Vaccaro
Alexander R., MD, PhD, MBA, Business of Medicine, Spinal Disord Tech, Vol 00, Number 00, 2015,
p1-3.
Squazzo Jessica D., The Journey to Value-based Care for Population Health, Healthcare Executive,
Jan/Feb 2015, p28-35.
Psek, Wayne A., Stametz Rebecca A., Bailey-Davis Lisa D., Davis Daniel, Darer, Jonathan, Faucett
William A., Henninger Debra L., Sellers Dorothy C., Gerrity Gloria, Operationalizing the Learning
Health Care System in an Integrated Delivery System, The Berkeley Electronic Press, 2015, p1-11.
Teisberg Elizabeth O., Phd, Wallace Scott, JD, MBA, Creating a High-Value Delivery System for Health
Care, Semin Thorac Cardiovasc Surg 21, 2009, p.35-42.
55
11:36 am – 11:43 am
Transitioning from Volume to Value:
Private Practice Models are More Nimble
Daniel B. Murrey, MD, MPP
The drive to transition from volume to value assumes that the market will reward value creation:
improvement in outcomes that matter to patients and/or a reduction in the cost to achieve those
outcomes. The relative complexity of the care environment in which orthopedics is practiced slows
adoption of new processes, but equally important is the complexity of governance in these
institutions. In larger organizations such as health systems, the decision to change processes and
strategy require not only buy-in from involved clinicians, but also approval of the operational teams,
finance teams, and clinical support teams. These are often separate decision-making bodies with
relatively independent authority. Because the clinicians are also the owners and governors of
private physician practices, the buy-in of physician leadership is the only gating step to adoption of
a value agenda assuming adequate capital and commitment to data transparency and
accountability.
56
THE KNEE SOCIETY AWARDS
The John N. Insall, MD Award
1:01 pm – 1:11 pm
Do Injections Increase the Risk of Infection Following TKA?
Nicholas A. Bedard, MD; Andrew J. Pugely, MD; Jacob M. Elkins, MD, PhD; Kyle R. Duchman, MD;
Robert W. Westermann, MD; Steve S. Liu, MD; Yubo Gao, PhD; John J. Callaghan, MD
Background
Infection following TKA can result in disastrous consequences. Previous research regarding
injections and risk of TKA infection have produced conflicting results and have been greatly limited
by small cohort size. The purpose of this study was to evaluate if injection prior to TKA increases
the rate of post-operative infection and identify if time between injection and TKA effect the rate of
TKA infection.
Methods
The Humana dataset was reviewed from 2007-2014 for all patients who received a knee injection
prior to TKA. CPT codes and laterality modifiers were used to identify patients who underwent knee
injection followed by ipsilateral TKA. Postoperative infection within six months of TKA was identified
using ICD-9/CPT codes and compared between cohorts based upon duration between injection and
TKA.
Results
In total, 29,603 patients (35.4%) had an injection in the ipsilateral knee prior to TKA and 54,081
patients (64.6%) did not. Rates of any post-operative infection were significantly higher in patients
with an injection than those without (4.4% vs 3.6%), as were rates of infection requiring return to
the operating room (1.5% vs 1.0%). Odds ratios for these endpoints were 1.2 and 1.4, respectively
(p<0.001 for both). Analysis by proximity between injection and TKA revealed the odds of any postoperative infection remained significantly higher for the injection cohort out to a duration of 6
months between injection and TKA, as did the odds of operative innervation for TKA infection when
injection occurred within 7 months of TKA. When the duration between injection and TKA was longer
than 6 or 7 months, the odds ratios were no longer significantly elevated at these endpoints,
respectively.
Conclusions Injection prior to TKA was associated with a higher odds of post-operative infection and
appears to be time dependent with closer proximity between injection and TKA having increased
odds of infection.
57
The Chitranjan S. Ranawat, MD Award
1:12 pm – 1:22 pm
No Difference in Two-Year Functional Outcomes Using
Kinematic Versus Mechanical Alignment in TKA
Simon W. Young, FRACS; Matthew L. Walker, FRACS; Ali Bayan, FRACS;
Toby Briant-Evans, FRCS; Paul Pavlou, FRCS, Bill Farrington, FRCS, FRACS
Background
Neutral mechanical alignment (MA) in total knee arthroplasty (TKA) aims to position femoral and
tibial components perpendicular to the mechanical axis of the limb. In contrast, Kinematic
Alignment (KA) matches implant position to the pre-arthritic anatomy of the individual patient, with
the aim of improving functional outcome. However comparative data between the two techniques
is lacking.
Questions/Purposes
(1) Are two-year patient-reported outcome scores enhanced in patients with KA compared to MA
technique?
(2) How does post-operative component alignment differ between the techniques?
(3) (3) Does the rate of two-year complications requiring re-operation differ?
Methods
Ninety-nine primary TKAs were randomized to either MA (n=50) or KA (n=49) groups. In the KA
group, patient specific cutting-blocks were manufactured using individual pre-operative MRI data.
In the MA group, computer navigation was used to ensure neutral mechanical alignment accuracy.
Post-operative alignment was assessed with CT scan, and functional scores were assessed preoperatively and at 6 weeks, 6 months, 1 and 2 years postoperatively.
Results
There was no difference in 2-year change scores (post-op minus pre-op score) in KA versus MA
patients for the Oxford Knee Score (21.9 vs 20.0, p=0.4), Western Ontario and McMaster
Universities score (38.3 vs 35.1, p=0.32), or Forgotten Joint score (29.2 vs 26.7, p=0.8). Postoperative hip-knee-ankle axis was similar between groups (KA 0.4° vs MA 0.7° varus), but in the
KA group the tibial component was in mean 2.1° more varus than the MA group (95% CI 1.0°-3.2°,
p=0.0003) and the femoral component in 1.4° more valgus (95% CI 0.55°-2.3° p=0.003).
Complication rates were similar between groups.
Conclusion
We found no difference in two-year patient reported outcome scores in TKAs implanted using the
KA versus MA technique. Currently, it is unknown if the alterations in component alignment seen
with KA will compromise long-term survivorship of TKA.
Level of Evidence
Level 1 Therapeutic Study, Randomized Controlled Trial
58
The Mark Coventry, MD Award
1:23 pm – 1:33 pm
Oral Antibiotics Reduce Reinfection Following 2-Stage Exchange:
A Multi-Center, Randomized Controlled Trial
Craig J. Della Valle, MD; Jonathan M. Frank, MD; Erdan Kayupov, MSE; Mario Moric, MA;
John Segreti, MD; Erik Hansen, MD; Curtis Hartman, MD; Kamil Okroj
Background
A substantial number of patients develop recurrent periprosthetic joint infection (PJI) following twostage exchange arthroplasty. One potential strategy to decrease the risk of failure is to administer
additional antibiotics after the second stage reimplantation.
Questions/Purposes
1. Does 3 months of oral antibiotics decrease the risk of failure following a two-stage exchange?
2. Are there any complications related to the administration of oral antibiotics following a two-stage
exchange?
3. In those patients that have a reinfection, is the infecting organism different from the initial
infection?
Patients and Methods
Following Institutional Review Board approval seven centers enrolled patients who were
randomized to receive three months of oral antibiotics or no further antibiotic treatment after
operative cultures following the second stage reimplantation were negative. Oral antibiotic therapy
was tailored to the original infecting organism(s) in consultation with an Infectious Disease
specialist. A priori power analysis determined that 77 patients per group would be required to
demonstrate a reduction in infection recurrence from 16% to 4% (β=0.80 and α=0.05). A logrank
survival curve was used to analyze the primary outcome of reinfection.
Results
Forty-five patients were successfully randomized to the antibiotic group and 47 patients to the
control group. The mean follow-up was 14.8 months in the antibiotic group and 10.1 months in the
control group. There have been three failures in the antibiotic group compared to nine amongst
controls (7% vs 19%; p=0.0457 using log rank survival curve analysis). Four patients had an
adverse reaction to the oral antibiotics and four patients were noncompliant with taking them. Eight
of the nine failures in the control group were with new organisms and two of the three failures in
the antibiotic group were with the same organism.
Conclusions
This multicenter randomized trial suggests that at short-term follow-up, the addition of three months
of oral antibiotics significantly improved infection-free survival. Further follow up of this cohort of
patients will be necessary to determine if these results are durable over time.
Level of Evidence
Level of Evidence Level 1, randomized control trial study.
59
Session VII: Case Presentations
2:51 pm – 2:58 pm
When is TKA Appropriate?
Ryan M. Nunley, MD
Introduction
1. TKA is one of the most successful operative procedures in Orthopaedic Surgery
2. Clear evidence that utilization of TKA will continue to increase over next 20 years
3. Implant design, durability, and surgical technique have improved long term outcomes
4. Patient selection, pre-operative optimization, and minimization of perioperative
complications is increasingly more important with the transition to bundled payments
Review the role of conservative management
1. Viscosupplementation injections-controversy over efficacy and AAOS guidelines
2. Steroid injections- timing and number of injections prior to TKA may influence outcome
3. Role of Physical therapy
4. Role of weight loss
Risk Factors
1. Too young or too old….Is there a sweet spot for age at time of TKA?
2. Previous knee arthroscopy… Is it as benign as we think?
3. Minimal knee osteoarthritis on plain radiographs…setup for unexplained painful TKA?
4. Severe degenerative changes with flexion contracture and varus/valgus fixed deformity…is
too much deformity a deterrent to outcome?
Success
1. Patient Selection
2. Pre-operative optimization
3. Appropriate timing and management of patient expectations
References
1. Brophy RH et al. Total knee arthroplasty after previous knee surgery: expected interval and
the effect on patient age. J Bone Joint Surg Am. 2014 May 21;96(10):801-5
2. Mather RC et al. Economic evaluation of access to musculoskeletal care: the case of waiting
for total knee arthroplasty. BMC Musculoskelet Disord. 2014 Jan 18;15:22
3. Bedair H et al. Economic benefit to society at large of total knee arthroplasty in younger
patients: a Markov analysis. J Bone Joint Surg Am. 2014 Jan 15;96(2):119-26
4. Polkowski G et al. Is pain and dissatisfaction after TKA related to early-grade preoperative
osteoarthritis? Clin Orthop Relat Res. 2013 Jan;471(1):162-8
5. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis (OA) of the knee.
Evidence-based
Guideline. Ed 2. Rosemont, IL: American Academy of Orthopaedic
Surgeons. Available from: http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp.
60
2:59 pm – 3:06 pm
When Enough is Enough?
Michael Ries, MD
Failed two stage revision TKA for treatment of infection or multiply revised TKA’s with segmental
bone loss can be reconstructed with a tumor prosthesis. However, larger amounts of segmental
bone loss requiring replacement may be associated with greater areas of devascularized bone and
soft tissue which could affect outcomes and complications.
We reviewed our cases of non-oncologic femoral endoprosthetic reconstructions for revision TKA
with distal femoral bone loss (n=22). Cases were categorized as distal femoral replacement (DIS)
or diaphyseal femoral replacement (DIA) based on extension to or above the supracondylar
metaphyseal-diaphyseal junction respectively.
Infection free survival at 2 years (DIS=75% vs. DIA=20%) and 5 years (DIS=75% vs DIA=10%) was
worse for larger endoprostheses. Larger endoprostheses had higher all cause reoperation rates
(DIS=33% vs DIA=90%; p=0.012). Implant survival rates for longer reconstructions were worse at 2
years (DIS=100% vs. DIA=40%) and 5 years (DIS=90% vs. DIA=30%). Length of endoprosthesis did
not affect ambulatory rates of patients at their most recent follow-up (DIS=72.7% vs. DIA=70%;
p=1.000).
Endoprosthetic replacement for the treatment of multiply failed TKA with segmental distal femoral
bone loss proximal to the supracondylar metaphyseal-diaphyseal junction results in high infection
and reoperation rates. Limb salvage remains possible with chronic antibiotic suppression.
However, amputation may be a more viable option when bone loss in this patient population extends
into the distal diaphysis.
61
3:07 pm – 3:14 pm
Periprosthetic Fractures about the Knee
Bassam A. Masri, MD, FRCSC
Introduction
Fractures about a knee replacement are much less common that those about a hip replacement.
They can occur intraoperatively, or more commonly post-operatively. Fractures of the femur, tibia
and patella have been described, and will be discusses separately, both in the post-operative as
well as the intra-operative setting.
Post-operative fractures
Femur
Classification
Fractures of the femur after a total knee arthroplasty usually occur in the supracondylar region. The
authors’ recommended classification system was described by Lewis, Rorabeck, and Anglis. There
are three types:
Type I: Fracture undisplaced, component solidly fixed
Type II: Fracture displaced, component solidly fixed
Type III: Component loose, regardless of displacement of fracture
Treatment
Non-operative
While traditionally this was the treatment of choice in the past, the morbidity of prolonged traction
and bed rest is no longer justified, with the availability of safe and effective surgical techniques.
Perhaps the only indication at present for non-operative treatment a Type I fracture in an elderly
patient who is a poor surgical candidate. In the authors’ experience, these indications are very few.
Operative Treatment
Type I and II
Type I and II fractures may be treated with internal fixation. The advent of locked plating has made
treatment much more predictable and at present, intramedullary nailing is much less indicated.
Type III
If the implant is loose, it should be revised, regardless of the degree of displacement of the fracture.
The fracture can be reduced and fixed with an intramedullary stem extension. It is important to bone
graft these fractures, and to avoid cement intrusion into the fracture. Occasionally, there is so much
comminution or bone loss due to osteopenia or osteolysis. In these cases, revision with an allograftprosthetic composite may be performed in younger patients. Alternatively, in older or in low demand
patients, a tumor prosthesis can be used to replace the distal femur. This is the most common
treatment option.
62
Tibia
Classification (Mayo Clinic Classification- adapted from Stuart MJ, Hanssen AD: Total knee
arthroplasty: periprosthetic tibial fractures. Orthop Clin North Am 30(2):279-286, 1999)
The Mayo Classification System takes into consideration the anatomic location (Types I-IV) as well
as the status of fixation of the components and the time of injury (subcategory A, B, and C)
Type I: Condylar
Type II: Adjacent to stem
Type III: Distal to stem
Type IV: Tibial tubercle
Subcategories:
A: Prosthesis well fixed
B: Prosthesis loose
C: Intraoperative fracture
Treatment
Type I
Type I fractures almost never occur without loosening of the tibial component, and therefore type
IA fractures do not occur. The treatment of Type IB fractures is therefore revision total knee
arthroplasty. The area of fracture has sufficient bone loss that simply internal fixation is rarely if
ever sufficient. In most cases, revision with modular augments or bone graft for larger defects is
required. As in most revision operations with poor bone stock, a stem is necessary.
Type II
Type IIA: These are about half as common as type IIB fractures, and occur as a result of
significant trauma. Non-operative treatment with rigid immobilization is successful with no effect on
knee function.
Type IIB: These fractures are often related to massive osteolysis. They require revision
arthroplasty with a long stem. Often, there is insufficient bone stock for a revision arthroplasty, and
reconstruction with a structural allograft is often necessary. In older patients, a tumour prosthesis
may be used to allow expedient rehabilitation.
63
Type III
Type IIIA: These fractures need to be treated independent of the knee replacement with
open reduction and internal fixation, as the presence of a knee replacement precluded
intramedullary nailing.
Type IIIB: These are challenging fractures whose treatment needs to be individualized
depending on the patient and the fracture. Occasionally, osteosynthesis to re-establish an intact
tibia should be done initially, followed by revision total knee arthroplasty after fracture healing, if
the fracture is well distal to the knee. If the fracture is proximal enough to be bypassed with a stem,
revision arthroplasty with a long stem is the treatment of choice.
Patella
Classification (Goldberg et al, CORR 1988)
Type I: Extensor mechanism intact, not extending to implant surface
Type II: Extensor mechanism not intact, extending to implant surface
Type III: Inferior pole fracture
A: Patellar tendon rupture
B: Patellar tendon intact
Type IV: Fracture dislocation
Treatment
The treatment principles depend on the status of the extensor mechanism and on the status of
fixation of the patellar component.
If the extensor mechanism is intact, and the prosthesis is solidly fixed (type I), then non-operative
treatment in a knee immobilizer should suffice. If the extensor mechanism is intact, but the patellar
component is loose, the prosthesis can be removed if the remaining thickness of the patella does
not allows resurfacing (less than 10 mm), or revised if the remaining thickness of the patella allows
resurfacing (greater than 10 mm).
If the extensor mechanism is not intact, the patellar component is often loose, except in Type III
fractures. The extensor mechanism needs to be repaired in all cases. If the patellar remnant is too
comminuted or does not allow resurfacing, then a patellectomy with soft tissue repair is indicated.
64
3:15 pm – 3:22 pm
Dealing with Extensor Mechanism Deficiency
Matthew S. Austin, MD
Extensor mechanism deficiency after total knee arthroplasty is rare, debilitating and associated with
generally poor surgical outcomes [1-2]. Failure can occur both acutely and with chronic disease.
Deficiency may occur within the quadriceps tendon, within the patella (secondary to fracture or
osteonecrosis) or within the patellar tendon. Non-surgical management, using braces and walking aids,
does not optimize patient function but may be a reasonable option in patients who are poor surgical
candidates. Before considering surgical management, a thorough history and physical exam should be
performed to assess for the chronicity of the injury, prior attempts at repair/reconstruction, medical
comorbidities and the extent of disability. Diagnostic and imaging studies should be used to identify
other concomitant issues including infection, implant failure, malalignment or fracture.
Quadriceps tendon rupture may be repaired primarily through bone tunnels or suture anchors[3] or can
be reconstructed with allograft reinforcement for more severe or chronic defects[1]. Primary repair of
the patellar tendon has high complication rates and poor results as compared to repair in native knees.
Reconstruction of the patellar tendon can be attempted in the acute setting with hamstring autograft[4]
or bone patellar bone allograft[5]. In more chronic cases, especially when there is retraction of the
patella, Achilles tendon allograft, whole extensor mechanism allograft[6] or synthetic mesh[7] are
commonly used options. For cases that involve an anterior soft-tissue defect, a gastrocnemius flap
reconstruction may be considered [8-9].
To date, there is no single method that reliably produces superior results. Although it is important to
choose a suitable graft for a given case of extensor mechanism deficiency, multiple studies have shown
that the technique of application, tensioning of the graft and the post-operative protocols such as
casting are just as crucial[10][7]. In summary, extensor mechanism deficiency is a challenging surgical
problem that requires careful patient selection and implementation of an appropriate reconstructive
technique suitable for each patient.
References
[1]
Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps Tendon Rupture After Total Knee
Arthroplasty. JBJS 2005;87-A.
[2]
Rand JA, Morrey, Bryan RS. Patellar Tendon Rupture After Total Knee Arthroplasty. Clin Orthop
Relat Res 1987:233–8.
65
[3]
Kamath AF, Summers N, Israelite CL. Suture Anchor Repair of Patellar Tendon Rupture after Total
Knee Arthroplasty. J Knee Surg 2013;26:128–31. doi:10.1016/j.arth.2011.01.006.
[4]
Cadambi A, Engh G a. Use of a semitendinosus tendon autogenous graft for rupture of the
patellar ligament after total knee arthroplasty. A report of seven cases. JBJS 1992;74:974–9.
[5]
Zanotti RM, Freiberg A a., Matthews LS. Use of patellar allograft to reconstruct a patellar tendondeficient knee after total joint arthroplasty. J Arthroplasty 1995;10:271–4. doi:10.1016/S08835403(05)80173-1.
[6]
Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, Valle CJ Della. Extensor Mechanism
Allograft Reconstruction for Extensor Mechanism Failure Following Total Knee Arthroplasty. JBJS
2015;97:279–83.
[7]
Browne J a, Hanssen AD. Reconstruction of patellar tendon disruption after total knee
arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint Surg Am
2011;93:1137–43. doi:10.2106/JBJS.J.01036.
[8]
Jaureguito JW, Dubois CM, Smith SR, Gottlieb LJ, Finn H a. Medial gastrocnemius transposition
flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty. J
Bone Joint Surg Am 1997;79:866–73.
[9]
Whiteside L a. Surgical technique: Muscle transfer restores extensor function after failed patellapatellar tendon allograft knee. Clin Orthop Relat Res 2014;472:218–26. doi:10.1007/s11999013-3101-9.
[10]
Nazarian B. Extensor mechanism allografts in total knee arthroplasty. Clin Orthop Relat Res
1999;367:123–9.
66
3:23 pm – 3:30 pm
Treatment of an Unstable Total Knee Replacement
Robert T. Trousdale, MD
Mayo Clinic, Rochester, MN
I. Types of Instability
1.
2.
3.
4.
Medial-lateral instability (varus-valgus)
Symmetrical extension instability (recurvatum)
Flexion instability
Global instability
II. Treatment
1. Principle: Use the least amount of constraint total knee that provides a well-balanced,
stable knee in both extension-flexion and flexion.
2. Treatment of:
a. Medial-lateral instability/varus-valgus instability: This is associated with
significant preoperative deformity, asymmetrical bone resection, improperly balanced, or
iantrogenic ligament injury. Treatment involves balancing the ligaments, occasional ligament
reconstruction, increasing the constraint to an unlinked varus-valgus constraint (VVC) design versus
a linked hinge.
b. Recurvatum: This is associated with neuromuscular disease or excessive distal
femoral resection. Treatment in most neuromuscular patients is usually a hinged component and
in those that have iantrogenic distal femoral resection one can treat with a less constrained implant
by building up the distal femur.
c. Flexion instability: This is associated with an undersized femoral component, an
increase in posterior tibial slope, failed posterior cruciate ligament, or under-resection of the distal
femur resulting in utilization of a thinner polyethylene to give the patient full extension and be loose
in flexion. Treatment involves upsizing the femoral component size to tighten the flexion space,
occasionally increasing the distal femoral resection to get a thicker polyethylene in place, using a
posterior stabilized knee or a VVC knee if needed.
d. Global instability: This is associated with a combination of the above ligament
deficiencies. This often requires increasing constraint to a VVC or a hinged component
67
3:31 pm – 3:38 pm
Diagnosis of Prosthetic Knee Joint Infection
Kevin L. Garvin, MD
University of Nebraska Medical Center
Prosthetic knee joint infection has emerged as one of the most common causes of a failed total
knee arthroplasty. While the presentation of infection may be obvious, it also may be elusive for
even the most skilled diagnosticians who struggle to make the correct diagnosis and identify the
offending pathogen. The first step along the path of diagnosis is recognizing the signs and
symptoms associated with a prosthetic joint infection. Whether the patient has a draining sinus or
the insidious onset of pain and stiffness, the evaluation must be thorough beginning with the
patient’s history, examination, radiographs and then continuing with serum studies of inflammation
(CRP, ESR). If the laboratory values are elevated or the surgeon has a high suspicion of infection,
then joint aspiration is recommended. The fluid is analyzed for white blood cell count, differential
(looking for neutrophils) and then cultured. Chronic versus acute infections have different
thresholds for the number of cells (3-4,000 cells/μL vs. 10,000 cells/μL) and the percent of
neutrophils (60-80% vs. 90%). Nuclear imaging has a limited role in the diagnosis.
Intraoperative evaluation of the patient is also essential including repeat aspiration, frozen section
analysis of the tissue, and culture of the fluid and tissue. When a stepwise algorithm for the
possibility or probability of infection is followed the diagnosis of infection can be established for the
majority of patients. Because a single test for the diagnosis of infection does not exist, objective
criteria established by the Musculoskeletal Infection Society (MSIS) aids in the diagnosis. The more
challenging diagnosis may be aided by newer diagnostic tests such as alpha defensin or enhanced
culture techniques, sonication of the knee implant, and holding cultures for up to three weeks to
allow slow-growing organisms to be identified.
It is possible that the diagnosis of infection is correct but the culture fails to identify a pathogen.
This diagnostic dilemma can occur in 7-12% of prosthetic joint infections. Limited evidence
supports treating these patients like patients with known bacteria including a two-stage
reimplantation and 4-6 weeks of parenteral antibiotics as directed by the infectious disease
specialists.
In summary, the diagnosis of a prosthetic knee infection requires a disciplined approach using wellestablished criteria. New diagnostic tests and techniques may prove to be helpful in situations
when the diagnosis is elusive.
References
1.
2.
American Academy of Orthopaedic Surgeons. The diagnosis of periprosthetic joint infections of
the hip and knee: Guideline and evidence report. Adopted by the AAOS board of directors.
Chicago, IL: American Academy of Orthopaedic Surgeons; 2010. Available from:
http://www.aaos.org/cc_files/aaosorg/research/guidelines/pjiguideline.pdf.
Accessed
December 15, 2015.
Bedair H, Ting N, Jacovides C, Saxena A, Moric M, Parvizi J, Della Valle CJ. The mark coventry
award: Diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop
Relat Res. 2011;469:34-40.
68
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, Steckelberg J, Osmon D.
Inflammatory blood laboratory levels as markers of prosthetic joint infection: A systematic
review and meta-analysis. J Bone Joint Surg Am. 2010;92:2102-2109.
Boot W, Moojen DJ, Visser E, Lehr AM, De Windt TS, Van Hellemondt G, Geurts J, Tulp NJ,
Schreurs BW, Burger BJ, Dhert WJ, Gawlitta D, Vogely HC. Missed low-grade infection in
suspected aseptic loosening has no consequences for the survival of total hip arthroplasty.
Acta Orthop. 2015;86:678-683.
Chalmers PN, Walton D, Sporer SM, Levine BR. Evaluation of the role for synovial aspiration in
the diagnosis of aseptic loosening after total knee arthroplasty. J Bone Joint Surg Am.
2015;97:1597-1603.
Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Parvizi J. Combined measurement
of synovial fluid alpha-defensin and C-reactive protein levels: Highly accurate for diagnosing
periprosthetic joint infection. J Bone Joint Surg Am. 2014;96:1439-1445.
Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Parvizi J. Diagnosing
periprosthetic joint infection: Has the era of the biomarker arrived? Clin Orthop Relat Res.
2014;472:3254-3262.
Di Cesare PE, Chang E, Preston CF, Liu CJ. Serum interleukin-6 as a marker of periprosthetic
infection following total hip and knee arthroplasty. J Bone Joint Surg Am. 2005;87:1921-1927.
Dinneen A, Guyot A, Clements J, Bradley N. Synovial fluid white cell and differential count in the
diagnosis or exclusion of prosthetic joint infection. Bone Joint J. 2013;95-B:554-557.
Greidanus NV, Masri BA, Garbuz DS, Wilson SD, McAlinden MG, Xu M, Duncan CP. Use of
erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before
revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am.
2007;89:1409-1416.
Janz V, Wassilew GI, Hasart O, Tohtz S, Perka C. Improvement in the detection rate of PJI in
total hip arthroplasty through multiple sonicate fluid cultures. J Orthop Res. 2013;31:20212024.
Johnson AJ, Zywiel MG, Stroh DA, Marker DR, Mont MA. Should gram stains have a role in
diagnosing hip arthroplasty infections? Clin Orthop Relat Res. 2010;468:2387-2391.
Martinez-Pastor JC, Macule-Beneyto F, Suso-Vergara S. Acute infection in total knee
arthroplasty: Diagnosis and treatment. Open Orthop J. 2013;7:197-204.
Oethinger M, Warner DK, Schindler SA, Kobayashi H, Bauer TW. Diagnosing periprosthetic
infection: False-positive intraoperative gram stains. Clin Orthop Relat Res. 2011;469:954-960.
Omar M, Ettinger M, Reichling M, Petri M, Guenther D, Gehrke T, Krettek C, Mommsen P.
Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip
arthroplasty. Bone Joint J. 2015;97-B:173-176.
Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A,
Wilson WR, Infectious Diseases Society of America. Diagnosis and management of prosthetic
joint infection: Clinical practice guidelines by the infectious diseases society of america. Clin
Infect Dis. 2013;56:e1-e25.
Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: The utility
of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011;93:2242-2248.
Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA,
Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: From the
workgroup of the musculoskeletal infection society. Clin Orthop Relat Res. 2011;469:29922994.
Portillo ME, Salvado M, Alier A, Martinez S, Sorli L, Horcajada JP, Puig L. Advantages of
sonication fluid culture for the diagnosis of prosthetic joint infection. J Infect. 2014;69:35-41.
69
20. Qu X, Zhai Z, Liu X, Li H, Wu C, Li Y, Li H, Zhu Z, Qin A, Dai K. Evaluation of white cell count and
differential in synovial fluid for diagnosing infections after total hip or knee arthroplasty. PLoS
One. 2014;9:e84751-e84751.
21. Randau TM, Friedrich MJ, Wimmer MD, Reichert B, Kuberra D, Stoffel-Wagner B, Limmer A,
Wirtz DC, Gravius S. Interleukin-6 in serum and in synovial fluid enhances the differentiation
between periprosthetic joint infection and aseptic loosening. PLoS One. 2014;9:e89045.
22. Schwarzkopf R, Carlson EM, Tibbo ME, Josephs L, Scott RD. Synovial fluid differential cell count
in wear debris synovitis after total knee replacement. Knee. 2014;21:1023-1028.
23. Shafafy R, McClatchie W, Chettiar K, Gill K, Hargrove R, Sturridge S, Guyot A. Use of leucocyte
esterase reagent strips in the diagnosis or exclusion of prosthetic joint infection. Bone Joint J.
2015;97-B:1232-1236.
24. Shah NB, Tande AJ, Patel R, Berbari EF. Anaerobic prosthetic joint infection. Anaerobe.
2015;36:1-8.
25. Tetreault MW, Wetters NG, Moric M, Gross CE, Della Valle CJ. Is synovial C-reactive protein a
useful marker for periprosthetic joint infection? Clin Orthop Relat Res. 2014;472:3997-4003.
26. Wetters NG, Berend KR, Lombardi AV, Morris MJ, Tucker TL, Della Valle CJ. Leukocyte esterase
reagent strips for the rapid diagnosis of periprosthetic joint infection. J Arthroplasty. 2012;27:811.
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Orthop Relat Res. 2014;472:424-429.
70
3:39 pm – 3:46 pm
Patient is Unhappy, But I Don't Know Why
Robert L. Barrack, MD
Washington University School of Medicine
There is growing evidence to suggest many patients experience pain and dissatisfaction after TKA
in spite of implants that appear to be adequately implanted. Important factors to consider other
than the implant design and surgical technique include patient expectations, certain patient
characteristics (both physical and psychological) and the degree of preoperative degenerative
arthritis.
In a recent study the relationship between early-grade preoperative OA with pain and dissatisfaction
after TKA was examined. [1] We evaluated all (n = 49) painful TKAs in a 1-year period that had no
evidence of loosening, instability, malalignment, infection, or extensor mechanism dysfunction and
classified the degree of preoperative OA according to the scale of Kellgren and Lawrence. For
comparison, we identified three other cohorts of TKAs from the same center and classified their
preoperative grade of OA: Group B (n = 100) was a consecutive series of primary TKAs performed
for OA during the same year; Group C (n = 80) were asymptomatic TKAs from 1 to 4 years
postoperatively; and Group D (n = 80) were TKAs with some degree of pain at 1 to 4 years
postoperatively. Patients in Group A had a higher incidence of early-grade OA is preoperatively
(49%) compared with any of the comparison groups: Group B, (5%); Group C, (6%); and Group D,
(10%). In another study, a surprisingly high incidence of persistent symptoms was identified in a
large group of TKA patients from total joint centers when questioned anonymously by a third party
interviewer. [2]
A high percentage of patients referred for unexplained pain after TKA had early-grade osteoarthritis
preoperatively. Patients undergoing TKA for less than Grade 3 or 4 OA should be informed that they
may be at higher risk for persistent pain and dissatisfaction. Other major factors predisposing to
dissatisfaction include unmet expectations and one of a number of preoperative patient
characteristics. [3] Although these patient factors may not constitute a contraindication to TKA,
these potential surgical candidacy should be informed that they are potentially at a higher risk for
persistent symptoms and dissatisfaction. Since unmet expectations are the strongest predictor of
dissatisfaction following TKA, realistic informed consent regarding TKA outcomes is critical. [4]
References
1.
Polkowski, G. G., 2nd, et al. (2013). "Is pain and dissatisfaction after TKA related to earlygrade preoperative osteoarthritis?" Clin Orthop Relat Res 471(1): 162-168.
2.
Parvizi, J., et al. (2014). "High level of residual symptoms in young patients after total knee
arthroplasty." Clin Orthop Relat Res 472(1): 133-137.
3.
Bourne, R. B., et al. (2010). "Patient satisfaction after total knee arthroplasty: who is satisfied
and who is not?" Clin Orthop Relat Res 468(1): 57-63.
4.
Husain, A. and G. C. Lee (2015). "Establishing Realistic Patient Expectations Following Total
Knee Arthroplasty." J Am Acad Orthop Surg 23(12): 707-713.
71
Session VIII: The Young Investigator Symposium
4:07 pm – 4:12 pm
Paper 1
Closed Incision Negative Pressure Therapy Versus Antimicrobial Dressings
Following Revision Hip and Knee Surgery: A Comparative Study
H. John Cooper, MD
Marcel A. Bas, MD
Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
Introduction
Wound complications and surgical site infections (SSIs) following revision hip and knee surgery are
a major source of patient morbidity and represent a substantial healthcare burden. Despite
improved infection control practices, SSI prevention remains an important clinical challenge and
demands innovative interventions. This study assesses the effect of closed incision negative
pressure therapy (ciNWT) on rates of wound complications and surgical site infections (SSIs)
following revision hip and knee surgery.
Methods
A retrospective quality improvement analysis of 141 consecutive revision hip and knee operations
performed by a single surgeon over a 34-month period was conducted. Preoperative SSI prevention
measures were standardized across the cohort. Closed incision NPT was used selectively in higherrisk patients with multiple risk factors for SSI over the last 15 months of the study period. Rates of
wound complications, SSIs, and reoperation through the first 90 days were compared with patients
treated with a sterile antimicrobial dressing (AQUACEL® Ag), which represents the standard-of-care
at our
institution.
Results
Three patients were lost to follow-up prior to final outcome, leaving 138 patients (97.9%) available
for analysis. Antimicrobial dressings were used in 108 patients, whereas ciNPT was used in 30
patients. Patients treated with ciNPT developed fewer overall wound complications (6.7% vs. 26.9%,
P = 0.032) and fewer total SSIs (3.3% vs. 18.5%, P = 0.045) compared with patients treated with
antimicrobial dressings. Additionally, there were trends toward a lower rate of superficial wound
dehiscence (6.7% vs. 19.4%, P = 0.163), fewer deep periprosthetic joint infections (0.0% vs. 9.3%,
P = 0.118), and fewer reoperations (3.3% vs. 13.0%, P = 0.191) among patients treated with ciNPT.
Discussion/Conclusion
Our findings suggest that ciNPT decreases the incidence of wound complications and SSIs in
patients undergoing revision hip and knee surgery, and may have potential for lowering the rate of
reoperation in this patient population.
72
4:13 pm – 4:18 pm
Paper 2
Discharge Destination after Total Knee Arthroplasty:
An Analysis of Post-Discharge Outcomes and Risk Factors
Calin S. Moucha, MD; Aakash Keswani
Background
This study aimed to compare risk of post-discharge adverse events in elective total knee
arthroplasty (TKA) patients by discharge destination, identify risk factors for inpatient discharge
placement and post-discharge adverse events, and stratify TKA patients based on these risk factors
to identify the most appropriate discharge destination.
Methods
Patients that underwent elective primary TKA from 2011-2014 were identified in the NSQIP
database. Bivariate and multivariate analyses were performed on perioperative variables.
Results
100,275 TKA patients were analyzed. The most common discharge destinations included home
(70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF) (11%). Bivariate
analysis revealed that rates of post-discharge adverse events were higher in SNF and IRF patients
(p≤0.001). In multivariate analysis, SNF and IRF patients were more likely to have post-discharge
severe adverse events (SNF: OR 1.38, p≤0.001; IRF: OR 1.30, p≤0.001) and unplanned
readmission (SNF: OR 1.45, p≤0.001; IRF: OR 1.40, p≤0.001) (Table 1). After stratifying patients by
strongest independent risk factors (OR ≥1.10, p≤0.05) for adverse outcomes post-discharge, we
found that home discharge is the optimal strategy for minimizing rate of unplanned 30-day
readmissions (p≤0.05 for 5 out of 6 risk levels) and severe 30-day adverse events post-discharge
(p≤0.05 for 3 out of 6 risk levels) (Table 2).
Conclusion
SNF or IRF discharge increases risk of post-discharge adverse events compared to home.
Modifiable risk factors for non-home discharge and post-discharge adverse events should be
addressed pre-operatively to improve patient outcomes across discharge settings.
73
Table 1. Risk factors for severe adverse events post-discharge and unplanned readmission
Outcome/Risk Factor
Odds ratio (95% CI)
Severe adverse event post-discharge
Severe adverse event pre-discharge
2.29 (1.65-3.20)
Rehab discharge destination
1.30 (1.10-1.53)
SNF discharge destination
1.38 (1.21-1.58)
Operative time
1.003 (1.002-1.004)
Male gender
1.50 (1.34-1.67)
Functional status
1.74 (1.27-2.38)
BMI>40
1.30 (1.13-1.51)
History of smoking
1.46 (1.23-1.73)
Pulmonary disease
1.27 (1.01-1.60)
Hypertension
1.25 (1.10-1.42)
Renal disease
3.12 (1.63-5.98)
Steroids for chronic condition within 30 days of procedure 1.71 (1.37-2.14)
Bleeding-causing disorder
1.77 (1.40-2.24)
ASA class ¾
1.39 (1.23-1.56)
General anesthesia
1.14 (1.02-1.27)
Unplanned 30-day readmission
Severe adverse event pre-discharge
2.80 (2.28-3.44)
Rehab discharge destination
1.40 (1.26-1.55)
SNF discharge destination
1.45 (1.33-1.58)
Age
1.02 (1.01-1.02)
Operative time
1.002 (1.001-1.003)
Male gender
1.34 (1.25-1.44)
Functional status
1.37 (1.09-1.72)
BMI>40
1.14 (1.03-1.26)
History of smoking
1.31 (1.16-1.48)
Pulmonary disease
1.54 (1.34-1.78)
Cardiac disease
1.28 (1.14-1.43)
Hypertension
1.30 (1.14-1.43)
Renal disease
3.11 (1.98-4.90)
Steroids for chronic condition within 30 days of procedure 1.38 (1.17-1.61)
Bleeding-causing disorder
1.71 (1.46-2.00)
ASA class ¾
1.44 (1.33-1.56)
74
p-value
<0.001
0.002
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.04
<0.001
<0.001
0.003
<0.001
<0.001
0.02
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.007
0.01
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
4:19 pm – 4:24 pm
Paper 3
Thrombogenic Risk of Unicompartmental Knee
Versus Total Knee Replacement
Edwin P. Su, MD; Lauren E. Mount, MD; Allina Nocon, MPH; Thomas P. Sculco, MD;
George Go, BS; Nigel E. Sharrock, BMedSci, MB, ChB
Introduction
The relative thrombogenic risk of unicompartmental knee replacement (UKR) compared to total
knee replacement (TKR) is unknown. This is important as it could provide a basis for DVT
prophylaxis. We looked at the association between procedure and time on circulating markers of
thrombin generation, thrombin-anti-thrombin complex (TAT), pro-thrombin F1+2 (F1+2), and
Interleukin-6 (IL-6), a pro-inflammatory cytokine.
Patients and methods
Following IRB approval, 75 patients undergoing unilateral TKR (n=25), UKR (n=25), or bilateral one
staged TKR (n=25), were studied. Inclusion criteria included: age 19 to 80; osteoarthritis or
avascular necrosis and surgery performed under tourniquet using combined spinal epidural
anesthesia. Patients were excluded if they had been on anticoagulation therapy prior to undergoing
surgery or had inflammatory arthritis or other inflammatory states. Blood samples were collected
from a radial artery catheter at 4 time points during surgery: 1) post anesthesia induction, 2)
immediately following incision with the tourniquet inflated, 3) with tourniquet release, and 4) at
wound closure. Samples were immediately stored in ice, centrifuged, and frozen at -20 Celsius. TAT
and F1+2, were measured using ELISA assays. The generalized estimating equations approach
was used to assess the effect of procedure (unicompartmental, unilateral TKR, and bilateral TKR)
and time (1, 2, 3, and 4), on (1) TAT, (2) F1+2, and IL-6. Pairwise comparisons were done by
procedure to investigate the interaction between procedure and time. Predictors of IL-6 elevation
were assessed in the same fashion. In assessing the relationship between tourniquet time (TT) and
change in IL-6 level, times 2 and 3 were chosen. A Spearman’s Correlation Coefficient was done to
examine the relationship between TT time and change in IL-6 level between Time 2 and 3. A pvalue less that <0.05 was considered significant.
Results
TAT increased throughout surgery (p<0.001) in all three groups. There was no difference in the
magnitude of the increase in either TAT or F1+2 between the different procedures. A significant
interaction was found between time and procedure for F1+2; p=0.01. A difference between Time
2 and 3 was found only for those who had a bilateral total knee procedure; p<0.001. There was a
significant increase in IL-6 throughout surgery (p<0.001). The largest increase was noted with one
staged bilateral TKR and there was minimal increase with UKR. , A difference was found between
75
procedure (p=0.003) and time (p=<0.001)). The strongest relationship between TT and change in
IL-6 level were in patients undergoing a UKR procedure; r=0.60, p=0.009. After adjustment for all
other predictors; BMI (p=0.05), ASA class (p=0.02), race (p=0.002), tourniquet time (p=0.02), and
having a bilateral knee replacement (p=0.01) were found to be predictors of IL-6 elevation.
Conclusion
There is a significant activation of thrombosis during UKR. Surprisingly, this appears of similar
magnitude to TKR. This suggests that patients undergoing UKR require thromboprophylaxis to the
same degree as patients undergoing TKR, from a surgical standpoint. However, a patient with UKR
mobilizes more quickly postoperatively and could mitigate this finding. Future studies are needed
to further explore the interaction between procedure and time, specifically for F1+2. IL-6 levels vary
according to procedure and time points of surgery. In patients undergoing UKR, a more limited
intervention, we observed a minimal rise in IL-6 throughout surgery. However, the strong
relationship between TT and change in IL-6 levels between time point 2 and 3 in UKR suggest strong
monitoring of TT can be of benefit to the patient.
76
Session IX: Transitioning to Outpatient TKA
4:36 pm – 4:43 pm
Building an Outpatient TKA Program
Keith R. Berend, MD
To progress to a same day surgery program for arthroplasty, it is important that we examine and
resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety of the
unknown and of surgical pain. The need for hospital stay is also related to risk arising from co-morbidities
and medical complications. Patients also need an extended stay to manage the side effects of our treatment,
including after effects of narcotics and anesthesia, blood loss, and surgical trauma.
The process begins preoperatively with an appropriate orthopaedic assessment of the patient and
determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the
expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group
that performs almost all pre-admission testing, we have established guidelines for patient selection for
outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must
have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that cannot be optimized for safe outpatient care may include: congestive heart failure, or valve
disease; chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive
sleep apnea with a BMI >40 kg/m2; hemodialysis or severely elevated serum creatinine; anemia with
hemoglobin <13.0 g/dl; cerebrovascular accident or history of delirium or dementia; and solid organ
transplant. Pre-arthroplasty rehabilitation prepares the patient for perioperative protocols. Patients meet
with a physical therapist and are provided with extensive educational materials before surgery to learn the
exercises they will need for functional recovery. Enhancement of our perioperative pain management
protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and
efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain,
reduce length of stay, and improve outcomes, especially in the short term.
Between June 2013 and December 2015, 1957 primary knee arthroplasty procedures (1010 total,
947 partial) were performed by the author and his 3 associates at an outpatient surgery center. Seven
percent of patients required an overnight stay, with a majority for reasons of convenience related to travel
distance or later operative time. Importantly, no one has required overnight stay for pain management.
Outpatient arthroplasty is safe, it’s better for us and our patients, and it is here now. In an outpatient
environment the surgeon actually spends more time with the patients and family in a friendly environment.
Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience.
1. Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM. The feasibility and perioperative complications
of outpatient knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1443-9.
2. Kolisek FR, McGrath MS, Jessup NM, Monesmith EA, Mont MA. Comparison of outpatient versus
inpatient total knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1438-42.
3. Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, Manley MT. Complications, mortality, and
costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay
patients. J Arthroplasty. 2014;29(3):510-5.
77
4:44 pm – 4:51 pm
Outpatient TKA: A Triumph of Knowledge over Reason
Bryan D. Springer, MD
With a shift in health care to value over volume and a surge in physician owned surgery
centers, there is an increasing interest in performing outpatient total joint arthroplasty. The exact
role and benefit to the patient in this venture has yet to be firmly elucidated. As we see an increasing
push from surgeons and centers to perform outpatient total joint arthroplasty we must ask first and
foremost what are the risk and benefits to the patients and what are the financial implications in
this current health care model.
Outpatient total knee arthroplasty most certainly be done safely, but not in everyone. Several
studies have demonstrated that major cardiac events and fatal or near fatal complications occur
on postoperative two1-3. The study by Parvizi et al determined that nearly 60% of patients that had
fatal or near-fatal complications had no identifiable predisposing risk factors. Patient selection
remains the key to building a successful outpatient total joint program3. Courtney et al identified
CHF, COPD, Coronary disease and Cirrhosis as independent risk factors for complications identified
these co-morbidities in patients that should not undergo outpatient or short stay total joint
arthroplasty4.
Outpatient total knee arthroplasty also has the potential to threaten our reimbursement for
TJA. In addition, with an emphasis being placed on prevention of readmission, a poorly selected
patient population for outpatient TKA may lead to financial penalties. Reimbursement of TJA is
determined by RUC valuations, a combination of minutes work, practice expense and malpractice
costs. A shift to outpatient TJA will only serve to lower the RUC valuation (minutes worked) and
ultimately lower out already diminishing reimbursement. Currently, Medicare penalized hospitals
3% for excessive readmission following TJA, with increasing penalties expected. An internal review
of our data showed nearly double the readmission rate for outpatient TKA compared to 1-2 days
inpatient stay5.
Outpatient total knee arthroplasty can be done safely but requires meticulous patient
selections, preoperative optimization and postoperative in-home support6. Before wide expansion
of outpatient total knee arthroplasty, more studies need to be done to identify proper patient
selection, optimum protocols, readmission prevention and financial implications to all total joint
surgeons.
1.
2.
Belmont PJ, Goodman GP, Kusnezov NA, et al. Postoperative myocardial infarction and
cardiac arrest following primary total knee and hip arthroplasty: Rates, risk factors, and time
of occurrence. The Journal of Bone & Joint Surgery. 2014;96(24):2025-2031.
Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients
undergoing total hip or knee replacement: a nationwide cohort study. Archives of internal
medicine. 2012;172(16):1229-1235.
78
3.
4.
5.
6.
Parvizi J, Mui A, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. Total joint arthroplasty: when
do fatal or near-fatal complications occur? The Journal of Bone & Joint Surgery.
2007;89(1):27-32.
Courtney PM, Rozell JC, Melnic CM, Lee G-C. Who Should Not Undergo Short Stay Hip and
Knee Arthroplasty? Risk Factors Associated with Major Medical Complications Following
Primary Total Joint Arthroplasty. The Journal of Arthroplasty. 2015.
Vegari D, Mokris J, Odum S, Springer B. Implications of outpatient vs. inpatient total joint
arthroplasty on hospital readmission rate. Paper 367. Paper presented at: annual meeting
of the American Academy of Orthopaedic Surgeons2014.
Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Malkani A. Patient selection in outpatient and shortstay total knee arthroplasty. Journal of surgical orthopaedic advances. 2013;23(1):2-8.
79
CME ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the accreditation requirements and policies of
the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American
Academy of Orthopaedic Surgeons and the Knee Society. The American Academy of Orthopaedic Surgeons is
accredited by the ACCME to provide continuing medical education for physicians.
CREDIT HOURS
The American Academy of Orthopaedic Surgeons designates this live activity for a maximum of 7.75 AMA PRA
Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in
the activity.
Upon completion of this activity, participants will be able to:
• Update clinical skills and basic knowledge through research findings and biomechanical studies.
• Discuss the various surgical and non-surgical treatments and management of conditions related to the knee joint.
• Determine indications and complications in total knee arthroplasty.
• Critique presentations of surgical techniques and demonstrations of treatment options.
• Evaluate the efficacy of new treatment options through evidence-based data.
FDA STATEMENT
Some pharmaceuticals and/or medical devices at the Specialty Day Meeting have not been cleared by the U.S. Food
and Drug Administration (FDA) or have been cleared by the FDA for specific purposes only. The FDA has stated that it
is the responsibility of the physician to determine the FDA status of each pharmaceuticals and/or medical devices he
or she wishes to use in clinical practice.
The Knee Society policy provides that “off label” uses of a device or pharmaceutical may be described in The Knee
Society’s CME activities so long as the “off-label” status of the device or pharmaceutical is also specifically disclosed
(i.e. that the FDA has not approved labeling the device for the described purpose). Any device or pharmaceutical is
being used “off label” if the described use is not set forth on the product’s approved label.
To obtain information regarding the clearance status of a device or pharmaceutical refers to the product labeling or
call the FDA at 1-800-638-2041 or visit the FDA internet site at http://www.fda.gov/cdrh/510khome.html
FINANCIAL DISCLOSURE
Each participant in The Knee Society Specialty Day Meeting has been asked to disclose if he or she has received
something of value from a commercial company, which relates directly or indirectly to the subject of their
presentation.
The Knee Society does not view the existence of these interests or commitments as necessarily implying bias or
decreasing the value of the author’s participation in the 2016 The Knee Society Specialty Day Meeting.
THE KNEE SOCIETY EDUCATION COMMITTEE:
Kevin John Bozic, MD, MBA, Chair: Submitted on: 11/09/2015; AAOS: Board or committee member; American Joint
Replacement Registry: Board or committee member; Harvard Business School: Paid consultant; Institute for
Healthcare Improvement: Paid consultant; Orthopaedic Research and Education Foundation: Board or committee
member; Yale-New Haven Center for Outcomes Research: Paid consultant
Keith R Berend, MD: Submitted on: 10/12/2015; AAOS Board of Specialty Societies (Knee Education
Representative): Board or committee member; American Association of Hip and Knee Surgeons: Board or committee
member; Clinical Orthopaedics and Related Research: Editorial or governing board; Journal of Arthroplasty: Editorial or
governing board; Journal of Bone and Joint Surgery - American: Editorial or governing board; Kinamed: Research
support; Knee Society: Board or committee member; Orthopedics: Editorial or governing board; Orthosensor:
Research support; Pacira: Research support; Reconstructive Review: Editorial or governing board; Zimmer Biomet: IP
royalties; Paid consultant; Research support
William L Griffin, MD: Submitted on: 10/12/2015; American Association of Hip and Knee Surgeons: Board or
committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker;
Research support; Journal of Arthroplasty, CORR: Editorial or governing board; Knee Society, AAOS: Board or
committee member Zimmer: Research support
80
Stephen J Incavo, MD: Submitted on: 01/26/2016; Biomet: IP royalties; Innomed: IP royalties; Journal of Arthroplasty:
Editorial or governing board; Knee Society: Board or committee member; Smith & Nephew: IP royalties; Wright
Medical Technology, Inc.: IP royalties; Zimmer: IP royalties; Paid consultant; Stock or stock Options
R Michael Meneghini, MD: Submitted on: 09/29/2015; Journal of Arthroplasty: Editorial or governing board; Knee
Society: Board or committee member; Stryker: IP royalties; Paid consultant; Research support
Timothy M Wright, PhD: Submitted on: 10/30/2015; Exactech, Inc: IP royalties; Stock or stock Options;
Knee Society: Board or committee member; Lima: IP royalties; Mathys Ltd: IP royalties; Orthobond: Stock or stock
Options; Stryker: Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties,
financial or material support; Zimmer: Paid consultant
PRESENTERS AND MODERATORS
Matthew Austin, MD: Submitted on: 12/15/2015; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Board or committee member; JayPee: Publishing royalties, financial or material support
Journal of Arthroplasty: Editorial or governing board; Link Orthopaedics: Paid consultant; Zimmer: IP royalties; Paid
consultant
David Christopher Ayers, MD: Submitted on: 10/01/2015; AAOS: Board or committee member; American Orthopaedic
Association: Board or committee member; Journal of Bone and Joint Surgery - American: Editorial or governing board
C Lowry Barnes, MD: Submitted on: 01/21/2016; American Association of Hip and Knee Surgeons: Board or
committee member; AR Orthopaedic Society: Board or committee member; Clinical Orthopaedics and Related
Research: Editorial or governing board; ConforMIS: Research support; Corin U.S.A.: Other financial or material support;
DJO: IP royalties; Paid consultant; HipKnee Arkansas Foundation: Board or committee member; Journal of
Arthroplasty: Editorial or governing board; JSOA: Editorial or governing board; Liventa: Research support; Stock or
stock Options; Mid American Orthopaedic Association: Board or committee member; None: Unpaid consultant; Pacira:
Research support; Responsive Orthopaedics: Stock or stock Options; Southern Orthopaedic Association: Board or
committee member; Zimmer: IP royalties; Paid consultant
Robert L Barrack, MD: Submitted on: 10/26/2015; Biomet: Research support; Hip Society: Board or committee
member; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Bone and Joint Surgery
- British: Editorial or governing board; Knee Society: Board or committee member; Medical Compression Systems:
Research support; National Institutes of Health (NIAMS & NICHD): Research support; Smith & Nephew: Research
support; Stryker: IP royalties; Other financial or material support; Paid consultant; Research support; The McGraw-Hill
Companies Inc: Publishing royalties, financial or material support; Wolters Kluwer Health - Lippincott Williams &
Wilkins: Publishing royalties, financial or material support; Wright Medical Technology, Inc.: Research support
Wael K Barsoum, MD: Submitted on: 10/01/2015; Active Implants: Research support; Cool Systems: Research
support; Custom Orthopaedic Solutions: Stock or stock Options; DJO, Inc.: Research support; Exactech, Inc: IP
royalties; iVHR: Stock or stock Options; KEF Healthcare (Board Member): Other financial or material support
Orthosensor: Research support; Orthovita: Research support; Otismed: Stock or stock Options; Stryker: IP royalties;
Paid consultant; Paid presenter or speaker; Research support; Zimmer: IP royalties; Research support
Marcel A Bas, MD: (This individual reported nothing to disclose); Submitted on: 11/12/2015
Ali Bayan, FRACS: Submitted on: 01/27/2016; Lima: Paid consultant; Paid presenter or speaker
Nicholas Bedard, MD: (This individual reported nothing to disclose); Submitted on: 01/27/2016
Keith R Berend, MD: Submitted on: 10/12/2015; AAOS Board of Specialty Societies (Knee Education
Representative): Board or committee member; American Association of Hip and Knee Surgeons: Board or committee
member; Clinical Orthopaedics and Related Research: Editorial or governing board; Journal of Arthroplasty: Editorial or
governing board; Journal of Bone and Joint Surgery - American: Editorial or governing board; Kinamed: Research
support; Knee Society: Board or committee member; Orthopedics: Editorial or governing board; Orthosensor:
Research support; Pacira: Research support; Reconstructive Review: Editorial or governing board; Zimmer Biomet: IP
royalties; Paid consultant; Research support
Michael E Berend, MD: Submitted on: 02/02/2016; Biomet: IP royalties; Paid consultant; Paid presenter or speaker;
Research support; Johnson & Johnson. Into our 501c3 research foundation: Research support; Journal of
Arthroplasty: Editorial or governing board; Knee Society: Board or committee member; Stryker: Research support;
Zimmer: IP royalties; Paid consultant; Paid presenter or speaker; Research support
Daniel J Berry, MD: Submitted on: 10/12/2015; American Joint Replacement Registry: Board or committee member;
DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Elsevier: Publishing royalties,
81
financial or material support; Hip Society: Board or committee member; Journal of Bone and Joint Surgery - American:
Editorial or governing board; Mayo Clinic Board of Governors: Board or committee member; Wolters Kluwer Health Lippincott Williams & Wilkins: Publishing royalties, financial or material support
Michael Bolognesi, MD: Submitted on: 10/01/2015; Amedica: Stock or stock Options; Unpaid consultant;
American Association of Hip and Knee Surgeons: Board or committee member; AOA Omega: Other financial or
material support; Arthroplasty Today: Editorial or governing board; Biomet: IP royalties; Paid presenter or speaker;
Research support; DePuy, A Johnson & Johnson Company: Research support; Eastern Orthopaedic Association: Board
or committee member; Journal of Arthroplasty: Editorial or governing board; Journal of Surgical Orthopaedic Advances:
Editorial or governing board; Kinamed: Paid presenter or speaker; TJO: IP royalties; Paid consultant; Stock or stock
Options; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker; Research support
Robert E Booth, Jr MD: Submitted on: 01/28/2016; CD Diagnostics: Stock or stock Options; Journal of Bone and Joint
Surgery - American: Editorial or governing board; Journal of Bone and Joint Surgery - AmericanClinical Orthopaedics &
Related Research: Editorial or governing board; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker;
Stock or stock Options
Kevin John Bozic, MD, MBA: Submitted on: 11/09/2015; AAOS: Board or committee member; American Joint
Replacement Registry: Board or committee member; Harvard Business School: Paid consultant; Institute for
Healthcare Improvement: Paid consultant; Orthopaedic Research and Education Foundation: Board or committee
member; Yale-New Haven Center for Outcomes Research: Paid consultant
Toby Briant-Evans, FRCS: (This individual reported nothing to disclose); Submitted on: 01/27/2016
Asokumar Buvanendran, MD: Submitted on: 01/26/2016; American Society of Regional Anesthesia and Pain
Medicine: Board or committee member; Anesthesia & AnalgesiaRegional Anesthesia and Pain Medicine: Editorial or
governing board; consultant about multimodal analgesia: Paid consultant; Pfizer: Research support; vital 5: Stock or
stock Options
John J Callaghan, MD: Submitted on: 10/12/2015; DePuy, A Johnson & Johnson Company: IP royalties; Paid
consultant; International Hip Society: Board or committee member; Journal of Arthroplasty: Editorial or governing
board; Journal of Arthroplasty (Deputy Editor): Publishing royalties, financial or material support; Knee Society: Board
or committee member; Orthopaedic Research and Education Foundation: Board or committee member; Wolters
Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support
Herbert John Cooper, MD: Submitted on: 11/24/2015; AAOS: Board or committee member; Journal of Arthroplasty:
Editorial or governing board; KCI: Paid consultant; Paid presenter or speaker; Research support
Medacta USA: Paid consultant; Zimmer: Paid consultant
Craig J Della Valle, MD: Submitted on: 10/01/2015; American Association of Hip and Knee Surgeons: Board or
committee member; Arthritis Foundation: Board or committee member; Biomet: IP royalties; Paid consultant;
Research support; CD Diagnostics: Research support; Stock or stock Options; DePuy, A Johnson & Johnson Company:
Paid consultant; Hip Society: Board or committee member; Knee Society: Board or committee member; Mid America
Orthopaedic Association: Board or committee member; Orthopedics Today: Editorial or governing board; SLACK
Incorporated: Editorial or governing board; Publishing royalties, financial or material support; Smith & Nephew: Paid
consultant; Research support; Stryker: Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins:
Publishing royalties, financial or material support
Douglas A Dennis, MD: Submitted on: 10/31/2015; Clinical Orthopaedics and Related Research: Editorial or
governing board; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker;
DePuy, A Johnson & Johnson Company, Porter Adventist Hospital: Research support; Innomed: IP royalties; Joint Vue:
Stock or stock Options; Journal of Arthroplasty: Editorial or governing board; Journal of Bone and Joint Surgery American: Editorial or governing board; Orthopedics Today: Editorial or governing board; Wolters Kluwer Health Lippincott Williams & Wilkins: Publishing royalties, financial or material support
Lawrence Douglas Dorr, DMD: Submitted on: 01/31/2016; DJ Orthopaedics: IP royalties; Total Joint Orthopedics:
Stock or stock Options
Kyle Duchman, MD: (This individual reported nothing to disclose); Submitted on: 10/06/2015
Michael Dunbar, MD, PhD: Submitted on: 10/01/2015; Arthropaedia: Editorial or governing board; Canadian Joint
Replacement Registry - Co-chair: Board or committee member; Canadian Orthopaedic Research Society-Program
Chair: Board or committee member; Canadian RSA Network - Chair: Board or committee member; DePuy: Research
support; EMOVI: Research support; Journal of Bone and Joint Surgery - British: Editorial or governing board; Kinduct:
82
Research support; Knee: Editorial or governing board; Medical Advisory Board for the Arthritis Society of Canada:
Board or committee member; Stryker: IP royalties; Paid consultant; Research support
Zimmer: Research support
Jacob Elkins, MD, PhD: (This individual reported nothing to disclose); Submitted on: 01/27/2016
Bill Farrington, FRACS, FRCS, FRCS (Ortho), MBBS: Submitted on: 01/27/2016; LIMA: Other financial or material
support; Stryker: Paid presenter or speaker; Research support
Thomas K Fehring, MD: Submitted on: 11/04/2015; American Association of Hip and Knee Surgeons: Board or
committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker;
Research support; Knee Society: Board or committee member
Jonathan Mordechai Frank, MD: (This individual reported nothing to disclose); Submitted on: 01/26/2016
Mark I Froimson, MD: Submitted on: 01/29/2016; American Association of Hip and Knee Surgeons: Board or
committee member; American Journal of Orthopedics: Editorial or governing board; American Orthopaedic
Association: Board or committee member; Journal of Arthroplasty: Editorial or governing board; Journal of Bone and
Joint Surgery - American: Editorial or governing board; Medical Compression Systems: Paid consultant; Stock or stock
Options; Mid American Orthopaedic Association: Board or committee member
Yubo Gao, PhD: (This individual reported nothing to disclose); Submitted on: 01/31/2016
Kevin L Garvin, MD: Submitted on: 10/20/2015; AAOS: Board or committee member; American Orthopaedic
Association: Board or committee member; Hip Society: Board or committee member; Wolters Kluwer Health Lippincott Williams & Wilkins: Editorial or governing board
George Go: (This individual reported nothing to disclose); Submitted on: 01/26/2016
Fares Sami Haddad, FRCS: Submitted on: 10/02/2015; Annals of the Royal College of Surgeons England: Editorial or
governing board; Bone and Joint Journal: Editorial or governing board; corin: IP royalties;
Journal of Arthroplasty: Editorial or governing board; matortho: IP royalties; Orthopedics Today: Editorial or governing
board; Smith & Nephew: IP royalties; Paid consultant; Research support; Stryker: Paid consultant
Erik Nathan Hansen, MD: (This individual reported nothing to disclose); Submitted on: 02/02/2016
Curtis W Hartman, MD: Submitted on: 10/01/2015; Pfizer: Research support; Smith & Nephew: Paid consultant; Paid
presenter or speaker; Research support; Trak Surgical, Inc: Unpaid consultant
Stephen M Howell, MD: Submitted on: 10/01/2015; AAOS: Board or committee member; American Journal of Sports
Medicine: Editorial or governing board; Biomet Sports Medicine: Paid consultant; Paid presenter or speaker;
Saunders/Mosby-Elsevier: Publishing royalties, financial or material support; ThinkSurgical: Paid consultant; Zimmer:
IP royalties; Paid consultant; Paid presenter or speaker; Research support
Colin Howie, ChB, MB, FRCS, FRCS (Ortho): Submitted on: 11/16/2015; British Orthopaedic Association: Board or
committee member; Journal Trauma Orthopaedics and BJJ: Editorial or governing board
Richard Iorio, MD: Submitted on: 01/19/2016; American Association of Hip and Knee Surgeons: Board or committee
member; APOS Medical & Sports Technologies Ltd.: Research support; Bioventis: Research support; Clinical
Orthopaedics and Related Research: Editorial or governing board; DJ Orthopaedics: Paid consultant; Ferring
Pharmaceuticals: Research support; Hip Society: Board or committee member; JBJS Reviews: Editorial or governing
board; Journal of Arthroplasty: Editorial or governing board; Journal of Bone and Joint Surgery - American: Editorial or
governing board; Journal of the American Academy of Orthopaedic Surgeons: Editorial or governing board; Knee
Society: Board or committee member; MCS ActiveCare: Paid consultant; Orthofix, Inc.: Research support; Orthosensor:
Research support; Pacira: Paid consultant; Research support; Vericel: Research support; Wellbe: Stock or stock
Options
Erdan Kayupov, MS: (This individual reported nothing to disclose); Submitted on: 01/26/2016
Aakash Keswani, BA: (This individual reported nothing to disclose); Submitted on: 01/27/2016
Jay R Lieberman, MD: Submitted on: 10/09/2015; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Editorial or governing board; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant;
Hip Innovation Technology: Stock or stock Options; Journal of Arthroplasty: Editorial or governing board;
Saunders/Mosby-Elsevier: Publishing royalties, financial or material support; Western Orthopaedic Association: Board
or committee member
83
Steve S Liu, MD: (This individual reported nothing to disclose); Submitted on: 01/28/2016
Adolph V Lombardi Jr, MD: Submitted on: 10/12/2015; Clinical Orthopaedics and Related Research: Editorial or
governing board; Hip Society: Board or committee member; Innomed: IP royalties; Journal of Arthroplasty: Editorial or
governing board; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Orthopaedics
and Traumatology: Editorial or governing board; Journal of the American Academy of Orthopaedic Surgeons: Editorial
or governing board; Kinamed: Research support; Knee: Editorial or governing board; Knee Society: Board or
committee member; Mount Carmel Education Center at New Albany: Board or committee member; Operation Walk
USA: Board or committee member; Orthosensor: IP royalties; Paid consultant; Research support; Pacira
Pharmaceuticals, Inc.: Paid consultant; Research support; Surgical Technology International: Editorial or governing
board; Zimmer Biomet: IP royalties; Paid consultant; Research support
Jess H Lonner, MD: Submitted on: 10/31/2015; American Journal of Orthopedics: Editorial or governing board; Blue
Belt Technologies: IP royalties; Paid consultant; Paid presenter or speaker; Stock or stock Options; CD Diagnostics:
Paid consultant; Stock or stock Options; Healthpoint Capital: Stock or stock Options; Journal of Arthroplasty: Editorial
or governing board; Knee Society: Board or committee member; Saunders/Mosby-Elsevier: Editorial or governing
board; Publishing royalties, financial or material support; Wolters Kluwer Health - Lippincott Williams & Wilkins:
Editorial or governing board; Publishing royalties, financial or; material support; Zimmer: IP royalties; Paid consultant;
Paid presenter or speaker; Research support
Steven J MacDonald, MD: Submitted on: 10/29/2015; DePuy, A Johnson & Johnson Company: IP royalties; Paid
consultant; Research support; Hip Innovations Technology, JointVue: Stock or stock Options; Knee Society: Board or
committee member; Smith & Nephew: Research support; Stryker: Research support
Bassam A Masri, MD, FRCSC: Submitted on: 10/12/2015; Canadian Orthopaedic Association: Board or committee
member; DePuy, A Johnson & Johnson Company: Research support; Journal of Arthroplasty: Editorial or governing
board
R Michael Meneghini, MD: Submitted on: 09/29/2015; Journal of Arthroplasty: Editorial or governing board;
Knee Society: Board or committee member; Stryker: IP royalties; Paid consultant; Research support
Michael A Mont, MD: Submitted on: 10/22/2015; AAOS: Board or committee member; American Journal of
Orthopedics: Editorial or governing board; DJ Orthopaedics: Paid consultant; Research support; Johnson & Johnson:
Paid consultant; Research support; Journal of Arthroplasty: Editorial or governing board; Journal of Knee Surgery:
Editorial or governing board; Medical Compression Systems: Paid consultant; Merz: Paid consultant; Microport: IP
royalties; National Institutes of Health (NIAMS & NICHD): Research support; Ongoing Care Solutions: Research
support; Orthopedics: Editorial or governing board; Orthosensor: Paid consultant; Research support; Pacira: Paid
consultant; Sage Products, Inc.: Paid consultant; Stryker: IP royalties; Paid consultant; Research support; Surgical
Techniques International: Editorial or governing board; Tissue Gene: Research support; TissueGene: Paid consultant;
U S Medical Innovations: Paid consultant
Mario Moric, MS: Submitted on: 11/23/2015; Zimmer: Paid consultant
Calin Stefan Moucha, MD: Submitted on: 01/27/2016; 3M: Paid presenter or speaker; Saunders/Mosby-Elsevier:
Publishing royalties, financial or material support
Lauren Elizabeth Mount, MD: (This individual reported nothing to disclose); Submitted on: 11/25/2015
Daniel Beasley Murrey, MD: Submitted on: 01/26/2016; AAOS: Board or committee member; Amedica: Stock or
stock Options; BioMedFlex: Stock or stock Options; Unpaid consultant; OrthoMedFlex: Stock or stock Options; Unpaid
consultant; Stryker: IP royalties
Allina A Nocon, MPH: (This individual reported nothing to disclose); Submitted on: 01/26/2016
Ryan Nunley, MD: Submitted on: 05/27/2015; American Association of Hip and Knee Surgeons: Board or committee
member; Biocomposites: Paid consultant; Biomet: Research support; Blue Belt Technology: Paid consultant;
Cardinal Health: Paid consultant; DePuy, A Johnson & Johnson Company: Paid consultant; Research support; Integra
Sciences: Paid consultant; Medical Compression Systems, Inc.: Research support; Medtronic: Paid consultant;
Microport: IP royalties; Paid consultant; Missouri State Orthopaedic Association Board Member: Board or committee
member; Polaris: Paid consultant; Smith & Nephew: Paid consultant; Research support; Southern Orthopaedic
Association Board Member: Board or committee member; Stryker: Research support
Kamil Okroj, BA: (This individual reported nothing to disclose); Submitted on: 01/26/2016
84
Mary I O'Connor, MD: Submitted on: 10/03/2015; Accelalox, Inc.: Stock or stock Options;
Accelatox, Inc.: Unpaid consultant; Zimmer: Paid consultant
Mark W Pagnano, MD: Submitted on: 01/31/2016; DePuy, A Johnson & Johnson Company: IP royalties; Hip Society:
Board or committee member; Knee Society: Board or committee member; Pacira: Paid consultant;
Stryker: IP royalties
Javad Parvizi, MD, FRCS: Submitted on: 09/09/2015; 3M: Research support; CD Diagnostics: Stock or stock Options;
Cempra: Research support; CeramTec: Research support; Datatrace: Publishing royalties, financial or material
support; DePuy, A Johnson & Johnson Company: Research support; Eastern Orthopaedic Association: Board or
committee member; Elsevier: Publishing royalties, financial or material support; Hip Innovation Technology: Stock or
stock Options; Jaypee Publishing: Publishing royalties, financial or material support; Journal of Arthroplasty: Editorial
or governing board; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Bone and
Joint Surgery - British: Editorial or governing board; Muller Foundation: Board or committee member; National
Institutes of Health (NIAMS & NICHD): Research support; OREF: Research support; PRN: Stock or stock Options;
SLACK Incorporated: Publishing royalties, financial or material support; Smith & Nephew: Paid consultant; Research
support; StelKast: Research support; Stryker: Research support; Wolters Kluwer Health - Lippincott Williams &
Wilkins: Publishing royalties, financial or material support; Zimmer: Paid consultant; Research support
Paul Pavlou, FRCS (Ortho): (This individual reported nothing to disclose); Submitted on: 01/26/2016
Gregory G Polkowski, II MD: Submitted on: 06/11/2015; American Association of Hip and Knee Surgeons: Board or
committee member
Andrew James Pugely, MD: (This individual reported nothing to disclose); Submitted on: 10/17/2015
Michael D Ries, MD: Submitted on: 11/11/2015; Foundation for the Advancement of Research in Medicine: Board or
committee member; OrthAlign: Stock or stock Options; Smith & Nephew: IP royalties; Paid consultant; Stryker: Paid
consultant
Aaron Glen Rosenberg, MD, FACS: Submitted on: 10/05/2015; Wolters Kluwer Health - Lippincott: Publishing
royalties, financial or material support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Editorial or governing
board; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker; Stock or stock Options
W Norman Scott, MD: Submitted on: 01/08/2016; Author, Surgery of the Knee 5th Edition, Elsevier: Publishing
royalties, financial or material support; Author, Surgery of the Knee 6th Edition, Elsevier: Publishing royalties, financial
or material support; OrthoDevelopment Medical Advisor to Board of Directors: Paid consultant; President & CEO ICJR
(International Congress for Joint Reconstruction): Board or committee member; Zimmer Past Royalty Bearing
Designer: IP royalties
Thomas P Schmalzried, MD: Submitted on: 05/27/2015; DePuy, A Johnson & Johnson Company: IP royalties; Stock
or stock Options; None: Research support; Orthopaedic Research and Education Foundation: Board or committee
member; Orthopedics Today: Editorial or governing board; Stryker: IP royalties; Paid consultant; Paid presenter or
speaker; Stock or stock Options
Thomas P Sculco, MD: Submitted on: 10/08/2015; American Journal of Orthopedics: Editorial or governing board
Exactech, Inc: IP royalties; Knee Society: Board or committee member
John Segreti: Submitted on: 02/03/2016; Merck: Paid presenter or speaker; Pfizer: Stock or stock Options
Nigel E Sharrock, MD: Submitted on: 01/26/2016; OR Comfort: Stock or stock Options; USCom: Stock or stock
Options
Bryan Donald Springer, MD: Submitted on: 10/01/2015; AJRR: Board or committee member; Arthroplasty Today:
Editorial or governing board; Convatec, Polaris: Paid consultant; DePuy, A Johnson & Johnson Company, Ceramtec:
Paid presenter or speaker; Joint purifications systems.: Other financial or material support; Journal of Arthroplasty:
Editorial or governing board; Knee Society: Board or committee member; Stryker: Paid consultant
S David Stulberg, MD: Submitted on: 10/31/2015; Aesculap/B.Braun: IP royalties; Paid consultant; Paid presenter or
speaker; Biomet: IP royalties; blue belt technologies: Stock or stock Options; Innomed: IP royalties; Johnson &
Johnson: Stock or stock Options; Peachtree Publishers: Publishing royalties, financial or material support; Stryker: IP
royalties; Paid consultant; Paid presenter or speaker; Stock or stock Options; Zimmer: Paid consultant; Paid presenter
or speaker; Stock or stock Options
Edwin P Su, MD: Submitted on: 01/27/2016; American Journal of Orthopedics: Editorial or governing board;
Orthoalign, Inc: Stock or stock Options; Smith & Nephew: Paid consultant; Research support
85
Robert T Trousdale, MD: Submitted on: 01/26/2016; American Association of Hip and Knee Surgeons: Board or
committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Hip Society: Board or
committee member; Journal of Arthroplasty: Editorial or governing board; Knee Society: Board or committee member
Thomas Parker Vail, MD: Submitted on: 10/04/2015; American Board of Orthopaedic Surgery, Inc.: Board or
committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Knee Society: Board or
committee member
Matthew L Walker, MD: Submitted on: 01/26/2016; Stryker: Research support
Robert W Westermann, MD: (This individual reported nothing to disclose); Submitted on: 01/27/2016; Report:
Adam Young, MD: (This individual reported nothing to disclose); Submitted on: 01/26/2016
Simon Young, MD, FRACS: Submitted on: 01/26/2016; Stryker: Research support; Vidacare: Research support
STAFF
Olga Foley: (This individual reported nothing to disclose); Submitted on: 10/05/2015
Lisa DuShane: (This individual reported nothing to disclose); Submitted on: 11/05/2015
The Knee Society
9400 W. Higgins Road, Suite 500
Rosemont, IL 60018-4976
Phone: (847)698-1632
Fax: (847)823-0536
Email: [email protected]
Website: www.kneesociety.org
American Association of Hip and Knee Surgeons
9400 W. Higgins Rd., Suite 230
Rosemont, IL 60018-4976
Phone: (847)698-1200
Fax: (847)698-0704
Email: [email protected]
Website: www.aahks.org
Please complete the evaluation online at: https://www.surveymonkey.com/r/KSSD16
or use the QR Code to access.
86

2016 Final Program

Transcription

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