VOLUME 8, ISSUE 17 | MAY 22, 2012

week in review

The 23 Top Foot & Ankle Surgeons in the U.S. ♦ 4Who better to pick the top foot and ankle surgeons than their own col- leagues? OTW has asked leading foot and ankle specialists to select the best of their peers. Here is what we heard.

New Policy Would Cut Some Spine Surgery 8Funding ♦ The Blues of Illinois say there is a lack of evidence to justify spinal fusion for DDD and other indi- cations. Spine’s best minds fire back in this OTW exclusive story by accusing the insurer of shoddy literature work and using unscientific guidelines. Read it here.

Orthopedics in the breaking news Amazon Basin ♦ Or- 13thopedists just want to fix “Fear and Medical Tour- things. Dr. Peter Cole decided to make ism” in Vegas a semi-annual trip to the jungle to fix 21...... some especially needy patients. He and OrthoSensor Builds Cash Stash his team could write a text book in pa- ...... thology with what they see in a week. Feds Give “All Clear Signal” on Infuse Dr. Cole’s labor of love and faith is sim- Investigation ply wonderful and uplifting. We hope ...... it inspires you too. Nevada Doc Builds Own Hospital, Rehab Unit Vince v. Hungerford ...... on Correcting Extra- Predict Arthritis Before Symptoms 17Articular Deformity ♦ Arrive! Extra-articular deformity? Go intra- ...... articular for the correction, says Kelly Arthritis: Manipulate Cilia, Reduce Vince. David Hungerford: There are Inflammation? many kinds and sources of deformity: ...... congenital, metabolic, etc. And what is CBS Featured Sealant for Low Back Pain the magnitude of the deformity, and the ...... location from the knee, etc.? For all news that is ortho, read on.

1-888-749-2153 | www.ryortho.com 2 VOLUME 8, ISSUE 17 | MAY 22, 2012

Orthopedic Power Rankings Robin Young’s Entirely Subjective Ordering of Public Orthopedic Companies

THIS WEEK: How fast the wind turns. Last week it was at our back as several companies pleasantly surprised with sales (NuVasive beats estimates, Biomet and SNN stand out) or earnings (Globus had huge earnings numbers). This week the wind is blowing hard from across the Atlantic. Bank runs in Greece. Spain and Italy teetering. And the threat of new global credit contraction.

LAST TTM OP 30-DAY RANK COMPANY COMMENT WEEK MARGIN PRICE CHANGE

If ever there was a time to appreciate headquarters in 1 1 Orthofix 16.23% 4.89% the Netherlands Antilles, this may be it.

NUVA so completely beat expectations that the glow 2 3 NuVasive 6.63 15.98 has yet to wear off. Time for another look at spine!

Symmetry Up 20% in the last month. SMA is being run by a 3 6 5.29 20.41 Medical comparatively young, strategic management team.

It had to happen eventually—ARTC is finally bottoming 4 NR ArthroCare (0.67) (1.04) out. Also is the 2nd lowest PE to Growth in Ortho.

Can’t fight the tape. CNMD deserves better valuation 5 2 Conmed 10.09 (7.99) than this but will require more strong quarters.

Integra Recent run up in IART’s price just triggered a profit 6 4 13.34 2.30 LifeSciences taking sell-off. 2nd lowest overall valuation in ortho.

In a stormy world, JNJ looks like an investor’s version Johnson & 7 5 24.93 0.14 of the London Fog Trench coat. Time-tested wind and Johnson rain protection.

Nearly un-noticed is the fact that 4 analysts have 8 7 Zimmer 24.95 (8.45) raised their estimates in the past 30 days.

As we see in ZMH, the market is just not enamored 9 8 Stryker 23.68 (9.38) right now with big ortho—regardless of demographic argument. In advance of this week’s release, most analysts are 10 9 Medtronic 28.24 (2.79) forecasting declining sales but higher margins for the quarter.

1-888-749-2153 | www.ryortho.com 3 VOLUME 8, ISSUE 17 | MAY 22, 2012 Robin Young’s Orthopedic Universe

TOP PERFORMERS LAST 30 DAYS WORST PERFORMERS LAST 30 DAYS COMPANY SYMBOL PRICE MKT CAP 30-DAY CHG COMPANY SYMBOL PRICE MKT CAP 30-DAY CHG

1 Kensey Nash KNSY $38.39 $334 34.80% 1 MAKO Surgical MAKO $22.17 $944 -46.31% 2 Symmetry Medical SMA $8.32 $305 20.41% 2 Bacterin Intl Holdings BONE $1.59 $67 -28.70% 3 NuVasive NUVA $18.73 $809 15.98% 3 TiGenix TIG.BR $0.60 $55 -23.97% 4 Wright Medical WMGI $19.71 $775 6.08% 4 Alphatec Holdings ATEC $1.65 $148 -23.61% 5 Orthofix OFIX $39.03 $731 4.89% 5 Tornier N.V. TRNX $20.68 $818 -12.93% 6 Exactech EXAC $16.52 $218 3.96% 6 TranS1 TSON $2.94 $80 -12.82% 7 Integra LifeSciences IART $32.96 $890 2.30% 7 CryoLife CRY $4.69 $129 -9.98% 8 RTI Biologics Inc RTIX $3.56 $199 0.56% 8 Stryker SYK $50.26 $19,146 -9.38% 9 Johnson & Johnson JNJ $63.35 $173,983 0.14% 9 Zimmer Holdings ZMH $58.86 $10,367 -8.45% 10 ArthroCare ARTC $24.80 $686 -1.04% 10 Conmed CNMD $26.96 $763 -7.99%

LOWEST PRICE / EARNINGS RATIO (TTM) HIGHEST PRICE / EARNINGS RATIO (TTM) COMPANY SYMBOL PRICE MKT CAP P/E COMPANY SYMBOL PRICE MKT CAP P/E

1 Medtronic MDT $36.96 $38,460 11.51 1 Wright Medical WMGI $19.71 $775 50.54 2 Zimmer Holdings ZMH $58.86 $10,367 11.94 2 NuVasive NUVA $18.73 $809 43.56 3 Johnson & Johnson JNJ $63.35 $173,983 12.62 3 Symmetry Medical SMA $8.32 $305 33.28 4 Stryker SYK $50.26 $19,146 13.19 4 Kensey Nash KNSY $38.39 $334 26.85 5 Orthofix OFIX $39.03 $731 13.99 5 Exactech EXAC $16.52 $218 23.27

LOWEST P/E TO GROWTH RATIO (EARNINGS ESTIMATES) HIGHEST P/E TO GROWTH RATIO (EARNINGS ESTIMATES) COMPANY SYMBOL PRICE MKT CAP PEG COMPANY SYMBOL PRICE MKT CAP PEG

1 Orthofix OFIX $39.03 $731 0.81 1 Wright Medical WMGI $19.71 $775 6.00 2 ArthroCare ARTC $24.80 $686 0.98 2 NuVasive NUVA $18.73 $809 4.50 3 Stryker SYK $50.26 $19,146 1.22 3 CryoLife CRY $4.69 $129 4.19 4 Zimmer Holdings ZMH $58.86 $10,367 1.28 4 Symmetry Medical SMA $8.32 $305 2.77 5 Integra LifeSciences IART $32.96 $890 1.34 5 Johnson & Johnson JNJ $63.35 $173,983 2.15

LOWEST PRICE TO SALES RATIO (TTM) HIGHEST PRICE TO SALES RATIO (TTM) COMPANY SYMBOL PRICE MKT CAP PSR COMPANY SYMBOL PRICE MKT CAP PSR

1 Alphatec Holdings ATEC $1.65 $148 0.75 1 TiGenix TIG.BR $0.60 $55 47.58 2 Symmetry Medical SMA $8.32 $305 0.85 2 MAKO Surgical MAKO $22.17 $944 11.17 3 Conmed CNMD $26.96 $763 1.05 3 Synthes SYST.VX $165.78 $19,691 4.96 4 Exactech EXAC $16.52 $218 1.06 4 Kensey Nash KNSY $38.39 $334 4.66 5 CryoLife CRY $4.69 $129 1.08 5 TranS1 TSON $2.94 $80 4.18

PSR: Aggregate current market capitalization divided by aggregate sales and the calculation excluded the companies for which sales figures are not available.

Advertise with Orthopedics This Week Click Here for more details or email [email protected] Tom Bishow: 410.356.2455 (office) or 410.608.1697 (cell)

1-888-749-2153 | www.ryortho.com 4 VOLUME 8, ISSUE 17 | MAY 22, 2012

The 23 Top Foot & Ankle Surgeons in the U.S. By OTW Staff

ho do other orthopedists want In alphabetical order, here are the top (AOFAS). He is also a founding mem- treating their feet? We asked! 23 foot and ankle surgeons in America. ber of the Foot & Ankle Institute at WLeaders in the foot and ankle realm OrthoCarolina. “He is the ‘go to guy’ let us know their thoughts on the top Ned Amendola, M.D. is professor and for professional athletes with foot and orthopedic surgeons in their subspe- director of the University of Iowa (UI) ankle problems. And he is just a very cialty. Sports Medicine Center. Dr. Amen- nice guy.” dola was named recipient of the Kim Here is that list. We don’t have “the mar- and John Callaghan Endowed Chair Donald E. Baxter, M.D. is an orthope- ket” on lists…this isn’t the be-all and in Sports Medicine by the UI in June dic surgeon with Athletic Orthopedics end-all list—but it is a list of who are 2009. “He is a superb team physician & Knee Center in Houston, Texas. He arguably the finest foot and ankle physi- with a good perspective on the field. He is also a past president of AOFAS. “He has a very practical way of managing cians, teachers, investigators or admin- has made significant contributions to the injured athlete.” foot and ankle, and in particular, he is istrators in the country. This informa- known for innovations in understand- tion was obtained via a telephone survey Robert B. Anderson, M.D. is an ortho- ing problems related to runners.” of thought leaders in the field. The infor- pedic surgeon with OrthoCarolina, and mation in quotes is what we heard about is a past president of the American James W. Brodsky, M.D. is an ortho- these surgeons. Orthopaedic Foot & Ankle Society pedic surgeon with Orthopedic Associ-

Source: Wikimedia Commons and Pavlov by Repin

1-888-749-2153 | www.ryortho.com 5 VOLUME 8, ISSUE 17 | MAY 22, 2012 ates of Dallas, and is clinical professor rienced, and is known for his work with books, and helped develop the STAR of orthopaedic surgery at the University elite athletes.” ankle. He probably knows more about of Texas (UT) Southwestern Medical the forefoot than anyone else in the School. He is also director of the Foot J. Chris Coetzee, M.D., Mb ChB is an U.S.” and Ankle Surgery Fellowship Training orthopedic surgeon with Twin Cities Program at Baylor University Medical Orthopedics in Minneapolis and clini- Jonathan T. Deland, M.D. is an asso- Center and UT Southwestern Medical cal associate professor at the University ciate attending orthopedic surgeon and Center. Dr. Brodsky is a past president of Minnesota Department of Orthopae- chief of the Foot and Ankle Service at of the AOFAS. “He is a specialist in total dic Surgery. Dr. Coetzee is also an asso- Hospital for Special Surgery. Dr. Deland ankle replacement, bunion surgery, and ciate editor for Foot & Ankle Interna- is also associate professor of surgery diabetic foot problems; he does great tional. “What a bright guy and a great (orthopaedics) at Weill Cornell Medi- work in his gait lab.” researcher.” cal College. “He is the world expert on posterior tibial tendon dysfunction, one Thomas O. Clanton, M.D. is chief of Mike J. Coughlin, M.D. is in indepen- of most controversial topics in our spe- the Foot and Ankle section at the Stead- dent practice in Boise, Idaho, and is a cialty.” man Clinic in Vail, Colorado, and is a former president of the AOFAS. He was past president of the AOFAS. Dr. Clan- also president of the International Fed- James K. DeOrio, M.D. is associate ton is an affiliated clinical professor at eration of Foot & Ankle Surgeons from professor of orthopedics at Duke Uni- the University of Texas Health Science 2002-2005. “He is extremely innova- versity Medical Center who was for- Center at Houston. “He is highly expe- tive, is a co-author of two major text- merly chair of Mayo Clinic Orthopae-

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1-888-749-2153 | www.ryortho.com 6 VOLUME 8, ISSUE 17 | MAY 22, 2012 dics in Florida. At present, Dr. DeOrio Columbia University, senior attending and Ankle Fellowship program at that also holds appointments at Mayo Clinic Orthopedic Surgeon at St. Luke’s-Roo- institution. “He is a very clear thinking, College of Medicine, F. Edward Hebert sevelt Hospital, and assistant attending top notch clinician who is also a highly School of Medicine, and Uniformed surgeon at the Hospital for Special Sur- sought after speaker. He is an expert on Service University of the Health Sci- gery. Dr. Hamilton is a past president of the management of diabetic ankle frac- ences. “He is a real talent, and is very the AOFAS and is the official orthopedic tures and flatfoot deformities.” experienced with total ankle replace- surgeon of The New York City Ballet. ment.” “He is THE guru of the management of Thomas H. Lee, M.D. is an orthope- orthopedic problems in dancers.” dic surgeon with the Orthopedic Foot Rick D. Ferkel, M.D. is an orthopedic & Ankle Center in Westerville, Ohio. surgeon with the Southern California Sigvard T. Hansen, Jr., M.D. is Profes- Additionally, Dr. Lee was a design sur- Orthopedic Institute, and is director sor Emeritus at the University of Wash- geon on the INBONE II Total Ankle of the Sports Medicine Fellowship Pro- ington in Seattle. He is also director of the System. “He is a very creative, dynamic, gram at the same facility. Dr. Ferkel is Sigvard T. Hansen Foot & Ankle Insti- high volume surgeon.” also a clinical instructor of orthopedic tute, and was a founding member of the surgery at the University of California Orthopaedic Trauma Association. “He is Roger A. Mann, M.D. is an ortho- Los Angeles. “He is an acknowledged IT as far as traumatology. And there is no pedic surgeon with Oakland Bone & expert in arthroscopic ankle techniques type of case that he turns away.” Joint Specialists, and is a past president who has tremendous experience.” of the AOFAS. He is co-author of the Jeffrey E. Johnson, M.D. is professor most widely used orthopedic textbook John S. Gould, M.D. is professor and of orthopedic surgery at Washington on foot and ankle surgery, entitled, section head of foot and ankle at the University School of Medicine in St. ‘Surgery of the Foot and Ankle.’ Dr. University of Alabama in Birmingham. Louis. He is also chief of the Foot and Mann was lead investigator on the FDA He is the lead author of ‘Operative Foot Ankle Service and director of the Foot study evaluating the STAR ankle. “He Surgery,’ and is a past president of the AOFAS. “He is a superb clinician who has written an impressive book on foot and ankle surgery. His technique is very THE IMPLANT SURFACE subtle and his understanding of pathol- TECHNOLOGY COMPANY ogy is so thorough that he picks up things you don’t think about.” REDEFINING THE ROLE OF Steven L. Haddad, M.D. is an ortho- pedic surgeon with the Illinois Bone INTERBODY FUSION DEVICES & Joint Institute in Chicago. He is also Osteocalcin Levels 1 300 Associate Professor of Clinical Ortho- 5 # • # paedic Surgery at the University of 225 • Chicago Pritzker School of Medicine. In 150 75 addition, Dr. Haddad is section head of ng Osteocalcin/Cell (x10 ) 0 Smooth Titan Spine Foot and Ankle Surgery at NorthShore TCPS PEEK Titanium Surface University Health Systems. “He is very innovative, especially with the ankle SURFACE STRUCTURE SCIENCE arthroscopy. He is creative and has the best PowerPoint presentations of any- To Learn more, please visit our Spineweek one in the country.” booth #815, or scan the QR code.

1 Olivares-Navarrete, R., Gittens, R.A., Schneider, J.M., Hyzy, S.L., Haithcock, D.A., Ullrich, P.F., Schwartz, Z., Boyan, B.D., 2012, Osteoblasts exhibit William G. Hamilton, M.D. is clinical a more differentiated phenotype and increased bone morphogenetic production on titanium alloy substrates than poly-ether-ether-ketone, The Spine Journal, v. 12, p. 265-272. professor of orthopedic surgery at the Notice: one or more products are covered by patents www.titanspine.com College of Physicians and Surgeons of Advertisement

1-888-749-2153 | www.ryortho.com 7 VOLUME 8, ISSUE 17 | MAY 22, 2012 is a leader in the field who has made plasty; he is the co-founder of Kyphon. at the University of Utah in Salt Lake an enormous contribution in bringing Before retiring from practice in 2009, City. He also holds an adjunct profes- foot and ankle to the consciousness of Dr. Reiley practiced at Berkeley Ortho- sorship in the Department of Bioengi- orthopedic surgeons.” pedics Surgical group. A founder of the neering. Dr. Saltzman is a past presi- group, Dr. Reiley practiced there for dent of the AOFAS. “He has been criti- Mark S. Myerson, M.D. is director of over 20 years. “He is a flexible thinker cal of the science in our field, and has the Institute for Foot and Ankle Recon- who has really changed how orthope- been extremely involved with the NIH struction at Mercy Medical Center in dists practice worldwide.” [National Institutes of Health] to bring Baltimore, Maryland. Dr. Myerson is a the highest level of academics to foot past president of the AOFAS. “He is a Charles L. Saltzman, M.D. is profes- and ankle.” prolific researcher and clinician and is sor and chair of orthopaedic surgery a founder of a website that helps sur- Lew C. Schon, M.D. is an orthope- geons advance their clinical knowl- dic surgeon with Greater Chesapeake edge—FOOTinnovate.com.” Orthopaedic Associates, LLC at Union Memorial Hospital in Baltimore. He John S. Reach, Jr., M.Sc., M.D. is assis- holds academic appointments at tant professor of Yale Orthopaedics and Georgetown University Medical Cen- is director of the Yale Foot and Ankle ter and Johns Hopkins School of Medi- Service. He has pioneered and advocat- cine. “He is a bright thinker, a good ed for the use of handheld ultrasound surgeon, and the most forward-think- visualization to detect and treat mus- ing clinical researcher we have. He is culoskeletal conditions—both in the experienced with orthobiologics trials, consultation room and in the operat- and has done a lot of work on nerves ing room. “He does any and all types in the foot and ankle.” of foot and ankle surgery, including trauma, forefoot and hindfoot surgery. David B. Thordarson, M.D. is profes- The fact that he does trauma is impres- sor of orthopaedic surgery at the Uni- sive because most surgeons who have versity of Southern California; he is also been in practice for years leave trauma vice chair for education and residency to the younger guys.” program director. In addition, Dr. Thor- darson serves as editor-in-chief of Foot Mark A. Reiley, M.D. is the chief medi- & Ankle International. “He has good cal officer, inventor and founder of SI- hands, is smart, and is very facile in the BONE, Inc. He is also the creator of OR. He also possesses a wide depth of the INBONE Total Ankle System. Dr. knowledge.” ♦ Reiley developed and patented kypho- Advertisement

1-888-749-2153 | www.ryortho.com 8 VOLUME 8, ISSUE 17 | MAY 22, 2012

New Policy Would Cut Some Spine Surgery Funding By Walter Eisner

2011, a Local Coverage Determination (LCD) in Florida, citing Milliman Care Guidelines said that Medicare will no longer cover multi-level lumbar fusion for symptomatic degenerative disc dis- ease (DDD).

Milliman Company develops and pro- duces “evidence-based clinical guide- lines used by more than 1,800 clients, including more than 1,000 hospitals and 7 of the 8 largest U.S. health plans.” The guidelines are not peer reviewed and are developed internally.

In both cases, physician societies were able to convince the insurers to modify their proposals, slightly. http://medicalpolicy.hcsc.net ,Morguefile, and RRY Publications LLC Photo Creation The Blues Proposal pinal fusion is considered not more than 16,000 people and serving medically necessary when the more than 13 million members. It is the In Illinois, BCBSI lists 11 conditions for sole“S indication is disc herniation, DDD, fourth largest health insurance compa- which surgery may be considered nec- facet syndrome, or initial discectomy ny in the country. essary, in addition to the four “non-nec- and/or laminectomy for neural struc- essary” conditions noted above. They ture decompression.” Death by a Thousand Increments also listed three conservative non-sur- gical therapies which must be included So says Blue Cross Blue Shield of Illi- Illinois’ BCBSI is just the latest. Blues in nois (BCBSI) in a May 14, draft medi- North Carolina, Florida and Minnesota before surgery will be considered. cal policy summary. The reason? “Lack have placed new restrictions on backs of evidence of improved outcomes.” of policyholders whose physicians have The insurer listed a number of studies Within hours, spine surgeons were recommended spine fusion surgery. The (see OTW Summary of the Proposed online alerting colleagues. insurers have responded to the ensuing BCBSI Policy on page 12) to justify their outcry from physician societies by walk- proposal of limiting surgery and requir- “This is a new draft policy for public ing back the more onerous portions of ing additional non-surgical treatments. comments. It is by no means a final pol- the proposed restrictions, but not back icy,” BCBSI’s media and public affairs to where the original policy started. Call Surgeon’s Push Back manager told us in an email on May 17. it death by a thousand increments. Gunnar Andersson, M.D., Ph.D., and Health Care Service Corporation Milliman Care Guidelines Frank Phillips, M.D. of Midwest Ortho- (HCSC) operates the Blue Cross and paedics at Rush (Rush University Medi- Blue Shield plans in Illinois, New Mex- The Blues in North Carolina made the cal Center in Chicago) are deeply con- ico, Oklahoma, and Texas, employing same proposal in 2010 and, in June cerned.

1-888-749-2153 | www.ryortho.com 9 VOLUME 8, ISSUE 17 | MAY 22, 2012

Disappointing Literature Review by nal fusions for treatment of chronic Insurers back pain. The numbers of fusions are increasing and the costs are increasing “There is a tendency to select those even faster making a legitimate target studies that support your opinion and for the insurance companies when they deselect others” noted Dr. Andersson. are trying to reduce their costs.” “There is also a tendency to lump all patients together and make sweeping However, he said he is disappointed at decisions regarding groups of patients how insurers are reviewing the litera- some of who would respond very ture. well to fusion treatments and others who probably would not. So while we “Non-Transparent, Non-Validated need to make a better job in selecting Guidelines” the appropriate patient as surgeons Gunnar Andersson, M.D., Ph.D. the insurers should refrain from using Dr. Phillips said there is no doubt that sweeping decisions. By doing so a num- “There are several reasons for this,” everyone should strive towards more ber of patients who would have signifi- said Andersson. “One is pain itself, efficient delivery of health care. “How- cant clinical benefit will be excluded which when it becomes chronic does ever the use of non-transparent, non- from that opportunity.” not always have a specific anatomic validated guidelines to direct treatment cause. Another is the fact that many decisions is not in our patients best Of course, added Dr. Andersson, the of our patients are different and there- interests.” scientific community is struggling with fore unlikely to all respond to the same how to best treat chronic back pain and treatment. I’m not surprised that the “The insistence that surgical treatments degenerative disc disease. insurers are challenging the use of spi- be compared to non-surgical therapies

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1-888-749-2153 | www.ryortho.com 10 VOLUME 8, ISSUE 17 | MAY 22, 2012

ise that fusion can reduce pain and dis- ment options for carefully selected ability in the treatment of low back pain patients with disabling low back pain from DDD in carefully selected patients. due to degenerative disease at one or He added, “In addition to the surgical two levels. versus non-surgical trials mentioned in the BCBSI statement, data from Level NASS is reviewing the BCBSI policy and 1 studies comparing various surgi- will submit its comments by the May cal strategies (including the U.S. IDE 31st deadline. TDR FDA Trials) have been published supporting effectiveness. Furthermore See ISASS Rebuttal (Next Page) numerous high quality non-random- Frank Phillips, M.D. and http://www. ized trials should be considered as part rushortho.com/frank_phillips.cfm of the evidence base.”

represents the wrong paradigm. These Societies Respond should not be viewed as competitive treatments as they are typically applied Chicago is also home to the largest in series rather than in parallel. For spine surgery societies: North American most conditions, and in particularly Spine Society (NASS), American Acad- the treatment of low back pain, surgery emy of Orthopaedic Surgeons (AAOS) should only be considered after failure and The International Society for the of appropriate non-surgical interven- Advancement of Spine Surgery (ISASS). tions.” ISASS President Steven Garfin, M.D., Considerable Evidence Supporting provided OTW with a statement that Fusion BCBSI was basically cherry picking Steven Garfin, M.D. evidence that supports their view and Phillips said there is a considerable ignores evidence that recommends that body of literature supporting the prem- fusion surgery be considered as treat- LEAD the Spine

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1-888-749-2153 | www.ryortho.com 11 VOLUME 8, ISSUE 17 | MAY 22, 2012

ISASS Rebuttal Except for one retrospective cohort study, these other studies are not (Steven Garfin, M.D., President) considered. Instead BCBSI quotes a study from 1992 which states that there were no randomized trials of fusion which is correct and another BCBSI’s draft policy is moderately onerous in the sense that most study from 1999 which also did not find any randomized controlled trial indications for a spinal fusion are still covered. The areas where lumbar which is also correct. spinal fusions procedures “are not considered medically necessary” include patients where the sole indication is a disc herniation or neuro They also quote a guideline for the performance of fusion procedures structure compression (initial discectomy/laminectomy) “as well as” published by the American Association of Neurological Surgeons and degenerative disc disease and facet syndrome. the Congress of Neurological Surgeons in 2005 which concluded that the evidence at that time was weak and recommend the need for the This is the area where the primary controversy exists. neurosurgical community to design and complete prospective random- ized trials to answer the many lingering questions with rigorous scientific While many patients with degenerative disc disease or facet syndrome power. will not have that diagnosis as their sole indication, there are patients with chronic low back pain who have not responded to appropriate What they did not quote was the recommendation from the guideline non-operative treatment and who will benefit from a surgical procedure. that fusion surgery be considered as treatment options for carefully se- Those patients may now lose the opportunity of a clinically meaning- lected patients with disabling low back pain due to degenerative disease ful improvement. Given that all patients are different, sweeping policy at one or two levels. They also quote a technology assessment by the statements can exclude appropriate patients from appropriate clinical Agency for Healthcare Research and Quality in 2006 which correctly care. concluded that are no randomized controlled trial evidence that directly compares lumbar spinal fusion with nonsurgical conservative treat- BCBSI bases their decision on the “lack of evidence of improved out- ments in populations older than 65 years of age for any indication. It is comes for spinal fusions.” unlikely that randomized controlled trials for this particular purpose will be specifically performed in populations older than 65 years. AHRQ also There are six randomized controlled trials of fusion surgery versus non- concluded that “lumbar fusion may result in some benefit compared with surgical therapy of which BCBSI reviews. In addition there are at least conservative treatment in middle age patients with axial back pain who 15 publications comparing prospectively in randomized trials fusion have severe disability or pain from disc disease”. This statement was surgery versus a different fusion technique or lumbar arthroplasty. There not included in the reviews. In aggregate all the studies show that there are also retrospective controlled trials, prospective non-comparative are patients who clearly benefit from spinal fusion surgery. It is also true cohort studies and studies of surgery only cohorts. that not all patients require surgery.

NuVasive’s Lukianov – “A New Reality” ed consequence of “Obamacare” [The Un-vetted Milliman Guidelines Affordable Care Act], whereby payers are deeply concerned about their future “Despite overwhelming evidence in the bottom line and taking steps to improve form of the HTA [Health Technology it now. Assessment] and various other scien- tific publications (SPORT, et al.), which “Given the forthcoming changes asso- clearly support the need for spine sur- ciated with Obamacare, [resulting] in gery for specific indications. The BCBSI higher costs to payers as well as their requirements are more closely linked to subscribers, the payers are playing the Milliman style guidelines, neither of a financially driven game of reduc- which are grounded in scientific litera- ing access to needed spine surgery,” ture or vetted by surgeons,” continues Alex Lukianov, chairman and observed Lukianov. Lukianov CEO of NuVasive, Inc Lukianov says that this is unfortunately Lastly, Lukianov feels the spine market Alex Lukianov, chairman and CEO of the new reality in terms of what it will has bottomed out versus growing in NuVasive, Inc. said he believes that what take to get appropriate surgical spine the U.S. “The ongoing attacks by pay- we are seeing in Illinois is an unintend- care in the U.S. ers have created a surgery lag effect.

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Patients still get treated albeit later rath- er than sooner. This lag effect is largely OTW Summary of the Proposed cal techniques of fusion to each other. factored into spine market growth pro- Blue Cross Blue Shield of Illinois jections.” Policy In a 2004 article, Deyo and Mirza state that it is not clear whether some patients End Game Intervertebral disc pain is a potential really benefit from spinal fusion com- cause of low back pain [LBP]…There is a pared to rehabilitative approaches, and If history is a guide, the surgical soci- lack of consensus in the medical litera- the complication rate is relatively high eties, physicians and their patients will ture as to what extent the intervertebral compared to other types of back surgery hammer at Blue Cross Blue Shield until disc is innervated. and to non-surgical treatment. May 31. Then the insurer will announce modifications to their proposal based on The vast majority of cases of chronic LBP In 2005, two spine surgeon societies evidence of their choosing and declare do not require surgery, and conservative (AANS/CNS [American Association of themselves reasonable and flexible. non-surgical treatment will nearly always Neurological Surgeons/Congress of Neu- be tried first. rological Surgeons]) found that many of In the meantime, more patients will the published studies had flawed results have to endure non-surgical treatments National survey data indicate that the due to poorly defined outcome mea- until they meet the new guidelines. That number of spinal fusion operations rose sures, inadequate numbers of patients, is the new reality as the science of spine 77% between 1996 and 2001, in contrast and comparison of dissimilar treatment care continues to search for the elusive with hip replacement and knee arthro- groups (Heary 2005). pain generator of lower back pain. ♦ plasty, which increased 13-14% during the same period (UW Med Report 2004). In 2005, Fairbank et al. conducted a multicenter randomized controlled trial to Treatment for lumbar disc disorders is assess the clinical effectiveness of surgi- controversial. The relationship between cal stabilization (spinal fusion) compared an abnormal disc and neural dysfunc- with intensive rehabilitation for patients tion does not correlate statistically with with chronic low back pain. Both groups the imaged pathology. Biochemical and reported reductions in disability during inflammatory factors play primary roles. two years of follow-up, possibly unrelated to the interventions. No clear evidence Biological influence of a disc herniation is emerged that primary spinal fusion Customized Automated expected to change over time and to be surgery was any more beneficial than Messaging altered by passive and active non-surgi- intensive rehabilitation. What we do cal interventions (Wheeler et al. 2011). In 2006, Maghout et al. concluded that • Reduce No-Shows A 1992 review by Turner et al. could find increased use of intervertebral fusion de- • Streamline Collections no randomized trials of fusion. Combin- vices after their introduction in 1996 was • Improving Patient Outcomes ing many studies of fusion performed for associated with an increased complica- • Help Stimulate Patient Understanding many different clinical indications, they tion risk, without improving disability or What sets us apart found an average of 68% of patients reoperation rates. reported a satisfactory outcome. A 1999 • Money Back Satisfaction Guarantee Cochrane review (Gibson et al.) conclud- In 2006, the Agency for Healthcare • Superior In-House Customer Support ed that at that time there was no accept- Research and Quality (AHRQ) con- • Hosted & Hardware Solutions Available able evidence of any form of fusion for cluded that there is no RCT evidence that • No Hidden Fees, Flat Rate Plans Available degenerative lumbar spondylosis, back directly compares lumbar spinal fusion Call or Visit us at: pain, or “instability.” The authors could with non-surgical conservative treatments phonetree.com/OTW12 find no randomized clinical trials (RCTs) in populations older than 65 years of age 877.259.0658 comparing fusion to a nonsurgical alter- for any indication. Advertisment native, only trials which compared surgi-

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Orthopedics in the Amazon Basin By Biloine Young

nearby region, in an Amazon frontier city called Pucallpa. With her infant in a sling over her back, and supporting her walking with the help of a pole, she trekked over muddy rainforest trails and floated by dugout canoe for an 18 hour journey to get to the hospital.

Here she met Peter Cole, Chief of Orthopaedic Surgery at Regions Hospi- tal, Saint Paul, Minnesota. Cole made

Caption: Dr. Peter Cole’s at Work in Pucallpa, Peru/Source: Scalpel at the Cross. www.scalpelatthecross.org

hen the little girl, who lived in a village on a tributary of the Ama- Wzon River in Peru, was bitten on the leg by a poisonous snake, she developed a serious condition called a “compart- ment syndrome.” It took her frightened parents a couple of days to get her to a rudimentary government jungle hospi- BIG Smile After Prosthesis tal where doctors found that the pres- sure on the child’s blood vessels had a plaster cast mold of the stump of her caused the muscle tissue to die. To save leg, took it with him on his return to her life they amputated her leg above the U.S., and left it with the Tillges Cer- the knee. tified Orthotic & Prosthetic Company in Maplewood, Minnesota. When Cole A decade and a half later, the girl, now returned to Pucallpa six months later, grown and the mother of an infant, he had with him a new leg for the young learned through jungle missionaries, woman. “The first time anyone had that an American orthopedic surgeon seen her smile,” said Cole, “was when was visiting a riverfront hospital of a Alejandra Before Prosthesis she was taking her first steps with the

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prosthetic. Everyone was clapping and ‘right time’, until our kids were ready, and establish a permanent base. They crying.” we would never have gone,” Cole said. purchased 25 acres and, in 2005, built Their youngest son, Channing, was six a guest house that would sleep 15. They Peter Cole’s journey from Saint Paul months old on his first trip. In Pucallpa, affectionately called it “Jungle Bunks.” to the jungle village of Pucallpa on the Cole walked into the rundown govern- The guest lodge is built on pilings fif- Ucayali River, a major tributary of the ment hospital, introduced himself, and teen feet above ground, because, in the Amazon, began, in one respect, as a said that he just wanted to check out rainy season, the Amazon rises 32 feet. boy of 10. He moved with his parents what sort of facility they had. To his A 50 meter long board walk leads up to Caracas, Venezuela, where his father delight he was welcomed with “com- to the door to traverse the water during and grandfather were involved in the plete open arms. They latched onto the monsoons. oil business, and lived there for almost me,” he said. “They wanted to take me four years where he learned Spanish. on rounds, scrub for surgery, and show In the initial years, beginning in 2004, “It was a very impressionable time of them how to do things. To this day I the project was completely financed by my life,” he says. Furthermore, though have never even shown them proof that the Coles. Over the past seven years, as Cole did his undergraduate work at I am a doctor.” the scale of the project has grown, they Emory University in Atlanta, he went have added to their payroll a mission to medical school at the University By 2004 Cole had established sufficient- director and secretary, as well as a full of Miami in South Florida. “Half of ly strong relationships with the hospi- time Peruvian surgeon. Cole explained our staff and patients were Latin,” he tal, local government officials, and the that, with the growing number of trips, remembers. “I had a lot of close Cuban outlying missionary settlements that he the fiscal health of the mission depends friends. I’ve always had an affinity for and Nancy decided to buy some land on weaning the organization off their the Latin culture.”

A meeting with Craig and Heather Gahagen, while Cole was in medical school, was providential. Gahagen was an aviation missionary, operating an aviation program that had been found- ed by his father in the 1960s and which connected missionary settlements in the Amazon basin. His base was about 40 miles west of the Brazilian border. Cole remembers Gahagen challenging him and his wife Nancy. “When med school is done, you won’t have any excuses,” he told them, “You have to come down and visit us.” The day after his gradu- ation from medical school, in 1991, Peter and Nancy Cole flew to Peru. During the three weeks they spent in the village of Pucallpa the two Christian couples dreamed about “how we could marry our two professions. And that is when it started,” Cole said.

It began with the Coles making semi- annual trips to the jungle village. “We believed that if we waited until the Dr. Peter Cole with Leyla and Betty

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majority support. The mission current- ly runs on about $120,000 a year.

The Mission Director, Lisa K. Schroder, ® was hired in 2006. Cole describes Sch- nanOss roder as being “a talented and fearless worker” who lives in Rochester, Indi- Bioactive ana, and travels to the Twin Cities once a month to meet with Cole “She is a wife and mother of two boys, who left a high-powered career as an engineer for Zimmer Inc. and committed to an out-of-home job helping the fledgling 3D project,” he said. In addition to her background in orthopedic engineering, Schroder has an MBA from Purdue. Another dimension brought to you by Twice a year, Cole and Schroder take from 12 to 20 team members to Pucall- pa for a week-long marathon visit. Word goes out months in advance when a medical trip is taking place. On the day the medical team arrives at the jungle city, patients begin lining up at Advertisement 4:00 in the morning at the hospital. If the visit is for a week, the team will see about 100 people on Monday, and iden- Cole is proud of the fact that all of the building a hospital and running it with tify the 25 they will operate on the rest surgery is performed at the local hos- our own people, or going down with of the week. pital. As he explained, “We are not just our team and taking over a hospital. Rather, we work with the hospital per- sonnel, rub elbows, teach, and dem- onstrate how we treat patients by our actions.

They are so grateful for what we do, that they open up clinic space, staff operating rooms with their anesthe- tists, their OR nurses, their floor nurs- es. Even the Chief Hospital Director welcomes us with a ceremonial greet- ing. This approach really helps us to disseminate information, to spread a culture of care in a place where life is very cheap,” he said.

Cole’s team members counter the rac- ist attitudes that exist in Peru toward the indigenous people. “The Amazon Team Member Sarah Molitor with Patient Yanndo Indians are not seen in the same regard

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as people of Spanish descent,” he said. he says. “Not so at the far reaches of the runs the mission at the local organiza- “Just the fact that we would talk to these Amazon!” tional level, particularly as it relates to patients, look them in the eye, hold gearing up for trips and patient care. their hands, is unusual for them, and I The mission has recently added anoth- believe makes a difference.” er dimension to his work in Peru. As Cole explains that his Peruvian col- he explains, “In my U.S. life I am an leagues at the government hospital have Cole notes that an orthopedic team at investigative researcher who promotes a hard time understanding his desire to work is not like a primary care situa- and publishes functional outcomes follow up on his patients. (Cole confess- tion. “There is a lot of complicated tech- in orthopedic surgery, in a genre of es that, in this case, he may be impos- nology involved in orthopedics. We use research termed, evidence-based medi- ing his American culture on the local more tools, implants, and instrumenta- cine. I felt that it was disingenuous of medical system.) They wonder why the tion than any other specialty,” he said. me to be a champion of outcomes in Americans want to set up a clinic to see Because these are not available at the orthopedic surgery, which emphasizes all of the patients he had operated on government hospital, every member close follow-up of patients, and then go in the past—who they believe are doing of his team takes with them from the down to the Amazon and never know just fine. “They do not understand that States, a trunk of implants and instru- what happened to my patients.” I want to know the good as well as the ments that are stockpiled for use with bad outcomes. It helps us prognosticate patients. As a result, a couple of years ago, the for other patients. It helps us see what organization hired the Peruvian general we could do even better,” he says. About 60% of Cole’s patients are indi- surgeon Rosa Escudero, M.D., to work viduals who have deformed bones. He full time following up on the patients. So what drives Cole? Part of the appeal says that bones that did not heal prop- “She goes into the villages, into the is that he finds orthopedics to be a won- erly are all over the Amazon because Indian tribes, even the barrios, to get derful field. Orthopedists, he says, “are there are no orthopedic surgeons there. follow up. That is gold to me! As a phy- all guilty of wanting to fix things. I like “If you are hurt there you do not get sician I am just not comfortable render- to take something broken and fix it, and treated.” He emphasizes that this is ing a treatment and not knowing what see the result the next day,” he said. “It not “slam-bam surgery.” A single sur- happens.” Cole said that Escudero also is not like managing diabetes or hyper- gery can take up to five hours. But the tension. It is a very ‘immediate gratifica- results transform lives. “Take a young tion’ kind of field.” girl with a thigh bone that has not healed,” he said. “She lives on crutch- “What is often left unspoken”, Cole es, will never get married, will be an explains, “is that his work in Pucallpa outcast in her village, and will be com- is a Christian ministry”. He is quick to pletely marginalized in this culture. add that it is not a Bible distribution Some infants with deformities, such as network and certainly not a proselytiz- clubfoot, are even killed by their Indi- ing ministry. “We are there to demon- an parents because they are believed to strate our love for God by loving oth- be possessed,” he said. ers through our work.” The ministry is named, Scalpel At The Cross. “The Cole says he could write a text book in scalpel represents the surgeon’s profes- pathology with what he sees in a week sion. I lay that at the foot of the cross at Pucallpa. “If you have a tumor in the to be used by God however He wants. U.S. it will manifest so early and be I put my talents there. I am an instru- treated so early, that you never see what ment of His,” he said. Cole invites it is like when it is taking over an entire people to visit the website at www. leg and is growing through the skin,” scalpelatthecross.org. Chavez Diaz Elmer x-ray of patient needing Ex-Fix ♦

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Vince v. Hungerford on Correcting Extra-Articular Deformity By Elizabeth Hofheinz, M.P.H., M.Ed.

xtra-articular deformity? Go intra- articular for the correction, says EKelly Vince. Not so fast, counters David Hungerford…there are many kinds and Kelly G. Vince, M.D., F.R.C.S.(C) sources of deformity: congenital, meta- University of Auckland bolic, traumatic, and surgical, and what New Zealand is the magnitude of the deformity, and the location from the knee, etc. There VS are multiple considerations. David S. Hungerford, M.D. This week’s Orthopaedic Crossfire® Johns Hopkins University debate is “Extra-Articular Deformity: Baltimore, Maryland Always Correctable Intra-Articularly.” For the proposition was Kelly G. Vince, M.D., F.R.C.S.(C) from the University of Auckland in New Zealand. Against the Moderator: Steven J. MacDonald, M.D., F.R.C.S.(C) University of Western Ontario proposition was David S. Hungerford, M.D. of the Johns Hopkins University in Baltimore; moderating was Steven Wikimedia - KaihsuTai and Current Concepts in Joint Replacement/RRY Photo Creation J. MacDonald, M.D., F.R.C.S.(C) of the University of Western Ontario. like fracture work, it’s in the plane of the our extramedullary cutting guides span joint. For the next phase of planning, the joint and tibia, and correspond to Dr. Vince: “I like to correct these defor- you need full length X-rays.” the mechanical axis.” mities inside the joint. Extra-articular deformity is a limb deformity with “We only need that femur film. We “Surgical technique: the alignment of implications for the joint; it should draw the mechanical axis, the bone cut the new arthroplasty comes simply from be easy to solve. When it comes to should be at right angles to it, and you the component position and the bone varus-valgus alignment issues it’s the can set your IM [intramedullary] guide cuts. Then things get a little challeng- mechanical axes that we must examine. accordingly. If you have navigation it ing in that we must do ligament releases When it comes to flexion-extension makes everything simple. It requires and possible constraint…and in very problems, we can ignore most of them. a bit more attention to the soft tissue few cases I have done ligament advanc- The mechanical axis: center of knee, surgery, but results in a postoperative es and even ligament reconstructions. center of hip, center of ankle. And the result with a restoration of the angle Consider a gentleman with a midshaft anatomic axis just drifts and melts away that you would like.” femur fracture. There’s a little more because it is distorted.” valgus in the distal cut…and requires “Some of them look intimidating— having to do a little more release of the “Sagittal deformities: you get an impos- until you draw that simple angle that medial collateral ligament.” ing looking X-ray and you’re not sure goes from the center of the head to the what to do. The secret is that this distal femur, and at right angles. When “Another patient with bilateral femur patient bends well and extends well, it comes to tibial extra-articular defor- fractures…really impressive malunion and we should probably just ignore it— mities these are straightforward because that nobody wants to revisit. She was

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unable to accept blood transfusions, tal, and carry on. And then they said he showed a case in which he did an and I didn’t want to do two opera- they won’t do the correction if it doesn’t extra-articular correction. So if we tions—four because it’s bilateral—and correspond to the tibial axis. It wouldn’t come to the conclusion that there will I didn’t want her to have blood loss at bother me to make that cut—center of be cases where an extra-articular defor- one surgery. So we did it all intraop- knee to center of ankle—and then do a mity should be corrected extra-articu- eratively with aggressive releases, and rebuilding of the bone.” larly, the question is, ‘How do you make supplemented things with a non-linked that decision?’” constrained device.” “A case I did in Australia: because I wanted to have the options of con- “The question is, ‘When do you do “At times I’ve done ligament advanc- straint and fixation, I actually did an intra-articular and when do you do es—Ken Krackow’s technique—which osteotomy along with the case so that extra-articular?’ In most deformities, I’ve modified very slightly. At times I’ve the stem could go up the canal, and I’d the deformity is because of intra-artic- done ligament allografts including an have those options. How simple can it ular bone loss, and it doesn’t make any Achilles tendon that’s anchored below be with intra-articular correction? But difference how much that is, it can the tibial component, and goes through if you correct the osteotomy the hip always be corrected intra-articularly. a drill hole in the femur.” has to get accustomed to a whole new When you get to extra-articular defor- range of motion—and you’re going to mity you have lots of kinds and sources “When it comes to the limits of cor- have to do some pretty daunting sur- of deformity: congenital, metabolic, rection, there is a paper from Taiwan gery at the knee as a result. In conclu- traumatic, surgical.” which was inspired by John Insall. They sion: keep it simple.” say that they can’t do a distal femoral “The issues: the magnitude of the defor- cut if it goes through the attachments in Dr. Hungerford: “I think the opera- mity, the location from the knee—a the collaterals—and that makes sense. tive word in this discussion is ‘always.’ deformity that is close to the knee has What I would do is cut a little more dis- Kelly already proved my point in that almost a 1-to-1 degree deformity of the

SPINE DESK REFERENCE GET LISTED NOW! PUBLISHING THIS SUMMER. | DEADLINE: June 25, 2012 For more information contact [email protected]

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knee itself, whereas an extra-articular affects stability only in extension, est degree…where the same degree deformity near the hip or ankle has very meaning that you produce instability of instability on the medial side is not little impact. Also, is it medial or lat- on the medial side in extension, but well tolerated.” eral? Is the femur involved, or the tibia? not in flexion, therefore the ligamen- The malalignment on the knee when tous alignment that you need to do “Some deformities which are multifac- it’s supracondylar is about 20 degrees, becomes quite a bit more complex. torial—lateral translation, anterior rota- whereas when it’s subtrochanteric it’s The tibia deformity that you create tion, and severe deformity—are much almost zero. Same with the ankle. If you intra-articularly to correct an extra- better taken care of by an osteotomy. In have a big deformity at the ankle you articular deformity affects stability in one patient who had a high tibial oste- might want to do something, but it has both flexion and extension, and in otomy for varus disease, where it’s vast- very low impact on the knee unless it’s those cases ligamentous releases and ly overcorrected, had good joint space. close to the knee.” ligamentous reconstructions are more I decided to do an extra-articular cor- straightforward.” rection back to neutral as the first step. “The varus deformity requires a lateral After 15 years she has not yet had a total resection, so in this case you have a lat- “All you really need to do is to tem- knee replacement.” erally based wedge…and this becomes plate…you’re going to determine the an issue in making this decision. With cut that is required, so this automati- “So you have a decision tree of whether a valgus deformity you’ll have a medial cally takes in account the level of defor- to correct intra-articularly or extra- based wedge intra-articularly to correct mity. Lateral over-resection is better articularly, and whether it’s a separate the deformity.” tolerated by the simple fact that the procedure or a combined procedure… lateral side of the joint is dynamically and then, whether residual deformity is “Femoral and tibial intra-articular stabilized. So you can tolerate, func- acceptable (and I think that’s not).” correctionsOTWPrintAd_All are Ads_5x4.25:Layout not equal. The 1 1/13/12femur 3:26tionally, PM Page lateral 3 instability of a mod- Moderator MacDonald: “Kelly, not everyone is set up with navigation, so you can’t use an IM alignment rod for your femoral resection…take us through how you do that in the OR… an extra-medullary referencing for a standard femoral cut.”

Dr. Vince: “Whether you decide to do an intra-articular correction or the kinds of osteotomies that David has described, get a long film. From that, draw the mechanical axis from the cen- ter of the femoral head to the center of the femur (if the deformity is in the femur), and then draw the right angle at the distal part of it. Before naviga- tion, I would draw that line, and if the malunion or deformity was proxi- mal to where the IM guide would go, you would also draw the IM guide on the X-ray and measure that angle. If the deformity precludes the use of IM guides then I’ve gone to intraoperative Advertisement X-rays to confirm the cut.”

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Moderator MacDonald: “Any of you by having their malalignment corrected used a technique where you are looking to neutral. In all but one of those cases under fluoro with the femoral head and that proved to be true. I had a patient marking the femoral head using that as with a segmental fracture with about a your guide with a long rod intraopera- 20-degree varus deformity of her tibia at tively?” several levels and she looked like she’d be a good candidate for a valgus oste- Dr. Vince: “That would be a variation otomy…and that worked for almost 10 of an intraoperative X-ray.” years. Ten years later it was a neutral total knee replacement.” Dr. Hungerford: “I would agree with what he said about if you’re going to Moderator MacDonald: “Sometimes do this correction and you’ve done when you plan these cuts out the soft your templating and made your mark tissue balancing is a little wonky—not you can put your distal femoral cutting so predictable. Any tips there?” guide on as to where you think that line ends up, take an intraoperative X-ray Dr. Vince: “Look at the patient with and it’s the equivalent of a postoperative a big varus bow in the femur, so you X-ray. Most instrumentation systems may not be tuned into the fact that they have the ability to make small correc- have a big deformity. If you correct that tions if you wanted to.” appropriately you’re going to have to do a large medial release or leave them Dr. Vince: “Add a spacer block that the malaligned, overloading the medial alignment rod goes through and stick it side. We want to get the cuts where in the joint parallel to your new cut on they should be, do the releases and the femur, and look at where that rod not be fearful of over-releasing in these hits the femoral head.” cases because we should have planned to have constraint available (or some Moderator MacDonald: “David, if you other plan).” ♦ must do a corrective osteotomy, how do you determine when you’re able to Please visit www.CCJR.com to register incorporate that into your total knee for the 2012 CCJR Winter Meeting, construct or when you’re going to have December 12 - 15 in Orlando, Florida. to do a separate procedure? Or do you get a custom stem?”

Dr. Hungerford: “You don’t have to make a corrective osteotomy at the site of the deformity. You could have a 45-degree malunion of the femur “You may now view in the midshaft and you could make content from the CCJR about a 22-degree supracondylar oste- Meetings on the CCJR otomy that you could do at the same Mobile App. Please time as a total knee replacement. In scan the QR code to most cases I would like to not subject download the CCJR the patient to two separate surgeries, Mobile App to your but I’ve done four or five in which I Android or iOS mobile thought that the patient might well get Advertisement device, or visit www. a significant improvement functionally ccjrmobile.com.”

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trict of Massachusetts pursuant to ment walked away empty handed. He company HIPAA requesting production of docu- believes this news removes a significant ments relating to Infuse. Medtronic overhang to Medtronic and its spine Feds Give “All Clear then received supplemental subpoe- business because there was a concern Signal” on Infuse nas or document requests, including a that Medtronic would have to settle this Investigation December 18, 2008 civil investigative case for a significant amount of money. demand from the Massachusetts Attor- Such a settlement would have acceler- he government has closed its inves- ney General’s Office, an October 14, ated the decline in Infuse because sur- Ttigation of Medtronic, Inc.’s activi- 2011 subpoena issued by the California geons would have grown increasingly ties surrounding its Infuse bone graft. Attorney General’s office, and several concerned about being sued for using inquiries from the United States Senate the bone graft off-label. The company announced on May 16 Finance Committee. that it has been notified by the U.S. “This news could represent a turn- Department of Justice and the Office of The investigation apparently widened ing point for the beleaguered product the United States Attorney for the Dis- last year after researchers involved in because it could be a signal to sur- trict of Massachusetts that federal pros- Medtronic’s clinical trials were criticized geons that Infuse may be okay. This is ecutors have closed their investigation. by The Spine Journal and U.S. sena- important to Medtronic and the spine tors. They claimed Infuse isn’t as safe industry in general because Infuse is Chris O’Connell, Medtronic’s executive as Medtronic says and that Medtronic’s considered a very effective product that vice president and head of the group paid trials led to biased results. Yale helps increase fusion rates,” concluded which includes the spine business, said, University is currently reviewing the Biegelsen. “We are pleased.” safety of the spine product. Medtronic is paying the school $2.5 million for an Medtronic will report quarterly spine This ends federal civil and criminal independent review. sales on May 22. investigations of the company that began on October 6, 2008, when Given the duration of the investigation, —WE (May 17, 2012) Medtronic received a subpoena from Wells Fargo Analyst Larry Biegelsen the U.S. Attorney’s Office for the Dis- said he was surprised that the govern-

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“Fear and Medical that “building on quality health care” Cheryl Smith as a medical tourism sales and excelling at specialties and treat- manager. Smith told physician attend- Tourism” in Vegas ments people can’t get anywhere else ees at the symposium that they are now are the most important elements in “brand ambassadors.” Smith, wrote edical tourism is usually associ- developing a thriving medical tourism Velotta, told the group, “You can man- Mated with foreign exotic places industry. age their experiences when they’re here, like India, Thailand and Costa Rica. and we want to give people a healthy Yevgeniy Khavkin, M.D., is a neuro- reason to choose Las Vegas.” But Vegas? The metaphors are beyond surgeon at the Nevada Spine Institute, tempting. One-armed bandits; what which markets in Russia, China and Velotta cited the example of an exist- happens in Vegas...; gambling with Middle East. Khavkin said Russian ing specialty at the Gastric Band Insti- your health; Fear and Healing in Vegas. patients are convinced that the best tute, which offers surgical remedies for Our gonzo-journalism hero, Hunter medical care in the world is offered in obesity. Such a specialty has what many Thompson, would be inspired. the U.S. and he and his physician wife consider to be a perfect medical tour- are more than willing to see their for- ism operation. Surgeries are short and According to a story by Richard Velotta mer countrymen as patients. relatively painless, but patients need to on May 16 in VEGASINC, a group called stay in the area for several days for post- the Southern Nevada Medical Industry The asset analysis reported by Velotta surgical follow-ups. Coalition is in the process of drafting an would be an inventory of the medical asset analysis and a quality algorithm specialties available in Southern Nevada Perhaps to have a walletectomy per- before writing a feasibility study on how while the quality algorithm would formed at one of the family friendly to grow Southern Nevada’s $50 billion compare quality of care and treatment casinos. They could also save the stem medical tourism industry as well as its outcomes achieved in the area against cells from the gastric procedure and $106 billion medical wellness industry. peers nationwide. prepare them for regenerative thera- pies. Your fat stays in Vegas, but you Velotta writes that at a recent sympo- The Las Vegas Convention and Visitors take the stem cells home. sium an all-star panel of doctors agreed Authority embraced the concept, hiring Panelists agreed that as the reputation of medical professionals in Las Vegas becomes more widely known, more specialists will consider moving to the city. But they bet- ter sharpen up their skills as brand man- agers.

We’d love to hear from our readers which specialty med- ical services they’d suggest to the coali- tion.

—WE (June 16, 2012)

Steve Marcus and Las Vegas Sun/Cleveland Clinic Lou Ruvo Center for Brain Health, designed by Frank Gehry

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OrthoSensor Builds investor confidence in OrthoSensor and key information to a graphic display, the tremendous market opportunity for enabling surgeons to make informed Cash Stash intelligent orthopedics,” said Pierce in adjustments to the soft tissues to opti- the May 7 press release. “Since the start mize implant placement. The company rthoSensor, Inc., developer of an of our limited release in September, the says that accurate implant placement orthopedic device that provides O OrthoSensor Knee Balancer has been and soft tissue balance have been shown real-time data to surgeons during sur- adopted in some of the most prestigious to extend the life of implants, reduce gery, announced in early May that the orthopedic facilities in the United States the incidence of revision surgeries and company has raised an additional $15 and is providing a wealth of data asso- improve patient function. million in financing. The additional ciated with soft tissue tensioning and capital raised the company’s total Series knee kinematics. We will utilize these The company has three product plat- B investment to $36 million. funds to expand the commercial launch forms: OrthoSensor Surgical, Ortho- of the Knee Balancer and to bring to Sensor Implantables and OrthoSensor Jay Pierce, the company’s CEO, said the market the next products in our port- Analytics. Ft. Lauderdale, Florida-based company folio of intelligent orthopedic devices. will use the cash to expand the com- Our cutting edge technology is poised —WE (May 15, 2012) mercialization of its first product, the to transform the treatment of musculo- OrthoSensor Knee Balancer, as well as skeletal disease by facilitating evidence- bringing new products to the market. based orthopedics.” The company announced a partnership with Stryker Corporation last August to use the device with the Stryker Triath- Intelligent Orthopedics lon knee implant. Pierce reportedly said the “intelligent” device has the potential The Knee Balancer is embedded to be compatible with any implant. with sensors that provide sur- geons with actionable data on “The strong interest in our latest round implant fit and knee kinematics. of funding demonstrates the continued The sensors wirelessly transmit

OrthoSensor, Inc./OrthoSensor Knee Balancer

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biologics ing from a variety of ailments. large joints “It’s a growing concept,” says Darryn Save That Cord! Keast, the regional manager for Med- Nevada Doc Builds Cells, the company responsible for col- Own Hospital, Rehab shton Arbuckle had barely been lecting Ashton’s blood. “Since 2010, Unit Aborn at City Hospital in Dubai cord blood has surpassed bone marrow as the transplant of choice because there before a doctor was collecting blood t is many orthopedists dream to own is no pain or risk. Because more people from his umbilical cord and preparing their own surgery facility—to con- are storing, more of these samples are I it for shipment. Within hours the refrig- trol outcomes with their own clinic and available,” he said. erated blood was on its way to the UK staff. One who has done that is Michael to be placed in a cryogenic storage unit Crovetti, M.D. who practices out of the There are now more than 200 cord for the next 25 years. As reported by Coronado Medical Center, Las Vegas, blood banks operating in the U.S. and Alice Haine for the UAE The National Nevada. Ignoring the fact that reim- internationally. In the U.S. the FDA now on May 10, the Arbuckles arranged for bursements for surgical procedures regulates cord blood banking nationally. the procedure because of the possibility were being cut, three years ago Crovetti that the stem cells in baby Ashton’s cord Twenty-seven states have enacted cord blood could save his life and the lives of blood education bills that cover 81 % any siblings he may have in the future. of U.S. births. Of those four states only require education about cord blood Umbilical cord blood is a rich source of donation while the other 23 follow the stem cells which have the ability to self- federal Institute of Medicine guidelines renew almost indefinitely. They also can that call for parent education about all develop into cells with specialized char- options for their child’s cord blood. acteristics that researchers believe may, Courtesy of Dr. Michael Crovetti and Coronado Medi- in the future, be useful in the treatment —BY (May 17, 2012) cal Center of scores of illnesses. invested $2.5 million in a surgery site and $1.2 million in a recovery suite The first suc- concept to help rehabilitate patients cessful cord following their procedures. blood trans- plant to regen- While Crovetti admitted to a reporter erate blood and for the Las Vegas Review Journal that he immune cells might be a “control freak” he notes that took place in his hip and knee replacement patients France in 1988 are walking a few hours following their on a six-year-old surgery. His staff nurses, anesthesiolo- American boy gists and assistants have been with him suffering from for years and provide the team effort Fanconi’s ane- that, he maintains, controls the out- mia. According come he wants. to Haine, since then more than “Repetition is the secret to success in 30,000 cord my business because that’s what pre- blood stem-cell vents mistakes being made. It’s about transplants have not skipping steps, making sure every taken place on box is checked. Repetition equals safe- patients suffer- Wikimedia Commons and Jeremy Kemp ty for the patients,” Crovetti said in the

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May 13 press release. The second criti- cal criteria for him is that his patients see an upbeat and positive staff that is driven by the desire to provide the best patient outcomes. “It comes down to patient satisfaction and that comes from working well together. The biggest feedback I get is how pleasant and won- derful everyone is,” he said.

According to the Review Journal, Nevada is one of 22 states that require national accreditation from a regula- tory body in order for an office-based surgery center to exist. The three pri- mary accrediting organizations that are recognized by states that require accreditation are the Joint Commission on Accreditation of Healthcare Organi- zations, the Accreditation Association for Ambulatory Health Care (AAAHC) and the American Association for Accreditation of Ambulatory Surgery Facilities.

Crovetti received his accreditation from AAAHC and has a transfer agreement with a nearby hospital in case he runs into surgery complications. He has also received accreditation for his recovery suite model, a concept he is pitching to other surgeons around the country. His belief is that, while he, himself, follows best practices when it comes to surgery, a patient’s ultimate benefit comes when he or she start moving that replaced knee or hip as soon as possible after surgery.

So far Crovetti’s enterprise is succeed- ing, despite tough economic times. Advertisement Besides the quality of the service, the key appears to be volume. Crovetti, While Crovetti admits that his timing “Nothing is going to replace watching a who primarily replaces knees and hips, could not have been worse when he guy who just had his hip replaced walk- does about 600 surgeries a year. He has opened a surgery center in 2009 and ing down the hall three hours later,” he partners who share the facility with the recovery suites in 2010, there is one said. him. Altogether, they do about 2,000 image he sees almost daily that convinc- surgeries annually at the site. es him that he made the right decision. —BY (May 18, 2012)

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Nanoparticles Reduce immune toxicity substantially by incor- porating non-immune stimulatory Joint Damage DNA into nanoparticles. Thus, DNA nanoparticles protect healthy tissues esearchers from the Georgia Health from immune-mediated destruction, Sciences University (GHSU) have R and may alleviate damage to joints in discovered that a DNA-covered sub- patients with arthritis.” microscopic bead used to deliver genes or drugs directly into cells to treat dis- As for when might this work result in ease appears to have therapeutic value a treatment, Dr. Mellor commented to just by showing up. Indeed, within a OTW, “This study, and related work in few hours of injecting empty-handed Medical College of Georgia other centers, has created a completely DNA nanoparticles, the team found an new perspective on how to manipulate increased expression of an enzyme that effective in reducing joint damage in a the immune system to prevent, slow calms the immune response—indoleo- mouse model of rheumatoid arthritis. or reverse immune-mediated destruc- mine 2,3 dioxygenase, or IDO. This point is important because DNA tion of healthy tissues in several mouse nanoparticles are versatile and can be models of human autoimmune diseas- “It’s like pouring water on a fire,” said readily adapted for clinical applications es. It is difficult to estimate how long it Dr. Andrew L. Mellor, Director of the such as arthritis treatment. For exam- will take these new scientific insights to GHSU’s Medical College of Georgia ple, polymer scientists have developed work their way into new clinical treat- Immunotherapy Center and the study’s biodegradable polymers with lower ments and procedures, but these new corresponding author, in the May 15, immune toxicity, both highly desirable developments could lead to initial clini- 2012 news release. “The fire is burning features for clinical reagents to treat cal trials in the next 5-10 years.” down the house, which in this case is the arthritis. In our study, we also report- tissue normally required for your joints ed a simple but novel way to reduce —EH (May 18, 2012) to work smoothly,” Mellor said of the immune system’s inexplicable attack on bone-cushioning cartilage. “When IDO levels are high, there is more water to control the fire.”

Follow-up studies include document- ing all cells that respond by producing more IDO. GHSU researchers already are working with biopolymer experts at the Massachusetts Institute of Technol- ogy, the University of California, Berke- ley and the Georgia Institute of Tech- nology to identify the optimal polymer. The polymer used in the study is not biodegradable so the researchers need one that will eventually safely degrade in the body. Ideally, they’d also like it to target specific cells, such as those near inflamed joints, to minimize any poten- tial ill effects.

Dr. Mellor told OTW, “The most important point to emerge from our study is that DNA nanoparticles were Advertisement

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Practice Makes TKRs Shorter, ciplinary inpatient co-management approach. The hospital with the shortest operating time was equipped with a dedi- Fewer and Better cated operating room team that was reserved for total knee replacement surgery. here total knee replacements (TKR) are concerned, practice appears to speed everything up. According W —BY (May 17, 2012) to a study in Health Affairs, reported May 10 by Becker’s Spine Review writer Sabrina Rodak, the patients of sur- geons who performed more total knee replacements tended to have shorter lengths of hospital stay, shorter operating times and fewer complications than those operated on by surgeons who performed fewer such surgeries.

Five hospitals that are organized under the High Value Healthcare Collaborative, a consortium of health systems, examined differences in their mode of delivery of care to primary total knee replacement patients. They found that there was significant variation among the five institutions in how they related to their patients.

For example, the hospitals with the lowest in-hospital com- plication rate had a preoperative approach to outpatients that used a multispecialty evaluation of the patient. When the patient was in the hospital the staff used a multidis- Andrew Huth Photography and RRY Publications

Predict Arthritis Before Symptoms Arrive!

ow, a research team from the NUniversity of Missouri’s (MU) Comparative Orthopaedic Laboratory has found a way to detect and predict arthritis before patients begin suffering from symptoms. The study, published in the Journal of Knee Surgery, involved analyzing the joints of dogs that suffer from arthritis.

James Cook, a researcher from the MU College of Veterinary Medicine and the William C. and Kathryn E. Allen Distin- guished Professor in Orthopaedic Sur- gery, along with MU researchers Bridget University of Missouri Garner, Aaron Stoker, Keiichi Kuroki, Cristi Cook, and Prakash Jayabalan, if a patient is developing arthritis as well gle drop of fluid from a patient’s joint, have developed a test using specific bio- as predict the potential severity of the which is obtained with a small needle markers that can accurately determine disease. The test can be run off of a sin- similar to drawing blood.

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“With this biomarker test, we can study Arthritis: Manipulate the levels of specific proteins that we now know are associated with osteoar- Cilia, Reduce thritis,” Cook said in the May 15, 2012 Inflammation? news release. “Not only does the test have the potential to help predict future cientists from Queen Mary, Univer- arthritis, but it also tells us about the Ssity of London have found a new early mechanisms of arthritis, which therapeutic target to combat inflamma- will lead to better treatments in the tion: primary cilia. They took cartilage cells and exposed them to a group of Wikimedia Commons and Katherine Connolly-Dart- future.” mouth Electron Microscope Facility inflammatory proteins called cytokines, “This test has already shown early use- specifically interleukin-1 (IL-1), to see ter manipulate the primary cilium, we fulness for allowing us to monitor how whether there were any changes to the could potentially attenuate or even pre- different treatments affect the arthritic primary cilia. There were… vent inflammation,” he said. joints in people,” Cook said. “With fur- ther validation, this test will allow doc- The research, published in the journal As for where they go from here, Dr. tors to adjust and fine tune treatments Cellular and Molecular Life Sciences, Knight told OTW, “Ongoing research in to individual patients. Also, being able revealed tiny organelles called pri- my group, funded by Arthritis Research to tell patients when they are at a high mary cilia are important for regulating UK and the BBSRC [Biotechnology risk for developing arthritis will give inflammation. Dr. Martin Knight who and Biological Sciences Research doctors a strong motivational tool to led the research at Queen Mary’s School Council], is investigating the role of a convince patients to take preventive of Engineering and Materials Science specific primary cilia signalling path- measures including appropriate exer- said in the May 9, 2012 news release: way, known as hedgehog signalling. cise and diet change.” “Although primary cilia were discov- This pathway is aberrantly activated in ered more than a century ago, we’re osteoarthritis and drives the degradation Asked to describe the process of how only beginning to realise the impor- of the cartilage and yet nobody knows the test is being adapted to humans, tance they play in different diseases and why. We hypothesize that mechanical Dr. Cook told OTW, “It is actually conditions, and the potential therapeu- injury and subsequent inflammation already adapted to humans in terms of tic benefits that could be developed alters the structure of primary cilia the methodology—meaning, we use from manipulating cilia structure and leading to changes in cell function and the exact same technique (1-2 drops function.” the development of arthritis. The next of fluid from the joint) and the exact critical phase of our cartilage research same panel of proteins for humans “When we exposed the cells to IL-1, at Queen Mary University of London, as we do in dogs—we just have not in just three hours the primary cilia is to identify pharmaceutical agents in obtained nearly as much data in peo- showed a 50% increase in length. But the form of small molecules which reg- ple yet as we have in dogs—so we what was most interesting was when we ulate cilia structure. This will allow us need to keep doing studies to make treated cells to prevent this elongation to manipulate the complex structure- sure that we validate the test for all the of the cilium. The cartilage cells had a function relationship for primary cilia applications in people, i.e., screening greatly reduced response to the inflam- thereby controlling the cellular signal- for early arthritis, determining sever- matory proteins and were therefore not ling pathways that lead to joint inflam- ity of arthritis, and assessing response as inflamed. This suggests a brand new mation and arthritis. We are in the pro- to various treatments—these valida- therapeutic target for inflammation.” cess of applying for grant funding for tion studies will take several years and this ambitious proposal which we hope are part of the process for gaining FDA Co-author Dr. Angus Wann, said this will lead to a totally novel treatment for approval for clinical use of this as a is the first time primary cilia have been arthritis and an improved understand- diagnostic test in people.” suggested as a target for novel thera- ing of this complex disease.” pies to reduce the effects of inflamma- —EH (May 18, 2012) tion. “If we can work out how to bet- —EH (May 16, 2012)

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discogenic pain by sealing the painful do not have large disc herniations spine disc disruptions, reducing inflamma- or a history of lumbar spine surgery. tion, and enhancing tissue repair. While surgery is an appropriate option CBS Featured Sealant for many patients, company officials for Low Back Pain The company completed a 15-patient, believe that there is a great need for an Phase II clinical trial with a two-year fol- interventional treatment for patients low up in January 2011. The Phase III with early disc degeneration when sur- n May 6 a national TV program trial, which is randomized and placebo gery is the least desirable option. They (CBS Sunday Morning) focused O controlled, will involve 260 subjects in maintain that, currently, there is no attention on the Phase III clinical study 20 centers across the U.S. Enrollment is conservative or interventional therapy being conducted by Biostat System for more than 85% complete, according to with unequivocal efficacy for treating the treatment of discogenic low back Gary Sabins, president and CEO of Spi- chronic discogenic pain in this patient pain. The Biostat System, as described nal Restoration, who said, “Spinal Res- population. by its manufacturer, Spinal Restoraton, toration is excited about the progress Inc., is a new drug limited by federal law that has been made toward developing The Biostat System study is the first to investigational use only. The system the rigorous scientific evidence neces- intradiscal biologic therapy for dis- consists of BIOSTAT BIOLOGX Fibrin sary to obtain regulatory approval for cogenic pain to enter into a Phase III Sealant, a human derived, resorbable the Biostat System.” clinical trial. An estimated four million biologic tissue sealant, and a proprietary adults in the United States suffer from application system designed to safely low back pain. deliver the biologic to the intervertebral Investigators are studying the Biostat disc. Proponents assert that application System in subjects who suffer from —BY (May 18, 2012) of the sealant to the disc may alleviate chronic discogenic low back pain but

Biostat System

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OIC Launches Pedicle na in the May 14, 2012 news release. OIC entered the medical device market “This is another demonstration of how in 2010, pledging to save more than a Screw System we deliver high quality implants at cost- billion dollars in health care costs by effective levels while strengthening our 2015. The company will be exhibiting he Orthopaedic Implant Company position in the marketplace.” at the 10th Annual Orthopedic, Spine (OIC) has announced the launch T and Pain Management-Driven ASC of its Pedicle Screw System. The new Conference June 14 – 16 in Chicago. product line is used for stabilization The new system provides surgeons President Itai Nemovicher will be pre- and fixation during posterior spinal with a full range of implants with reli- senting the company’s new product line fusion procedures. able and reproducible results. The sys- and will be available to discuss OIC’s tem includes poly-axial pedicle screws, cost-effective approach to working with “Our pedicle screw product line repre- rods and cross connectors for posterior hospitals and insurers. sents a simple, intuitive system that can lumbar fusions. The system’s unique set save hospitals and surgery centers up to screw design prevents cross threading, According to OIC, its implants are 50 $3,000 per fusion level,” said OIC’s V.P. and components are color-coded by to 60% of the average market price of of Business Development Mark Medi- size for easy identification. premium implants, potentially saving health care systems millions of dol- lars a year. High-quality, low-cost implants and products can be used for a variety of procedures, including treatment of broken bones, lumbar fusions and joint replacements. All OIC products are FDA approved and manufactured in ISO 13485 facilities.

Asked how they save $3,000 per fusion, Itai Nemovicher told OTW, There are a number of ways we are able to drive down the cost. We’ve created a system that is simplistic and includes instrumentation that surgeons/OR staff are very familiar with. This offers surgeons/OR staff a level of comfort that provides OIC the ability to reduce our costs by elimi- nating the need for representation on a case by case basis. In addition and staying true to OIC’s vision of fiscal responsibility, we don’t over inflate our implant pricing to what the cur- rent market tolerates. Even though OIC could apply a larger premium on our pricing to align them with hospi- tal dictated formulary/matrix pricing, we choose not to.

The Orthopaedic Implant Company —EH (May 16, 2012)

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HSS, Boachie, Open “The medical outreach program has tion, Dr. Boachie-Adjei told OTW, “Six been sustained by more than 1,800 months ago we were completing the Orthopedic Hospital in donors who have contributed in furnishing and equipment installation Ghana excess of $10 million and a $1.5 mil- while holding outpatient clinics for lion Ghanaian government grant,” patients who were coming to our old hana…where the dreams of one said Dr. Boachie-Adjie in the April 26, clinic. A lot of sophisticated equipment Gorthopedist converge with the 2012 news release. “FOCOS aspires to needed expert installers for the U.S. and hopes of those needing care. Hospital become the premier orthopedic teach- Germany working with local engineers. for Special Surgery (HSS) and Oheneba ing hospital in sub-Saharan Africa. I New hospital accreditation applica- Boachie-Adjei, M.D., chief of the scolio- have worked with a pioneering team of tion had been submitted to the Ghana sis service at Hospital for Special Sur- international volunteers, including col- Health service and staff was recruited gery and founder and president of the leagues at Special Surgery, to make this and policies and procedures were put in Foundation of Orthopedics and Com- Hospital a reality.” place and all inspection programs were plex Spine (FOCOS), have announced arranged and completed by the admin- the opening of a 50-bed specialty hos- “As a world leader in musculoskeletal istrative staff.” pital providing comprehensive muscu- medicine, Hospital for Special Surgery loskeletal care for adults and children in is committed to national as well as Looking to the future, Dr. Boachie-Adjei Ghana, Africa. international outreach,” said Louis A. commented to OTW, “A year from now Shapiro, FACHE, president and CEO, we hope to be fully operational with “FOCOS’s mission is to provide afford- Hospital for Special Surgery. “We are a regular surgical schedule beside the able orthopedic care to those who would proud to have supported Dr. Boachie in quarterly mission trips. We want the not otherwise have access to such treat- his efforts to make the FOCOS Ortho- local surgeons to use the facility to treat ment,” explained Dr. Boachie-Adjei in paedic Hospital a reality.” orthopedic patients.” the April 26, 2012 news release. Dr. Boachie-Adjei was born in Kumasi, Asked what had to happen in the last —EH (May 14, 2012) Ghana, and immigrated to the United six months for this to come to comple- States in 1972. “The patients we treat both surgically and nonsurgi- cally have disabling muscu- loskeletal disorders includ- ing complex spine deformi- ties and pediatric orthopedic problems.”

The FOCOS Orthopaedic Hospital—located on 10 acres—will also serve those in need of emergency medicine, ambulance services, diag- nostics (including MRI, CT, echocardiogram, catheteriza- tion lab, complete labora- tory services and radiology), pharmacy and physiotherapy. Since its inception in 1998, Dr. Boachie-Adjei—through FOCOS—has treated more than 17,000 local and inter- national patients. Hospital for Special Surgery

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