Arthroscopy Association of North America: Past, Present, and Future—2016 Presidential Address

  • Jeffrey S. Abrams
    Address correspondence to Jeffrey S. Abrams, M.D., Princeton Orthopaedic Associates, 325 Princeton Avenue, Princeton, NJ 08540-1617, U.S.A.
    University Medical Center of Princeton, Princeton, NJ, Clinical Professor, Seton Hall University, Orange, NJ
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      I am honored to have served in 2016 as President of the Arthroscopy Association of North America (AANA) and to present to you my Presidential Address. I would like to welcome the audience—the membership and those who are not members but considering joining us. I would also like to welcome our friends to the north, our Canadians, to whom I owe so much in terms of education, background, culture, and of course, friendship. There are many international people in the audience. Over the years, I have been blessed with the opportunity to be able to visit your countries, spend time with you, and gain so much through education, your company, and your friendship. And of course, I would like to welcome the organizational Presidents who have come to the AANA meeting this year.

      Past, Present, and Future…

      There is a great tradition of Presidents of AANA, and these individuals have really structured the organization as you see it today. Many times, there are events, challenges, and difficulties—“speed bumps,” if you will—that require certain decisions; the past Presidents clearly have created a wonderful organization and made difficult decisions with a tradition of honor, respect, and education (Fig 1). I feel that we are all indebted to these individuals for their contributions.
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      Fig 1AANA past presidents, April 23, 2015, Los Angeles, CA.
      Where is AANA today? We are larger and reach an audience without boundaries, but there are challenges ahead, and I would like to share with you those challenges. Membership now exceeds 4,100, as presented in the membership report. As logic and history defines, if you just continue to do what you have done in the past, it becomes stale and repetitive. The design and the paradigm for learning for students, residents, and fellows need to be recognized and addressed through strategic planning for education in the future. Our mission statement, of course, is to continue medical education and develop surgical skills. We want to strive for competence, performance, and of course, improve our patient outcomes. So if I may, I would like to go over some of the critical issues we have had over the year and talk to you a bit about innovation, similar to that which individuals like Steve Snyder and Marlowe Goble experienced in shaping the design of our specialty and our future.
      Most realize that “meeting congestion” is an issue, including meetings you attend and possibly many meetings at which you teach. This is a common concern that many of you in the audience have experienced. It used to be that you could go to a meeting here and there, but the problem right now has become the number of meetings that you need to attend and how you can functionally be at home, at your office, and in the audience at a meeting. Consequently, we have competition of dates, competition of venues, and I would like to say that one of the strategic goals of my Presidency was to see whether we could combine society-sponsored meetings to reduce this congestion. Along that path, we have a meeting that is scheduled for September 2016 with the American Shoulder and Elbow Surgeons; they have offered this meeting in the past with the Academy, but instead, we are partnering with them this year in Chicago, combining basically 3 to 4 meetings into one venue, which will include the Orthopaedic Learning Center (OLC) for surgical demonstrations. The Biennial Shoulder and Elbow Meeting will include didactic and a Spanish-speaking OLC experience over the weekend. In addition, we will invite physical therapists and allied health professionals to the meeting and will hopefully set a pattern to see whether these combined meetings can be successful. This is an ambitious endeavor, but it looks very good at this time.
      Right now, we are an older generation that enjoys attending meetings, meeting with friends, going out to dinner, and learning in this environment. But there is a group of younger surgeons who are graduating from residency and fellowships who clearly have a completely different design on how they learn and get information, called the Internet. The percentage of individuals who actually read a newspaper is in single digits now. The majority go to the Internet, visit their favorite sites, and become educated on the day-to-day events. Like it or not, that is probably the direction that this type of meeting will go. That is not to be in competition with what we do here—because I still love this environment and love to have time to spend with all of you. The truth is that we will need another design for educating our membership, and that will include Internet-based education. We will have webinars, meetings, the case panels enjoyed by many. We can even have interviews. For that matter, we are looking at several different vendors—the G9 is one of the vendors that we have met with during our Board meeting—and it looks promising. I think moving toward that design is inevitable. Members will be able to stay at home to attend and try to be educated in the same way, rather than traveling away from home. Again, that is not to say that this meeting format will go away, but it may change in size, and we should be prepared for this.
      Surgical Skills work is certainly a big part of our mission. We moved into this large new building in Rosemont a couple of years ago; the new building includes the OLC. New expenses, new people, new equipment, and new partnerships came along with this change. However, thanks to key individuals, including Lise Puckorius, Kevin Plancher, and the committee, we have a design where the surgeons can come one-on-one and they can bring their assistants; this offers a personalized, individual mentorship similar to what Rick Ryu designed probably 3 to 4 years ago, with one-on-one tutorials. This new setting will include surgical demos offered a faculty that has been vetted and rated by the attendees and other faculty. You are constantly being scored both as an educator and to a certain extent as a student, because somewhere along the line—with your Board recertification and as outcomes—your surgical skills will be reviewed as well. It would be wonderful to be able to credential, be tested, and let individuals know where they stand in terms of surgical skills, certainly with the opportunity of designing and demonstrating improvement before and after a laboratory experience.
      The new AANA textbook series has arrived and is available for purchase. There was an initial series several years ago; this series is the update, with new, additional chapters supported by videos. I would like to thank Rick Ryu for his leadership and serving as a series co-editor, and I would also like to thank the individual textbook editors. When we asked the publisher what our pricing should be on this, it was nearly double. AANA decided on a break-even philosophy—to accommodate both our membership and industry—and so we chose not to go over $99.00 and limit additional documentation to the government. Because of Advamed rules, there is a requirement for industry to report when providing educational materials to physicians, including textbooks. This additional burden could jeopardize the generosity of some industry partners, and by reducing the price, this would put this textbook—or textbooks—in everyone's hands and enrich our learning experience.
      Arthroscopy has also moved in many directions under the leadership of Jim Lubowtiz. The services and expertise of Matt Provencher and Michael Rossi as the Assistant Editors-in-Chief—collectively with other assisting editors and the reviewers—have made this a world-class journal that is something to be very proud of. Some have termed it “the crown jewel.” Melissa Schmidt is the Managing Editor, and together with the AANA team, this has been a great collaboration. This relationship, defined by congeniality and education, should be rewarding.
      People question why AANA is in other parts of the world. Part of the answer is for us to share education, because I do not believe that we have all the answers. As Rich Hawkins has quoted, “I'm not even sure we have all the questions, never mind the answers.” That being said, I think that the Journal would be one way to monetize the aspect of our travel and our outreach. When we go to different countries, our international friends can purchase subscription series to our often-quoted “green journal.”
      There is significant competition with other forms of self-education. We are trying to look at other aspects of teaching, and Arthroscopy Techniques is really the next venue for this organization. In addition to having the written journal, we now have articles and videos submitted to a technique journal, which is an Internet-driven educational medium. The benefits to the authors are as they are with the written journal; they have PubMed Central credit—meaning they are cited—and this will not only be read by orthopaedic surgeons with passwords, but also by other individuals, because the content will be open access, with YouTube being part of the carrier in this endeavor. There are aspects that make certain types of articles difficult to put into print, particularly case reviews and certain techniques, and this offers opportunity to place these types of articles in a well-respected, well-visualized medium, which I believe will be helpful to those residents and fellows in the room. I would envision that surgeons preparing for a case would review and communicate at the scrub sink before they go into the room to take on the next difficult surgical challenge. In addition to the scientific channels, we are embracing industry, and Arthrex would be the first to take on the contract with submitting a certain number of articles and having several of their champions place articles on the ATech channels. The videos and articles are available not only by computer, but also by some of the mobile units, that is, your cell phone and tablets.
      This organization has always had a great respect for the military. Featured on your podium are active and retired military, so it is no surprise that orthopaedics and the military orthopaedic organizations are one, and both should partner in education. The education of the military surgeons can be somewhat abrupt. They go through their residency, followed by fellowship, and then they are asked to serve. Some of them may be deployed to Afghanistan within months of finishing their training. All of us understand how much value there was in being in practice for a certain amount of time before handling some of the more difficult and serious surgically treated injuries. Military surgeons find themselves in frontline positions with tremendous responsibilities, so AANA has assisted and exchanged experiences to provide additional education to our orthopaedic brotherhood. We have a SOMOS (Society of Military Orthopedic Surgeons) program at OLC, which includes mini-fellowships. The expanding relationship would include military traveling fellows, visiting certain institutions and practices around the country, and spending time with surgeons—whether it is a short period of time, or whatever the program will allow. We also know that the VA (Veterans' Administration) hospitals have been under great scrutiny in terms of the level of care given to the soldiers who have returned. We need to expand these educational opportunities to our military physicians. The number of orthopaedic and sports-related injuries that prevent an individual from going back into active military service is alarming. As dramatic as it is to see some of the most horrific pictures from people coming home, the truth of the matter is that a large percentage of people have become disabled in the military because of injuries that many of you have seen in this conference, including knee and shoulder injuries. Rob Hunter has gone to lobbyists and gained their attention, enlisting their help in trying to gain some financial assistance from the government in this military education. Up until now—and this will likely continue—the majority of this educational benefit is based on volunteer service. Currently, we have asked industry, physicians, and organizations to help fund those meetings. There are many entities involved in this partnership, and with anticipated success, we will have the government help underwrite some of the expenses of getting soldiers and physicians to orthopaedic educational events in the United States; I applaud this effort.
      Many people in the audience are involved in the recertification process for Board of Orthopaedic Surgeons. There has always been a relationship with the Academy, which has embraced additional assistance in preparation for the Board and has encouraged continued education and competence. That being said, I think it is very important that our organization, as educators, help prepare our surgeons for the recertification examinations. We have created 3 written examinations that help us with this self-assessment; it is a requirement to have at least 20 credits from self-assessment sources of CME, in addition to the ones that you get for attending meetings. Mark Getelman and his committee have created a new examination to help comply with recertification requirements.
      I would like to applaud Rick Angelo, as he has put together a project that I think is unique and innovative, along with many volunteers: the Copernicus project. This project was designed to create a measurement instrument for surgical skill that is more appropriate than measuring with a multiple-choice examination. This is an educational instrument, as well. You take the examination; you learn; you become a better surgeon. With Rick's direction and assistance from everybody in the audience, you would see how this may impact the credentialing process in the future and be of interest to an organization like ABOS (the American Board of Orthopedic Surgery), as well as perhaps even insurance carriers and hospitals.
      Our international collaboration cannot be understated. As I said earlier, the opportunity of visiting other countries to lecture and listen is the way we get better. We talked about several orthopaedic procedures in this meeting, and clearly there are some different opinions. I am not sure, as one would say, that either team has gotten it completely right. I think it is the open exchange of information that makes us have our eyes open, our ears listening, and our curiosity piqued to see what is available. ISAKOS (the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine) shares our dream of international collaboration, which is why we have visiting nations for our meetings–in this case, Canada is our featured nation. Famous shoulder surgeon Dr. Uhtoff is from Canada; many of us quote him in our papers as an individual who has taught us an awful lot about what can make a rotator cuff heal.
      The Foundation is very important and vital to our organization. AANA contributors to the Education Foundation are featured on the wall, just as a small demonstration of thanks. Ed Goss played a role with AANA as Executive Director, and now plays a significant role with our Education Foundation. I would suggest that our membership should consider joining the existing contributors to keep our mission healthy and productive. We are doing our best, and I think our Education Foundation certainly deserves to be applauded for its ability to put on meetings and continue to look at what this membership needs to get further and better at what we are supposed to do.
      Industry is a great partner in all this. I have always enjoyed the industry part of our relationships, not only for what you heard earlier this morning about innovation, but also for the ability to put on meetings and the ability to walk up and to interact with individuals who can help us with new techniques, new equipment, and perhaps familiarize us sometimes with opportunities that would not be so easy to obtain when we go back home and become quite busy. We have traveling fellowships. You might have met some of our traveling fellows who went through the East Coast of the United States; their final stop was this meeting in Boston. The traveling fellows were funded by industry and outside resources, to help defray some of the costs of this important educational project.
      Through AANA advocacy expertise, you heard critical and instructive comments about trying to protect your income. Our active committee has enlisted and informed many surrounding organizations. In fact, when it comes down to the American Academy of Orthopaedic Surgeons (AAOS), I think they look to the AANA leadership to lead the charge, because AAOS has, at times, been compared with a large battleship trying to turn around, whereas the agility and quickness of AANA can take on certain challenges—for instance, denials of payment and certain things that can affect our ability to treat our patients. The most recent one was the fact that the shoulder was grouped as a single environment and the coding systems were being dismissed and denied, which did not get much attention from CMS (the Centers for Medicare and Medicaid), the major organization that oversees the NCCI (National Correct Coding Initiative). Whether this comes from the White House is not clear, but the efforts of AANA's Louis McIntyre, combined with AAOS leadership, were able to change that decision, which benefits many shoulder surgeons.
      From a strategic position, our organization helps with reimbursement, not only to challenge denials, but also to “play offense”—to prepare our audience to anticipate changes in our collective future. I do not know how many of you have prepared yourself to take on surgical outcomes in the surgical outcome system. I will warn you that this is 2016. The payment that you were paid before was through an SGR (Sustainable Growth Rate) formula system, and all of these initials can become very confusing to me and maybe to some of you. The SGR formula was the way Medicare and the government reimbursed you. That has gone. In its place is MACRA (Medicare Access and CHIP Reauthorization Act), which includes surgical outcome measurements, unless you deal with bundle payments. So your practice and billing will change in the next 18 months, and if you do not do it differently, you will see substantial changes in your reimbursement. These could exceed a 20% difference, which is not a small change. I would pay attention to these lectures, as they may seem like they are distant, but this is all around the corner. In the next 18 months, start thinking about additional employees in your office and how you are dealing with data collection; if you do not start doing it in the very near future, you are going to find yourself being one of “the stories.” This is why you might look at a surgical outcome system where you can organize results and plot them out for a procedure. This can be compared with other individuals who are submitting data-creating graphics. This is not only an instrument for patients who would like to see how do you do with this procedure or how they will potentially do, but it also applies on a much larger scale. If we combine the surgical outcome system, potentially, with the work of JT Tokish and Richard Hawkins in South Carolina, we may find that we have successfully served the MIPS (Merit-Based Incentive Payment System) requirement in terms of getting it as a national quality review and we may have the opportunity to achieve the Board and the national CMS requirements, not only not being penalized, but being rewarded for our data collection.
      Let us switch gears a little bit. I would like to talk to you about innovation.
      You have had an opportunity to be enriched by several individuals at the podium during this meeting: Marlowe Goble, in his talk about the first suture anchor; Dave McGuire, who we sorely miss, who was a Past President and, in addition to his professionalism, was a tremendous innovator, particularly if you start talking about Kurowsaka interference screw fixation; and Dr. James Andrews, who—perhaps more on the technique than development of equipment and implants—clearly has changed the way we perform reparative, minimally invasive procedures on athletes. Ray Thal, for those of you who do not know, has helped AANA design an innovation center. That is a way for individuals in the audience who come up with ideas. If you listened to Steve Snyder's talk a little bit earlier today about having things patented, he provided a mechanism for individuals in the audience to deal with this in an inexpensive way where you can actually, through AANA, be attached to someone who could help you with that patent. Good ideas do not have to be aborted because of time and expense, because of the work of these individuals.
      I have had an opportunity to be part of innovation. I was a Fellow in London, Ontario, and here, and I was being taught by Rich Hawkins as we were trying to demonstrate quantifying humeral translation. We were just doing translation studies on lax and unstable shoulders, and were able to try to put a name that combined with the previous notoriety of “pivot shift” coming from Canada; we decided that “load-and-shift” would be a good title for this examination that started back during my fellowship year.
      A bidirectional repair would seem like a new concept. Actually, I reported and wrote on this technique in 1996 while traveling through France, presenting it to improve footprint coverage. At the same time, there were 2 other authors with similar techniques with medial and lateral row fixation, one of whom presented at the same meeting. So this seems to be new, but it maybe 20 years old. There may be good news and bad news about this, but there is no question it certainly has been embraced by surgeons trying to create coverage of a footprint and improving the healing process in an otherwise compromised area.
      Knotless anchors were not very popular for a bit. It took a while. I received a patent on an early design that is commonly used to capture the suture. I am not sure how this all happened, but recently, I was recognized for this patent with a very close friend of mine from home. Although this recognition was not monetary, I received an award for the knotless anchor and the design and was inducted into the New Jersey Hall of Fame. I shared the podium with some people who created things on the space shuttle, mass communications, fuel, and electronic cars. Tesla was posthumously inducted at the same meeting, and two Nobel laureates were at this meeting at the time.
      If I can, I will share with you a couple of thoughts and some concerns about new innovations. Resorption of bone graft and exposed hardware from a Latarjet is a concern and a complex surgical dilemma. I think we have to appreciate the significance of complications. Internationally, these things get mentioned, but surgical experience is considered the best way to reduce failure and complications. Some believe that Latarjet is a better way to go because of the likelihood of stabilization, but I do not think that we can underscore enough the fact that these complications can be devastating to a very young population. Hardware can become exposed in certain individuals, and these are difficult operations. I think we need to instruct caution; the pendulum may have pulled back from the arthroscopic techniques a little bit, but I would be cautious in trying to tell you whether we should be embracing some alternative techniques. When considering new technology, we should attend the OLC to perfect our technique and minimize the chances of a poor outcome. As an example, we have the patient with the reverse inverted pair. We are looking from an anterior-superior view at a shoulder with glenoid rim deficiency. We can take a piece of bone from the patient's clavicle and insert it through an anterior portal. With suture anchor fixation, we can use arthroscopic techniques to re-establish the anterior-inferior quadrant. We have radiographic confirmation of the intact glenoid rim. I believe that this will play a role in the recurrent dislocated shoulder.
      Rotator cuff repairs: you have heard some ideas this morning about novel ways of doing these. I think we are ignoring the fact that we are taking a compromised structure—in most cases, elderly patients' tissue loss—and trying to re-establish a tensionless construct. This is impossible. Your shoulders are under tension with your rotator cuff intact, and we need to recreate the proper degree of tension, so we need to take a longer and harder look at potentially grafting tissue. The patient's long head of the biceps can be used as the tendon extension of the supraspinatus, as it is sewn anteriorly into an anchor, posteriorly into the infraspinatus, and medially into the supraspinatus stump. Additional, exciting types of grafts are also available. We are looking at them closely, and I think by bringing in additional tissue, these can be done in a way that is not so time consuming and expensive. I believe that tissue loss has to be treated differently than just trying to revise or repeat the repair, and I think this may become more routine in our future. Do not let age scare you. I have a patient from Hopewell, NJ, a neighboring town to Princeton. He is 102 years old. I would like to say that follow-up even in community medicine can be pretty good, because at 84 years of age he tore his rotator cuff chopping a tree down in his backyard. We fixed his rotator cuff, and he came in to ask me about his other shoulder. When asked to lift his arms up, he still has pretty good function. I would not be afraid of dealing with older patients, trying to help them with their pathology, and improving their life.
      Strategic planning is important. This is an aspect of our organization that makes us unique. We need to actually have a structured approach and a structured schedule for developing the educational patterns and ways we deal with our membership to make this an enriching experience. This schedule is put together at our strategic planning meeting, and I applaud John Richmond and others following him in that endeavor, as we try to continue to evolve—just as this program, I think you would admit, is different and unique from other programs before it.
      This is my opportunity to express appreciation to a special friend and well-respected educator. I am honored to acknowledge my program chairman, Dr. J.T. Tokish. He has done a wonderful job throughout his term as Education Chair. He demonstrates character, which is hard to define, but certainly enviable in a leader. He is to be trusted, he leads in a humble way, and his goal is to make you more successful. He is a friend and respected educator, and you will be seeing a lot of Dr. Tokish in the future.
      Personally, I was asked about best decisions. I guess the first best decision has already been taken. That happened 31 years ago: marrying my wife, Kathleen. My second best decision involves the Board of Directors, a group of individuals who participated all the time. Their impact on what is going on in your organization is always being demonstrated, well stated, and well heard; they are always interested and always available. It is because of these individuals that you have an organization running as well as it is running. I, at times, deflected many problems to them, and they made the job here at the top quite adaptable.
      Your AANA office in Rosemont is exceptional. These are a group of dedicated people who have put together and have carried out the Board's wishes (Fig 2). The day-to-day operations need immediate attention and can be difficult for the physician at home. We pass on to them Board decisions; they give us suggestions, and through that, we exchange ideas and formulate a plan. It is these people's efforts that activate the Board decisions. I would like to introduce Laura Downes, who is your new Executive Director this year. Ed Goss, former Executive Director, will continue with the Education Foundation. Through her leadership and bringing to our organization new skills based on her prior experiences, such as introducing strategic planning, Laura will be a great asset to our Arthroscopy Association.
      Your fellowship never ends. There is no shortage of advice, but I will tell you, there is no shortage of well-meaning individuals who want nothing more than the success of their offspring. I would suggest that you continue to share that type of experience with your instructors. The truth of the matter is that your professional future does not happen without them. Being a mentor plays a special role in the recipient's life. Embrace this role.
      A lot of things come along as benefits of being in this organization, including forming relationships. I have many, many, many friends in the audience now. One group of individuals formed together somewhere back in…actually, during Dave McGuire's presidency. This friendship, referred to in 2008 as the “Rat Pack” of the AANA organization, has been well centered in the culture of AANA over the past decade (Fig 3). You need to continue to develop relationships. You need to continue to watch after them and do not assume that even if you have not been in communication with people for years, things just pick up when you can. Keep working on relationships. This is one of the major motivations for me in terms of coming to meetings; I owe a great deal to my friends.
      You cannot lecture and travel around the country unless certain things are looked after at home. In this particular case, I work in a small college town. Princeton Orthopaedic Associates, as was stated earlier, has grown in size, number, and reach. If your practice at home is doing well, then you have more opportunity to travel and offer education outside of your home city. If things are difficult there, you do not have this opportunity. So make sure you become famous at home before you try to do something on the road!
      Our brand new hospital is about 2 years old. I get a lot of walking because there is a single row of rooms from one end to the other, but exercise is good for most of us, and again, having hospitals in your partnership scheme is extremely important. I actually have partnerships with surgery centers, with the hospital being my other partner. Keep an eye on things, but the truth of the matter is that these types of relationships should not be alien to you. I think your future is that you need to increase your reach and increase your contact with these types of relationships.
      Kids are great. They bring you back, and they make it all real and important. I know I should have been at a few more events, but I have seen my children become palm trees in plays during elementary school. It is not uncommon for me to tell the operating room, “I'm buying pizza, I'll back in 40 minutes.” You try to do what you can to keep your family engaged in what you do, and you engaged in what they do.
      Richard Hawkins started off this meeting by talking about family and the journey. David Epstein talks about your DNA versus your environment. Clearly, my DNA perhaps should have pushed me further and higher, because the individuals in my family other than myself are quite accomplished in many ways. The honesty, the relationships, and the encouragement along the way have made a major impact and clearly define why I am who I am.
      I get to travel with Kathleen; in addition to accomplishing a “selfie” yearbook that you would not be able to lift and carry, she is a great partner in life. She has unselfishly been not only interested, but also a part of the journey with me, and I could not ask for a better partner. The journey takes many changes and alternate paths, some of them good and some of them bad. Some of them could not be here today, but are here in spirit. We love our friends and family and are there for them, in good times and sad times.
      Gaining a patient's trust is an important feature that surgeons develop. For example, an individual from Princeton comes in, and you try to say what can we do. Life can be tough at times and we need to be able to do the best we can. As surgeons, we can offer treatment combining preparation and opportunity. This individual basically has one limb; his other limb is paralyzed from childhood neurologic disorder. And you have that opportunity to change his life, as he has an injury to his healthy side. And in this case, do not ever underestimate a patient who trusts you. Do not take that trust for granted.
      I leave you in good hands. John Richmond, your next President, is an exceptional individual—talented and organized, with great communication skills—and he will serve you well. I am hoping that we did not leave him with any major burden, but we will be by his side, or just behind him, should he need any assistance with some of the projects that are ongoing, which is often the story in this position.
      So from my bride Kathleen and I: ciao, thank you, and enjoy the rest of your meeting. I appreciate the opportunity of serving as your President. Thank you.

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