The State of the World of

Musculoskeletal Health

MOVE
BETTER.
LIVE
BETTER.

Orthopaedic Surgery and

Rheumatology
2017–2018 Annual Report
“The field of musculoskeletal

health is advancing at a rapid pace,

with new methods of patient care,

cutting-edge research,

life-changing innovation

and knowledge sharing

across the industry.”

LOUIS A. SHAPIRO

President and
Chief Executive Officer
02
Message from the
Surgeon-in-Chief and
Physician-in-Chief

50
Reports from the Field

04
Cutting-Edge Initiatives
11 ways HSS is advancing

52
the field of musculoskeletal
health

Orthopaedic Surgery
Updates

16
Breakthroughs on
the Horizon
19 research initiatives that
will improve the care of both
routine and complex cases

46
38 Achievements and
Fast Facts

Local and Global

Leadership
Our impact on patient care, 80
48
research and education Rheumatology
in the U.S. and around the Updates
world

Our Partners in
Patient Care
Six departments that
enable HSS to deliver expert
musculoskeletal care

1
MESSAGE
The field of musculoskeletal health is
evolving rapidly. With the exponential
growth of technology and a focus on value-
based care, orthopaedics, as a specialty,
is becoming increasingly complex. A variety
of innovations are revolutionizing the
FROM THE field. Advances such as three-dimensional
surgical navigation, computer-aided design

SURGEON-IN-CHIEF and additive manufacturing are enabling

us to provide more precise, higher quality
care than ever before. At HSS, it is our

AND PHYSICIAN-IN-CHIEF privilege and responsibility to advance the

field of musculoskeletal health.

With access to a high volume of orthopaedic

patients over the course of our history,
we are more and more focused on how
patients fare in both the short-term and the
long-term. We are collecting and studying
patient-reported outcomes, such as pain,
function and quality of life, to understand
how much improvement our patients
achieve and evaluate whether — and how —
we can do better. As we care for patients
over their lifetimes, we continue to refine
our team approach through collaboration
with nurse practitioners, perioperative and
pain management physicians, and physical
therapists.

At HSS, we use a collaborative, multi-

disciplinary approach to improve
outcomes in our high volume of patients
with musculoskeletal health conditions and
disorders. This is especially effective when
treating complex conditions. For instance,
members of the Metabolic Bone Disease/
Musculoskeletal Oncology Service — which
is composed of physicians and nurse
practitioners who specialize in orthopae-
dics, endocrinology, rheumatology and
women’s health — and the Bone Health and
Osteoporosis Center of Excellence manage
patients with bone diseases. The Service
provides medical care for these patients,
while the Center performs scans and testing,
including trabecular bone score, body
2
composition, vertebral fracture assessment
and atypical femoral fracture assessment.
When patients require surgery, our
physicians ensure that they are medically
optimized to achieve the best possible
outcomes. Every HSS patient is assigned
a medical physician familiar with the
perioperative care of orthopaedic patients.
These physicians assess patients prior to
surgery and identify medical problems
that could affect surgical outcomes, such
as diabetes and obesity. Our perioperative
physicians also follow patients after surgery,
managing wound problems, leg swelling and
other complications. Carefully evaluating
patients before and after surgery helps to
decrease postoperative complications and
readmission rates.
To improve our care of both routine
and complex patients, many of our
physicians and scientists are working to
develop answers to questions that are
big and small so that we may enhance
knowledge in the field. There are 47 active
research registries at HSS with more than
190,000 patients enrolled. In 2018, our
genomics research program expanded
and is now focused on preventing and
repairing musculoskeletal tissue damage
related to acute or chronic injury, aging,
autoimmunity and inflammation. We are
also investigating medications that may
improve osseointegration, new methods of The state of the world of musculoskeletal
implant fixation, and molecular approaches health is continually advancing. We look
for rejuvenating spinal discs. Other areas of forward to helping more patients across the
research include innovative ways to relieve globe regain mobility through our cutting-
osteoarthritis pain, new types of stem cells edge research initiatives, collaborations with
to repair rotator cuff injuries, and total hip the local, national and international medical
replacement outcomes in patients with community, and professional education
rheumatoid arthritis. programs, which are featured on the
following pages.
At HSS, we aim to improve musculoskeletal
health around the world by sharing our
knowledge and collaborating with leaders
in the field. Through HSS eAcademy®, our
digital platform, we provide education
TODD J. ALBERT, MD, FACS
programs to professionals across the globe.
In the 2017–2018 academic year, more Surgeon-in-Chief and Medical Director
than 25,400 medical professionals from Korein-Wilson Professor of
130 countries chose HSS eAcademy® for Orthopaedic Surgery
continuing medical education. In 2018,
we continued to expand our international
presence by extending our collaboration
with Bumin Hospital Group in South Korea.
We partner with several Chinese institutions MARY K. CROW, MD
to educate orthopaedic surgeons and Physician-in-Chief
trainees through the HSS-China Orthopaedic Chair, Department of Medicine
Education Exchange, which involves annual Chief, Rheumatology Division
symposia, live videoconferencing and Benjamin M. Rosen Chair in Immunology
programs that enable Chinese orthopaedic and Inflammation Research
surgeons to travel to HSS to observe our Joseph P. Routh Professor of Rheumatic
clinicians or conduct research. Through Disease Medicine
the HSS Stavros Niarchos Foundation
Orthopaedic Seminar, Greek surgeons also
travel to HSS to learn about complex total
hip and knee replacements.
3
CUTTING-EDGE
INITIATIVES
01
Managing patients
with complicated joint
replacement needs
02
New hope for the youngest,
most complex hip patients
03
Advancing high-value
care and outcomes for
patients
04
Leveraging multidisciplinary
expertise to conquer
a debilitating condition
05 09
Taking the lead in responsible Creating a better
opioid prescribing future for scleroderma
patients
06
A new focus of periprosthetic 10
joint infection research Optimizing bone health
for the best surgical
07 outcomes
Using orthobiologics
to improve rotator cuff 11
outcomes Building a better
elbow
08
Enhancing surgical precision
with three-dimensional
navigation

4
 01
Some joint replacement patients are so complex that they
have trouble finding care. Oftentimes, they are referred to the
Stavros Niarchos Foundation Complex Joint Reconstruction
Center (CJRC) at HSS. The only center of its kind, CJRC tackles
the most challenging complex cases. “These are the kinds of
cases nobody wants to touch, that are fraught with disaster,” says

Managing Thomas P. Sculco, MD, Director of the Center, Thomas P. Sculco

MD Chair in Orthopaedic Surgery, Surgeon-in-Chief Emeritus
and Attending Orthopaedic Surgeon. “There are institutions that

patients with
do revisions, but there are very few places that do a lot of them,
like we do.”

The Center aims to obtain better data about these complex

problems, investigate algorithmic approaches for the best care,

complicated and guide surgeons in identifying specific problems and using

the best techniques to repair the damage. The Center, which
has 17 HSS surgeons, has enrolled over 900 patients since its

joint
inception almost two years ago. Fifty of these have come from
external sources. “We discuss each of these external cases, then
come up with a consensus on a treatment plan,” says Dr. Sculco.

Another goal of the Center is to conduct research on the causes,

replacement treatment and prevention of implant failure. The cases currently

in the Center’s revision registry provide a rich repository that
allows HSS to track outcomes and study significant clinical

needs
problems, such as joint infections and periprosthetic fractures.
“There’s no registry like it in the world,” says Dr. Sculco. “We have
an 80 percent follow-up at one year, and we plan to continue to
aggressively follow the outcomes prospectively.” The CJRC has
published 15 papers since its inception in January 2017 and has
presented data at the Hip Society and American Academy of
Orthopaedic Surgeons meetings.

The revision registry has generated tremendous interest from

surgeons and researchers around the world who would like to
learn from our experience. Eventually, Dr. Sculco plans to include
cases from other institutions in the registry. “When we refine
it, we’ll start to release it to centers that do a lot of revisions,” he
says. “I believe that what we’re doing here impacts physicians
and patients across the globe.”

“
HSS surgeons aim to obtain better
data about challenging cases and
guide physicians in using the best
techniques to address them.”

THOMAS P. SCULCO, MD
Director of the Stavros Niarchos Foundation
Complex Joint Reconstruction Center and
Thomas P. Sculco MD Chair in Orthopaedic Surgery

Three-dimensional
CT reconstruction
for a custom-made
titanium acetabular
component to
treat severe bone
loss during a
revision total hip
arthroplasty

5
 02
A hip or knee replacement for a young patient with juvenile
inflammatory arthritis or skeletal dysplasia can be life-changing,
but it’s technically challenging for the surgeon. Patients under
age 20 tend to have smaller, more deformed bones compared
to their older counterparts, and standard, off-the-shelf implants
sometimes can’t be used. At HSS, these patients often receive

New hope custom implants, thanks to a unique collaboration among

specialists who ensure seamless care. Our rheumatologists
provide proper medical care; our orthopaedic surgeons determine

for the
when surgery is appropriate; and engineers in our Department
of Biomechanics design the implants with our clinicians’ input.

To improve patient access to appropriately sized implants,

HSS is collaborating with WishBone Medical, Inc., a new global

youngest, pediatric orthopaedic company. We are developing a Pediatric

Total Hip system designed for children with juvenile idiopathic
arthritis or congenital dysplastic hip disease. The system will

most
be modular, meaning it can be used for patients with different
anatomical needs. “We have a database of 250 knee and 900
hip replacements in patients under age 35 with diseases such
as skeletal dysplasia, juvenile inflammatory arthritis, avascular

complex
necrosis and hemophilia,” says Mark P. Figgie, MD, Chief of the
Surgical Arthritis Service, Allan E. Inglis MD Chair in Surgical
Arthritis and Attending Orthopaedic Surgeon. “We are using that
database to design an implant system that will work for young

hip patients
patients. We are making good progress in coming up with some
preliminary designs.”

One important goal is to increase the longevity of implants in

juvenile arthritis patients under age 35. Research conducted by
Dr. Figgie has shown that survivorship in young patients is not as
good as it is in older patients. In the study, which was presented
at the American College of Rheumatology and American Academy
of Orthopaedic Surgeons annual meetings, HSS researchers found
that total hip replacements lasted at least 10 years in 85 percent
of juvenile arthritis patients and 20 years in half of those patients.
Now Dr. Figgie and colleagues are investigating why some complex
hip replacements fail or require a revision procedure. “The results
will help us to improve the design of hip implants,” he says. “These
patients need more durable results.”

“
We are using our database of 250 knee
and 900 hip replacements in patients
under age 35 with diseases such as skeletal
dysplasia and juvenile inflammatory
arthritis to design an implant system that
will work for young patients.”

MARK P. FIGGIE, MD
Chief of the Surgical Arthritis Service
Multiple epiphyseal and Allan E. Inglis MD Chair in Surgical Arthritis
dysplasia (top).
Bilateral hip
replacement
(bottom) required
custom implants
with corrected
anteversion.

6
 03
Our commitment to providing value-based care is reflected in our
high-quality services and low complication rates. “HSS leads the
country in performance on a number of different safety measures,”
says Catherine H. MacLean, MD, PhD, Chief Value Medical Officer.
“As a result, our total cost for an episode of care is lower than that
of other hospitals.”

Advancing While safety is of paramount importance, patients come to HSS

to get better. So we are focused on studying patient-reported
outcome measures, or PROMs. “We’re measuring PROMs as a

high-value standard of care because we want to understand how our patients

are doing in terms of improving their pain and functional status,”
says Dr. MacLean. One measure of functional status is the ability
to work — not just show up at work, but function at full capacity.

care and This is known as “presenteeism.” We are beginning to measure

HSS patients’ presenteeism before and after hip, knee and lumbar
spine surgeries. While preliminary results appear to be favorable,

outcomes
the studies won’t be complete for another year, says Dr. MacLean.

HSS physicians also aim to be responsible when prescribing medi-

cations. “Rheumatologists are the stewards of a number of very
expensive drugs, including adalimumab, infliximab, etanercept

for patients and rituximab — four of the five drugs with the highest dollar sales
worldwide,” says Dr. MacLean. “These medications are often
effective for rheumatoid arthritis (RA) patients, but there are less
expensive alternatives that may be appropriate for certain patients.
By routinely assessing disease activity and patient outcomes, we
can be more thoughtful about the drugs we prescribe.” At the
same time, physicians need to have open, honest conversations
with their patients about the costs of medical care — in particular,
these very expensive medications, which cost thousands of dollars
per month. Given the choice between two similarly effective drugs,
patients might prefer the less expensive option, especially if they
have a high co-pay or no insurance.

The highest value care for rheumatoid arthritis is that which

prevents long-term disease or joint damage. Hence, our first objec-
tive is to treat early and aggressively with the best drug for the
individual patient, be that a conventional drug or a more expensive
biologic one. This has resulted in a marked reduction in the devel-
opment of joint damage, deformity and disability. “When I was a
fellow, there were always wheelchairs in the rheumatology waiting
room,” says Dr. MacLean. “They are a pretty rare sight these days.”

At HSS,
rheumatologists
aim to be
thoughtful about
the drugs they
prescribe, since
there are often
less expensive
medications (left)
for patients.

7
 04
In 2017, HSS launched a multi-pronged effort to uncover the
mechanisms behind arthrofibrosis, a debilitating complication
of knee replacement surgery marked by stiffness and pain due
to excessive scar tissue formation inside the joint. The project
involves scientists and clinicians from nearly every department at
HSS — Orthopaedic Surgery, Research, Biomechanics, Radiology

Leveraging and Imaging, and Pathology and Laboratory Medicine — as well

as colleagues at Mayo Clinic. Supported by HSS Trustee Marina
Kellen French and the Anna-Maria and Stephen Kellen Foundation,

multidisciplinary
the study is already improving our understanding of the condition
and opening new lines of scientific inquiry.

The study has two arms. In the first, researchers are studying
patients who are undergoing knee replacement revision surgery

expertise to as a result of arthrofibrosis and other causes, such as implant

loosening and instability. Our radiologists are conducting imaging
studies to separate patients into groups based on the reason for

conquer
their revision surgery. They are performing CT to carefully assess
component alignment and rotation and MRI to identify the specific
regions in the joint with fibrosis and quantify the amount of fibrosis.
After the patients have surgery, our researchers are performing

a debilitating
comprehensive analyses of their joint tissues, blood and synovial
fluids. They are conducting molecular analyses, including RNA
sequencing, on the collected tissue. Although the data is
preliminary, the RNA sequencing analysis has already revealed

condition
discrete differences between the patients with arthrofibrosis
and those who are undergoing revision surgery for other reasons.
“What’s exciting is that we’re seeing distinct gene signatures, with
specific genes up- or down-regulated even in tissues that have
the same composition and histological appearance,” says Miguel
Otero, PhD, Co-Director of the Derfner Foundation Precision
Medicine Laboratory and Assistant Scientist. “If those results
hold up, we will begin to understand the mechanisms behind the
condition, which is the first step to developing a therapy.”

In the second arm of the study, researchers will collect data

from patients undergoing primary knee replacements to look for
blood or tissue-specific markers associated with arthrofibrosis
and cellular mechanisms that may predict the risk of developing
complications after surgery. In addition, in a randomized, placebo-
controlled, double-blind study, patients will receive IV steroids
Arthrofibrosis before and after surgery to see if arthrofibrosis can be thwarted.
after a total knee “There’s preliminary evidence to support this,” says Peter K. Sculco,
replacement MD, Assistant Attending Orthopaedic Surgeon and the study’s
Clinical Director. “Previous published work investigating the effect
of perioperative corticosteroids on early outcomes in patients
undergoing simultaneous bilateral knee replacements found
improvements in early range-of-motion and decreased pain. This
encouraged our group to look deeper into the cellular mechanisms
behind this clinical finding.”

HSS researchers will also use a preclinical model of arthritis to

assess how specific targets identified in collected patients’ samples
contribute to the development of fibrosis. The model may provide
a way to better define disease mechanisms and develop specific
and targeted therapies. “Members of the interdisciplinary group
involved in this study are experts in their respective disciplines,
and this has allowed the study to expand in exciting and novel
directions that leverage our knowledge of preclinical models and
translational science,” says Dr. Sculco. “Only a few institutions
have the expertise, clinical exposure and resources to make a
study like this possible.”

8
 05
Orthopaedic surgeons are among the top prescribers of opioids in
the country, and more than 40 percent of all U.S. opioid overdose
deaths in 2016 involved a prescription opioid, according to the
Centers for Disease Control and Prevention. HSS is leading the
response to the opioid epidemic by providing innovative, best-in-
class care and education on pain management locally and globally.

Taking HSS has appointed a Medical Advisor, created Opioid Prescribing

Practices and launched a Controlled Substances Task Force,
an enterprise-wide committee charged with spearheading

the lead in initiatives to promote conservative prescribing and use of

opioids. Physicians across the institution, including those from
Anesthesiology, Pain Management, the Department of Medicine
and Orthopaedic Surgery, work alongside physician assistants,

responsible nurses and administrators to accomplish Task Force goals. In

addition to promoting responsible prescribing and conservative
use of opioids, the Task Force has worked to optimize the complex

opioid
patient’s surgical experience; provide education and resources
to prescribers, patients and the community via multiple channels;
and invest in opioid research and track outcomes.

One of the Task Force’s key objectives was to create a screening

prescribing process for surgeons to identify patients with complex pain

needs. Prior to surgery, HSS surgeons and internists now ask
patients simple questions about medication use. Patients taking
opioids with a history of substance abuse are referred for a
preoperative evaluation. If necessary, they receive a toxicology
screening, and HSS works with the prescribing physician to taper
the drug before surgery. “If we can identify people who need to be
tapered, they’re much safer, the surgery is less complex, and the
recovery period is much more productive,” says Seth A. Waldman,
MD, Medical Advisor, Opioid Prescribing Practices, and Director
of the Pain Management Division.

One of the most important Task Force efforts, initiated in

conjunction with HSS surgeons, was the establishment of Service-
and procedure-specific guidelines for prescribing pain medication
postoperatively. As a result of these guidelines, short-acting
opioid pills issued at discharge were, at press time, expected to
be reduced by 500,000 in 2018. Other important Task Force
accomplishments include the following:

• In March 2018, HSS rolled out short-term surgical patient-

provider opioid agreements. They help surgeons to better set
patient expectations for opioid therapy.

• HSS now has a locked, DEA-approved medication drop box,

which allows patients to safely dispose of unused opioids.

• In June 2018, HSS convened a national forum to discuss opioid-

The HSS Education free arthroplasty regimens. HSS Journal will highlight the insights
Institute has gained in the February 2019 issue.
created webinars on
best practices for • As part of our mission to serve as the most trusted educator
opioid prescribing, in musculoskeletal opioid prescribing and pain management, the
such as a module HSS Education Institute has created webinars on best practices
entitled “Building
for opioid prescribing, fact sheets for patients and prescribers,
an Institution-wide
Response to the
and patient-facing videos on the HSS website.
Opioid Epidemic.”
“We are proud of what we have accomplished at HSS to date,” says
Dr. Waldman. “Our preoperative pain evaluation program is unique.
Our next steps are to continue to develop the evidence of its
efficacy, enhance our expertise with opioid-sparing techniques,
and share our patient care protocols to help improve patient
outcomes and reduce opioid risk nationwide.”

9
 06
Over the past 50 years, efforts to control periprosthetic joint
infection (PJI) have mostly centered on conquering the bacteria
responsible for this devastating surgical complication. Now HSS
researchers are focusing on a new goal: preventing bacteria
from gaining a foothold in the first place. “Certain patients
are at higher risk of having infections after surgery, so we’re

A new focus of turning our attention toward optimizing the host to prevent
these problems,” says Alberto V. Carli, MD, Assistant Attending
Orthopaedic Surgeon.

periprosthetic In disease model studies, HSS physicians and scientists have

found that suppressing the gut flora increased the risk of infection.
“We are now homing in on how abnormal gut flora can influence
the immune system,” says Mathias P. Bostrom, Chief of the Hip

joint infection Service, Eduardo A. Salvati MD Chair in Hip Arthroplasty, and

Attending Orthopaedic Surgeon. Research from Dr. Bostrom’s lab
suggests that chronic use of antibiotics alters the gut microbiome

research
and harms immune function, leading us to believe that “patients
may want to stop taking antibiotics for a while before undergoing
joint replacement surgery,” says Assistant Scientist Xu Yang, MD.
“Also, probiotics could be useful in improving the gut microbiome,
but we need to do further experiments to confirm that.”

In the meantime, HSS scientists are making remarkable progress

toward diagnosing PJI using next-generation DNA sequencing,
which could potentially be faster and more accurate than culturing
bacteria. So far, in a study funded by the Price Family Foundation,
samples of blood and synovial fluid have been collected from
50 patients to identify bacteria, and the results have correlated
with infection. “We’ve been able to isolate some organisms that
the culture was not able to grow,” says Michael B. Cross, MD,
Assistant Attending Orthopaedic Surgeon. “That could potentially
help eliminate a situation in which we know somebody has an
infection, but we can’t identify the type of bacteria.” In the future,
the technology could enable physicians to prescribe antibiotics that
can effectively treat the bacteria. “This would make treatment much
more precise,” says Laura Donlin, PhD, Co-Director of the Derfner
Foundation Precision Medicine Laboratory and Assistant Scientist.

“Certain patients are at higher risk of

having infections after surgery, so we’re
turning our attention toward optimizing
the host to prevent these problems.”

ALBERTO V. CARLI, MD
Assistant Attending Orthopaedic Surgeon

In disease model
studies, HSS
physicians and
scientists have
discovered that
suppressing the
gut flora can
increase the risk of
infection. They are
now researching
how abnormal gut
flora can influence
the immune
system.

10
 07
HSS orthopaedic surgeons and scientists are embarking on
a new type of stem cell research that holds tremendous promise
for regenerating damaged tissue and healing rotator cuff injuries.
Scott A. Rodeo, MD, Co-Director of the Orthopaedic Soft Tissue
Research Program and Attending Orthopaedic Surgeon, and
Christopher Mendias, PhD, Associate Scientist, were awarded an

Using $800,000 grant from the Orthopaedic Research and Education

Foundation (OREF) to study for the first time whether stem cells
derived from fat tissue can improve the outcomes of patients

orthobiologics
having surgery for rotator cuff tears. Such patients can have
continuing weakness and pain due to muscle atrophy. “This
research has great potential,” says Dr. Rodeo. “We’re treating
tissues that have intrinsically poor potential to heal and rejuvenate.”

to improve Stem cells harvested from fat, called stromal vascular fraction
cells (SVFCs), have been shown in preliminary studies to improve
the regeneration of injured tissue in other parts of the body, such

rotator cuff
as knee cartilage. SVFCs contain pluripotent stem cells, meaning
they can differentiate into muscle and tendon tissue. The fat
tissue is processed using centrifugalization, which isolates and
concentrates the stem cells. HSS is working with a manufacturer

outcomes
to isolate many more stem cells than previously possible.

In this Phase II study, patients will be followed for two years.

The effects of the therapy will be assessed through strength and
range-of-motion tests, imaging studies and patient-reported
outcome measures.

“
We’re treating tissues that
have intrinsically poor potential
to heal and rejuvenate.”
SCOT T A . RODEO, MD
Co-Director of the Orthopaedic Soft Tissue Research
Program and Attending Orthopaedic Surgeon

Dr. Rodeo is also launching a Phase I trial of human umbilical

vein endothelial cells (HUVEC) for rotator cuff repairs. These cells
produce factors that stimulate the tendon’s intrinsic stem cells
to enhance healing. Intrinsic stem cells help new blood vessels to
form and new cells to proliferate, strengthening tissue. Fifteen
patients will be enrolled.

HSS will be the first institution to use the HUVEC cells. The study
will build on past research, in which specialized endothelial cells
were used to effectively strengthen tendon repair. “With the
dawn of the orthobiologics era, it’s an exciting time in the field
of orthopaedics,” says Dr. Rodeo.

HSS orthopaedic
surgeons and
scientists are
studying stem cells
derived from fat
tissue (red cells,
above) and human
umbilical vein
endothelial cells
(top) to determine
whether they can
regenerate damaged
tissue and heal
rotator cuff injuries.

11
 08
The success of orthopaedic surgery is largely based on the proper
placement of hardware and screws. To enhance precision and
improve outcomes, some HSS orthopaedic surgeons have adopted
three-dimensional surgical navigation, which allows surgeons to
view where they are in the body in three dimensions in real time, in
a variety of procedures.

Enhancing In spine cases, HSS surgeons are comparing the accuracy

of pedicle screw installation using standard X-rays versus three-
dimensional surgical navigation. “In the past, studies like this

surgical only focused on whether the screw was too close to a nerve or
not,” says Sheeraz Qureshi, MD, MBA, Patty and Jay Baker Chair
in Minimally Invasive Spine Surgery and Associate Attending
Orthopaedic Surgeon. “That’s obviously very important, but there

precision are bony landmarks that you can’t see as well on an X-ray that are
also important for long-term success in terms of placing screws.
Early results are showing that there’s a clear advantage to three-

with three-
dimensional surgical navigation.”

Roger F. Widmann, MD, Chief of the Pediatric Orthopaedic Service,

Leon Root MD Chair in Pediatric Orthopaedics and Attending
Orthopaedic Surgeon, also finds the technology beneficial.

dimensional “It increases the probability that you will insert implants properly
because the technology provides the image guidance beforehand
rather than afterwards,” he says.

navigation The tool is being used to guide a growing number of pediatric

orthopaedic procedures, including those for tarsal coalition.
Historically, surgery to remove the bony bridge has had a
high failure and recurrence rate. “We realized we might not be
removing the entire bony bridge because it’s difficult to visualize
it intraoperatively with plain X-ray or fluoroscopic imaging,” says
Dr. Widmann. “Intraoperative three-dimensional imaging and
navigation allow you to remove the abnormal bone more precisely
and avoid removing normal, healthy tissue.”

The enhanced visualization of three-dimensional surgical

navigation has also proved useful for avoiding injury to the
growth plate around the knee for ACL reconstruction. “A three-
dimensional imaging study performed while the patient is on the
operating table can guide both the placement of drill holes and
insertion of graft and hardware, such that you protect the growth
plate,” says Dr. Widmann. It also enables surgeons to operate
on transitional fractures in the ankle without opening the joint,
reducing complications. “The applications for this technology are
only limited by your imagination and creativity,” says Dr. Widmann.

Three-dimensional
intraoperative
imaging and
surgical navigation
for placement of
thoracic pedicle
screws in an
adolescent

12
 09
Scleroderma is one of the most debilitating rheumatic diseases.
It is associated with significant morbidity and disability and has the
highest rate of all-cause mortality among the rheumatic diseases.
To date, no medication has been specifically approved for this
condition. Fortunately, HSS physicians and scientists have made
significant progress in investigating promising new treatment

Creating options. One area of focus is lenabasum, a cannabinoid receptor

type 2 (CB2) agonist. In 2017, Robert F. Spiera, MD, Director of
the Scleroderma, Vasculitis & Myositis Center of Excellence and

a better
Attending Physician, led a Phase II study of the drug sponsored by
Corbus Pharmaceuticals, which demonstrated acceptable safety
and tolerability and suggested a possible benefit in scleroderma
patients. He presented the results at the 2017 American College of

future for
Rheumatology Annual Meeting.

CB2 receptors are expressed on immune system cells, including

T cells, macrophages and B cells. They appear to modulate

scleroderma
immune function. “Triggering these cells turns off the propagation
of the inflammation phase of the innate immune response and
promotes expression of resolvins, which contribute to resolving
the inflammatory response, thereby ultimately diminishing tissue

patients
fibrosis,” says Dr. Spiera.

In a one-year, open label extension study that followed the Phase II

trial, patients taking lenabasum continued to see significant
improvements in inflammation and fibrosis. Dr. Spiera presented
these results at the European League Against Rheumatism
Congress in Amsterdam in June 2018. Now HSS is the lead site
for a year-long Phase III trial of lenabasum, which is currently
enrolling patients around the world. Positive results could help to
advance the drug on the path to FDA approval. “What’s appealing
about this drug is it appears to be very safe,” says Dr. Spiera.
Unlike medications that suppress the immune system, lenabasum
doesn’t appear to increase the risk of infection.

Dr. Spiera is also optimistic about a monoclonal antibody called

belimumab. In an HSS-sponsored, investigator-initiated trial
of the drug, patients with early diffuse scleroderma who received
the medication saw significant improvements in skin thickness
scores. The findings were published in Arthritis and Rheumatology
in January 2018.

The researchers also determined that the drug affects patients’

gene expression in skin biopsies. “Significant decreases in
expression of B-cell signaling and pro-fibrotic gene pathways
were observed in patients who improved on the drug and not in
those who didn’t improve,” says Dr. Spiera. This supports the idea
that the drug was having an effect. Dr. Spiera and his colleague,
Jessica K. Gordon, MD, Assistant Attending Physician, plan to
initiate a larger study of this strategy, which will begin in early 2019.

Although there’s a long road ahead for getting a new drug to market,
the prospects are promising. “It will be very exciting if either drug
pans out,” says Dr. Spiera. “This is a totally unmet need.”

Fibrotic skin from

a scleroderma
patient

13
 10
Patients with osteoporosis face unique medical challenges when
it comes to orthopaedic surgery because poor bone quality can
diminish the ability of an implant and bone to osseointegrate.
HSS physicians and scientists are at the forefront of research
into strategies to improve bone quality and enhance surgical
outcomes. Mathias P. Bostrom, MD, Chief of the Hip Service,

Optimizing Senior Scientist and Attending Orthopaedic Surgeon, is studying

teriparatide, a parathyroid hormone analogue that promotes
osteoblasts, which form new bone. “In disease models, we can

bone health
dramatically improve the amount of bone that grows onto an
implant using teriparatide and ultimately improve the fixation,”
says Dr. Bostrom. There are several studies underway on the
effects of teriparatide and other bone-building agents on

for the best

surgical outcomes.

Teriparatide is already being used in clinical practice at HSS.

Currently, all spinal fusion patients are undergoing DXA

surgical
and quantitative CT scans prior to surgery. If a patient has
osteoporosis, Spine Service physicians prescribe teriparatide
for three months prior to surgery and keep him or her on it
afterward. The Service is also embarking on new studies of bone

outcomes
quality. “This research could ultimately enable us to optimize our
surgical strategy around bone density,” says Frank J. Schwab,
MD, Chief of the Spine Service, David B. Levine MD Chair in
Scoliosis, and Attending Orthopaedic Surgeon.

HSS researchers are also investigating the factors associated

with fracture after knee replacement surgery. A retrospective
study of total knee replacements that failed determined that
patients with periprosthetic fractures were older and more likely
to be postmenopausal women — the same population that is
prone to osteoporosis. “It supported our hypothesis that patients
who undergo surgery with worse bone quality are more likely to
have this very serious outcome,” says Emily M. Stein, MD, MS,
Assistant Scientist and Associate Attending Physician.

Kyung Park-Min, PhD, Assistant Scientist in the Arthritis and

Tissue Degeneration Program, has received a grant from the
Cornell Clinical and Translational Science Center to study
a possible biomarker for osteoporosis. Her research focuses
on cells circulating in the blood that may become osteoclasts.
Dr. Park-Min’s current research goal is to determine whether cell
counts in patients correlate with bone loss, the first step toward
a blood test that could identify patients at risk of suffering a
fracture prior to surgery.

HSS physicians
are studying the
parathyroid hormone
teriparatide, which
has been shown
to dramatically
improve the amount
of bone that grows
onto an implant,
improving fixation.
In the disease
model at left, the
joint treated with
teriparatide has
more bone around
the implant (lower
left) than the one
in the control group
(top left).

14
 11
HSS engineers and orthopaedic
surgeons are on a mission to
improve the success rates of elbow
implants, which can be prone to
failure after a short time. They
have partnered with Italy-based

Building LimaCorporate S.p.A., a developer

and manufacturer of orthopaedic
implants and instrumentation, to

a better
develop an implant system that
embodies the power and complexity
of the joint itself.

The HSS team that created the

elbow new design — Timothy M. Wright,

PhD, Director of the Department
of Biomechanics and F.M. Kirby
Chair in Orthopaedic Biomechanics;
Robert N. Hotchkiss, MD, Anne
and Joel Ehrenkranz Chair in Hand
and Upper Extremity Research,
Medical Director of the Innovation
Institute, and Associate Attending
Orthopaedic Surgeon; Mark P.
Figgie, MD, Chief of the Surgical
Arthritis Service and Attending
Orthopaedic Surgeon; and Joseph
Lipman, MS, Director of Device
Development — has spent years
analyzing why retrieved implants
failed and gaining a better under-
standing of the joint. “We did some
testing in people’s upper extremities,
such as how much force they exert
on the elbow when they push up
out of a chair,” says Dr. Figgie. “It’s
really significant. Even though
people think of an elbow as being
non-weight bearing, very high loads
are generated across the elbow,
which can cause wear, loosening
and failure of an implant.”

The new implant has several

noteworthy features, including more
durable and wear-resistant surfaces.
“We’ve designed the surfaces so that
the ability of a patient’s ligaments
and muscles to keep the joint stable
is enhanced by the shapes of those
surfaces,” says Dr. Wright.

The elbow implant system is

currently under review by the
FDA for clearance.

A team of HSS
engineers and
orthopaedic
surgeons has
designed a new
elbow implant
system with
more durable and
wear-resistant
surfaces.

15
16
BREAKTHROUGHS
ON THE
HORIZON
01
A computer model of the knee
for more precise surgery
02
A molecular approach to
rejuvenating spinal discs
03
Toward a better understanding
of patient expectations
04
An innovative approach to
osteoarthritis pain relief
05
A new understanding of the
vascular anatomy of the
scaphoid bone
06
A better way to correct flatfoot
deformity in the elderly
07
A less invasive technique for
correcting rotational deformity
of the femur
17
08
Standardizing pre- and
postsurgical knee exams
09
A new era for knee implants
10
Uncovering the effects of
epidural steroid injections on
bone density
11
Improving outcomes for RA
patients undergoing joint
replacement
12
Improving clinical decision-
making in the OR in real time
13
Battling bone loss with a
promising microRNA-targeting
therapy
14
New possibilities for
scleroderma treatment
15
Insights into disparities in
orthopaedic care
16
Using precision medicine to
refine RA treatment
17
Defining a new form of arthritis
in cancer patients
18
A promising new target for
treating autoimmune diseases
19
Unraveling the molecular
mysteries of lupus
01
A computer
model of the knee
for more precise
surgery
Over the last five years, engineers in
the Department of Biomechanics,
Sports Medicine surgeons and Adult
Reconstruction and Joint Replacement
surgeons have been trying to find a
way to personalize ACL and total knee
replacement procedures to improve
outcomes. To prevent laxity or tightness
in the knee after surgery, engineers are
developing a computer model of the knee
that will allow surgeons to customize
the procedures based on a patient’s
unique anatomy. With ACL injuries, for
instance, “subtle differences in the shape
of a person’s bones and the properties
of his or her ligaments can affect the
outcome of surgery,” says Timothy M.
Wright, PhD, Director of the Department
of Biomechanics.
A three-dimensional scan of a patient’s
knee is taken, then engineers create a
computational model incorporating the
anatomical details of the scan to help
surgeons determine, for instance, where
to place an ACL graft and what other
structures around the knee need to be
repaired. “We’re getting close on this for
ACL repairs,” says Dr. Wright. “I think we’re
only a few years away from being able
to try this approach in patients.” Within
the same time frame, we also hope to
use computer models to customize the
position of implants for total knee replace-
ment. A model would include not only
a particular patient’s anatomy, but also
how the patient’s disease (for example,
osteoarthritis) has altered the properties
of the bones and ligaments that comprise
the joint.

Using computer-aided design drawings, engineers can create three-dimensional models of knee replacement
components (left). With a surgeon’s input, those models can be virtually implanted into models of knee bones
(right), which are obtained via imaging. Anatomical information is used to replace the soft tissue structures
with non-linear springs (the red lines), which function like soft tissue structures.

18
02
A molecular
approach
to rejuvenating
spinal discs

The key to reversing spinal disc
degeneration and easing back pain for
millions may lie in the molecular path-
ways involved in disc formation during
embryonic stages and maintenance during
neonatal stages of life. Chitra Dahia, PhD,
Director of the Spine Development and
Regeneration Laboratory and Assistant
Scientist, whose research is supported
by the Starr Chair in Tissue Engineering
Research, and her team have
shown that expression of
the protein sonic hedgehog
(Shh), which is secreted by
S1 /S2
In a study published in Biology Open in July
2018, Dr. Dahia and her colleagues showed
that activating hedgehog signaling in the
nucleus pulposus results in reactivation
of the dormant nucleus pulposus cells,
increasing production of the extracellular
matrix by the entire disc. Recently, Dr. Dahia
and her team showed that a small molecule
activator of hedgehog signaling can
CONTROL
reactivate the nucleus pulposus cells in the
aged disc. Dr. Dahia has applied for a patent
for this intervention and has launched a
deeper investigation into Shh’s mechanism.
“We’re looking for key molecules involved
in activating Shh signaling,” she says. “Our
goal is to develop downstream targets that
would help us to keep spinal discs healthy
over time.”
SmoM2 (RESCUED)

the nucleus pulposus, declines

over time and accelerates
disc aging. “Shh signaling is
critical for the proliferation
of disc cells and production
of the extracellular matrix,”
At top: Chitra Dahia, PhD, Director of the Spine Research Assistant; Dr. Dahia; Diviya Rajesh, student,
she says.
Development and Regeneration Laboratory and and Sarthak Mohanty, student. Above: Dr. Dahia has
Assistant Scientist, with her lab members. From left to discovered that activating hedgehog signaling in the
right: Paul Pricop, Research Assistant; Robert Pinelli, nucleus pulposus can help “rescue” the sacral disc.

19
03
Carol A. Mancuso, MD, Senior Scientist
and Attending Physician, has long
partnered with HSS orthopaedic surgeons
to develop surveys to measure patients’
preoperative expectations of improvements
in physical and psychological symptoms,
Toward a better social and occupational roles, and
functional outcomes. “We pioneered
understanding the formal study of patient expectations
in orthopaedic surgery,” says Dr. Mancuso.
of patient “Our surveys have been translated into
multiple languages and are used around
the world.”
expectations Measuring patient expectations of elective
orthopaedic surgery is important because
surgeons may not be aware that some
patients may have unrealistic expectations
about the outcome, says Dr. Mancuso.
Unrealistically high expectations can lead
to decreased adherence to postoperative
precautions necessary for healing,
disappointment with time to recovery,
and dissatisfaction with the outcomes
of surgery. Alternatively, inappropriately
low expectations may decrease patients’
motivation to participate in rehabilitation
and adopt long-term lifestyle modifications
to minimize progression of disease.
“While some expectations are universal,
like pain relief, most are specific for the
musculoskeletal condition that’s being
treated,” says Dr. Mancuso.
One study of elective foot and ankle
surgery patients, published in Foot & Ankle
International in June 2018, found that
women had higher expectations than men,
and patients with ankle instability or osteo-
chondral lesions had higher expectations
than those with mid- or hindfoot arthritis,
hallux valgus or hallux rigidus. Another
study, published in the August 2018 issue
of Spine, showed that patients were less
likely to expect complete improvement if
they had a previous lumbar spine surgery,
symptoms for longer duration or less
disability.
The simple act of completing a survey
helps patients distinguish between the
results they want versus what they can
reasonably expect. It also helps to improve
physician-patient communications.
Dr. Mancuso hopes these findings can
be used to develop patient education
programs to foster realistic expectations.

F U L F I L L M E N T O F E X P EC TAT I O N S BAS E D O N
LU M BA R S PI N E S U R G E RY E X P EC TAT I O N S S U RV E Y

100
S AT I S F I E D/
90 V E R Y S AT I S F I E D W I T H
R E S U LT S O F S U R G E R Y
80

70

60
PERCENT
PAT I E N T S 50

40

30

20

10

10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

S C O R E F O R E X P E C TAT I O N S F U L F I L L E D
2 Y E A R S A F T E R S U R G E RY F O R 4 0 2 PAT I E N T S
( M O R E E X P E C TAT I O N S F U L F I L L E D )

20
04
An innovative
approach to
osteoarthritis
pain relief
Cortisone injections can be effective for and Associate Attending Orthopaedic
patients with severe knee osteoarthritis, Surgeon. “A low, continuous dose of the
but the pain relief may not last long. medication may be more beneficial for a
Patients must return for subsequent longer period of time. The device may be
injections, which can be an inconvenience. able to help people delay having a knee
HSS orthopaedic surgeons have come replacement — or, as one patient volun-
up with an innovative solution: a small teered, help them resume exercise, lose
titanium screw containing a low dose weight and avoid knee replacement.”
of dexamethasone. It is inserted in the
knee joint in a procedure that takes Currently, a Phase II, multicenter study
less than 30 minutes, then it slowly and is being planned. Ultimately, the implant
“The device may
steadily releases the medication for up could benefit other patients as well. “This
be able to help people
to 18 months. “It offers tremendous delivery system could be used for different
delay having a knee
pain relief without the highs and lows of drugs and conditions,” says Dr. Hotchkiss.
replacement — or
cortisone injections,” says Mark P. Figgie, help them resume
MD, Principal Investigator, Chief of the exercise, lose weight
Surgical Arthritis Service, and Attending and avoid knee
Orthopaedic Surgeon. replacement.”
“In a recent pilot study of six months dura-
ROBERT N.
tion, we found that the device was stable,
HOTCHKISS, MD,
safe and provided a notable decrease in
co-inventor of the
pain in all six subjects,” says Robert N.
device, Medical
Hotchkiss, MD, co-inventor of the device,
Director of the
Medical Director of the Innovation Institute,
Innovation Institute,
and Associate
Attending Orthopaedic
Surgeon

From left to right: Dan Choi, M.Eng, Design

Engineer; Joseph Lipman, MS, Director of Device
Development; and Mark P. Figgie, MD, Chief
of the Surgical Arthritis Service and Attending
Orthopaedic Surgeon, discuss their research on
a drug delivery device for knee osteoarthritis.

21
05
A new
understanding
of the vascular
anatomy of the
scaphoid bone
A fracture affecting the proximal pole
of the scaphoid is notoriously difficult
to heal and can lead to osteonecrosis,
which causes severe wrist disability. HSS
researchers are investigating the reasons
for this in the hope of improving treatment.
At the American Academy of Orthopaedic
Surgeons (AAOS) Annual Meeting in March
2018, Duretti Fufa, MD, Assistant Attending
Orthopaedic Surgeon, presented data
suggesting that, contrary to conventional
wisdom, poor blood supply may not be
the reason these scaphoid fractures don’t
Lorich, MD, discovered that the proximal
heal properly. Dr. Fufa and colleagues
end of the bone receives more than
David L. Helfet, MD, Chief Emeritus of the
37 percent of the scaphoid’s blood supply.
Orthopaedic Trauma Service and Attending
However, the tip of the proximal pole has
Orthopaedic Surgeon, and the late Dean G.
minimal vasculature, which may explain
why healing rates are poor. Other possible
explanations include mechanical influences
or injury pattern.

Now Dr. Fufa is using these findings to

develop an alternate classification system
for describing scaphoid fractures, which
may help inform treatment approaches to
these injuries.

In a new study, Dr. Fufa and Michelle G.

Carlson, MD, Attending Orthopaedic
Surgeon, are attempting to determine
what factors predispose to nonunion
after surgical treatment of scaphoid
fractures. This debilitating condition
occurs in 13 to 40 percent of all
scaphoid fractures and tends to
develop in as many as half of fractures
Duretti Fufa, MD,
that are displaced by more than one Assistant Attending
millimeter. “If we can improve our Orthopaedic Surgeon,
ability to predict nonunion, we will be and HSS colleagues
able to better counsel patients about have discovered that
their prognosis,” says Dr. Fufa. The study the proximal end of the
evaluating factors that contributed to scaphoid bone receives
more than 37 percent
healing in 48 patients with scaphoid
of the scaphoid’s blood
fractures will be presented at the AAOS supply, but the tip of
meeting in March 2019. the proximal pole has
minimal vasculature,
which may explain why
healing rates are poor.

22
06
A better way to
correct flatfoot
deformity in
the elderly
Patients over 65 diagnosed with adult-
acquired flatfoot deformity have typically
been treated across the country with
fusion surgery, which realigns the foot but
leaves it stiffer. This puts more stress on
the ankle and compromises side-to-side
motion. All of this interferes with patients’
ability to walk. Despite these problems,
many surgeons do not contemplate flat-
foot reconstruction due to the prevailing
belief that older patients don’t heal as well
or can’t go through the recovery. We have
performed reconstruction, which entails
cutting and shifting the bones of the foot
into better positions, more and more
commonly over the last 10 years in this
patient population and noticed that older
patients actually do quite well. “We wanted
to see what the clinical outcomes really
were,” says Scott J. Ellis, MD, Associate
Attending Orthopaedic Surgeon.

In a study published in Foot & Ankle

International in 2018, Dr. Ellis, Jonathan T.
Deland, MD, Susan W. Rose and Jonathan
T. Deland Chair for Research in Foot and
Ankle Surgery and Attending Orthopaedic
Surgeon, and colleagues at HSS found
that patients older than 65 fared just
as well after having reconstruction of
stage II flatfoot deformity as younger and
middle-aged patients did. At the two-year
follow-up, the older group had significant
improvements in their pain levels, their
ability to participate in their usual activities
and sports, and their quality of life. In
addition, they were not any more likely to
undergo a subsequent revision surgery
than their younger counterparts were.
“It’s so important for older patients to be
as active as they can be,” says Dr. Deland.
“We’re trying to preserve motion and
function for as long as possible to improve
quality of life.”

Scott J. Ellis, MD, Associate Attending Orthopaedic

Surgeon, has found that patients over 65 can
benefit from flatfoot reconstruction.

23
07
A less invasive
technique for
correcting
rotational
deformity of
the femur
When a patient is a candidate for hip
preservation surgery, we ask: “What
is the anatomic deformity that is leading
to pain and arthritis in the hip, and can
it be corrected? If so, is it something we
can do in a minimally invasive procedure?”
says Robert L. Buly, MD, Chief of the
Hip Preservation Service and Associate
Attending Orthopaedic Surgeon. At
HSS, Dr. Buly and S. Robert Rozbruch,
MD, Chief of the Limb Lengthening and
Complex Reconstruction Service and
Attending Orthopaedic Surgeon, have
pioneered a technique called minimal
incision rotational osteotomy to correct
rotational deformity of the femur and
help protect and preserve the hip joint.
About 25 percent of Dr. Buly’s surgeries
are this variety.
WINDQUIST SAW PRIOR TO COMPLE TION
IS USED TO OF CUT, STEINMAN PINS
CUT FEMUR ARE PL ACED
With this innovative technique, surgeons
use a ½-inch incision for cutting the
bone and correcting the deformity
arthroscopically. Pins are used to correct
the version, and a rod is placed to stabilize
the femur. With this less invasive approach,
“the bone heals much faster because
it’s stripped less and the patient has
less pain,” says Dr. Rozbruch.
In a study published in the
Journal of the American
Academy of Orthopaedic
Surgeons in 2018, Dr. Buly,
Dr. Rozbruch and several
other researchers evaluated
surgical outcomes in patients
undergoing a minimally
invasive procedure known
as closed subtrochanteric
derotation osteotomy for excessive
anteversion or retroversion of
the femur. The results were rated as
excellent in 75 percent of patients and
good in 23 percent after 6½ years, even
though more than two-thirds of the patients
needed subsequent implant removal.
To ensure success with this technique,
a surgeon needs to know ahead of
time whether a patient has excessive
24
AF TER CUT IS MADE , A ROD IS THEN
PINS ARE ROTATED PL ACED TO
TO CORRECT THE STABILIZE THE
VERSION FEMUR
anteversion or retroversion of the femur
or socket. Clinical clues include a patient’s
foot progression angle while walking
and hip range of motion. Version of the
acetabulum and femur must be measured,
and the gold standard is a CT scan that
includes the hips and knees. Although
MRI can be used to estimate femoral
version, it is more time-consuming and
not as accurate.
In some cases, there is accompanying
rotational deformity of the tibia, which is
corrected during the same surgery with a
similar technique.
The collaboration between the Hip
Preservation and Limb Lengthening and
Complex Reconstruction services at HSS
has led to comprehensive and innovative
surgical care of our patients.
From left to right: Robert L. Buly, MD, Chief of
the Hip Preservation Service, and S. Robert
Rozbruch, MD, Chief of the Limb Lengthening and
Complex Reconstruction Service, have pioneered
a technique called minimal incision rotational
osteotomy to correct rotational deformity of the
femur and help protect and preserve the hip joint.
The procedure is explained in the graphic above.
08
When evaluating a patient prior to or
after ACL reconstruction or arthroplasty,
it’s often a challenge to gauge knee
stability. “Surgeons walk a fine line when
reconstructing or replacing the knee
joint,” says Carl Imhauser, PhD, Assistant
Standardizing pre- Scientist. “Patients with knees that feel
loose during a physical exam have a higher
and postsurgical risk of graft failure after ACL reconstruction,
for example. On the other hand, if a surgeon
knee exams makes the knee too tight, patients may be
unable to perform daily activities and might
be at increased risk of osteoarthritis in
the long-term.” To address this challenge,
Dr. Imhauser has been working with HSS
physical therapists and Sports Medicine
orthopaedic surgeons led by Thomas L.
Wickiewicz, MD, Attending Orthopaedic
Surgeon, to develop measurement tools
that will help clinicians objectively quantify
how tight or loose a patient’s knee feels in
multiple planes. His team in the Department
of Biomechanics has developed a specially
designed measurement device. The patient
sits in the device and the physical therapist
or surgeon can push, pull and rotate the
knee while measuring the loads the operator
25
applies and the resulting three-dimensional
motions of the joint. “Ultimately, we think
that these objective measurements
of knee stability are an important part of
planning more individualized surgeries,
with the goal of optimally restoring knee
mobility and reducing the chances that a
patient will need a second operation,” says
Dr. Imhauser.
After a five-year development effort,
Dr. Imhauser’s team has a working prototype
and is now validating that the system
provides consistent and accurate measure-
ments. He is also creating a database of
measurements on healthy volunteers who
have never experienced a knee injury.
Carl Imhauser, PhD, Assistant Scientist, has
collaborated with HSS Sports Medicine surgeons
and physical therapists to create a device that
objectively measures knee stability to help clinicians
evaluate patients before and after surgery. From
left to right: Hamidreza Jahandar, MS, Research
Engineer; Thomas L. Wickiewicz, MD, Attending
Orthopaedic Surgeon; Amanda Wach, MS, Research
Engineer; and Dr. Imhauser.

09
A new era for
knee implants
Nearly 50 years ago, HSS physicians
designed and developed the modern
total knee replacement. While it has
transformed the lives of millions of
patients, our physicians and scientists
are always searching for ways to refine it.
One area of focus is the way the majority
of implant components are fixed to the
bone. Bone cement has always been the
fixation material of choice, but the seven
to eight minutes surgeons need to wait for
the cement to set and harden is inefficient.
Moreover, the cement may degrade to
some degree after 15 to 30 years. “We’ve
always dreamed of placing the metal
components of a knee replacement
directly onto the bone with no cement
so the bone would reliably grow into the
pores of the implant,” says Timothy M.
Wright, PhD, Director of the Department
26
M I C R O M O T I O N ( μ m)
150 50 40 20 0
of Biomechanics and Senior Scientist.
“That way, you get true biological fixation.”
Today, that dream is coming closer to
fruition. Dr. Wright’s team of engineers
is taking advantage of improvements
in materials and additive manufacturing
techniques, which are used in three-
dimensional printing, and testing new
cementless, porous implants for the tibial
% YIELD STRAIN OF BONE
100 90 80 70 60 50 40 30 20 10 0
component of the total knee replacement.
Porous fixation surfaces have been
available on implant systems for some
time, but when a surgeon chooses to
use these devices without cement, they
produce inconsistent or unreliable levels
of implant fixation. “These new materials
and surface designs provide excellent
initial fixation between implant and bone,”
says Dr. Wright, noting that this type of
cementless fixation eliminates the concern
of degradation that may be associated with
cemented implants.
The results of these tests have been so
promising that Dr. Wright’s team is currently
working with LimaCorporate S.p.A., a
developer and manufacturer of orthopaedic
implant systems based in Italy, to bring the
technology to market sometime in 2020.
27
When designing cementless knee implants,
engineers need to take into consideration two
important but competing objectives. The first,
which is shown on the left, is that implant movement
must be minimized in the first eight to 12 weeks
after surgery to achieve fixation. The second
objective, shown on the right, is that the tight fit
that is required to minimize micromotion should
not create too large a stress on the adjacent bone.
10
Uncovering the
effects of epidural
steroid injections FIGURE 1

on bone density
While regular use of oral or intravenous
steroids is known to compromise bone
quality over time, the effect of epidural
steroid injections (ESI) on bone quality
has remained a mystery. In what is likely
the first study of its kind, researchers
led by Emily M. Stein, MD, MS, Associate
Attending Physician and Associate
Scientist, investigated the effects of ESI
on volumetric bone density in the lumbar
spine in patients who had been treated
for back pain. Using central quantitative
CT scans to measure bone density of the
lumbar spine, the researchers found that
patients who had undergone epidural
steroid injections had lower bone mineral
density at each vertebral level. There was
a dose-response relationship: People who
had higher cumulative ve doses over time
had the lowest bone mineral density in FIGURE 2
the lumbar spine (T12 2 to L5).

The study, which was s

rnal of
published in The Journal
gy
Clinical Endocrinology y
& Metabolism in
July 2018, did
not compare
the effects of
different steroid
delivery systems,
but epidural
steroid injections
probably have
more of a subtle
V
effect than oral or IV
steroid use, says Dr.. Stein.
“Still, three or more injections
seem to have a substantial effect on bone
density,” she says. “As clinicians, we should
think about ways to protect bone in people
who are getting these injections.” HSS co-
investigators included Richard S. Bockman,
MD, PhD, Chief of the Endocrine Service
and Attending Physician; John A. Carrino,
MD, MPH, Vice Chairman of Radiology and
Attending Radiologist; Alexander P. Hughes, Emily M. Stein, MD, MS, Associate Attending Physician and Associate Scientist, has discovered that patients
MD, Assistant Attending Orthopaedic who had undergone epidural steroid injections had lower bone mineral density at each vertebral level, and
Surgeon; and Joel M. Press, MD, Physiatrist- there was a dose-response relationship.
in-Chief and Attending Physician. The Journal of Clinical Endocrinology & Metabolism. Copyright © 2018, Oxford University Press

28
11
Although rheumatoid arthritis (RA)
patients have experienced improvements
in health-related quality of life and func-
tional status, rates of total hip replacement
and total knee replacement procedures
have remained stable. Most RA patients
Improving who undergo arthroplasty are taking
disease-modifying antirheumatic drugs
outcomes for and biologic therapies, which are known
to increase their risk of developing a pros-
RA patients thetic joint infection. As a result, patients
are typically instructed to stop taking their
medications prior to surgery. This may
undergoing joint increase their risk of having a flare periop-
eratively, which may have a negative effect
replacement on rehabilitation efforts and outcomes.
To investigate patient-reported RA
flares, HSS researchers launched the RA
Perioperative Flare Study. This is likely the
first study to prospectively assess post-
operative, patient-reported flares of RA in
patients undergoing THA and TKA using
the RA-FQ, a validated, patient-reported
outcome instrument for identifying
RA flares.
In the study, which was published in The
Journal of Rheumatology in May 2018, 120
HSS patients answered a questionnaire
each week for six consecutive weeks after
29
surgery. Patients who reported flares after
surgery were compared to those who did
not experience them. Lead author Susan M.
Goodman, MD, Director of the Integrative
Rheumatology and Orthopedic Center of
Excellence and Attending Physician, and
colleagues found that 63 percent of the
patients experienced a flare by six weeks
after surgery. The patients who flared
had significantly higher disease activity at
baseline, but preoperative antirheumatic
medication withdrawal was not an indepen-
dent risk factor for flares.
To improve outcomes and reduce the
risk of infection in RA patients, HSS
researchers are investigating the effects
of changing the perioperative medication
protocol. “We can withhold biologic medi-
cations for one-dose intervals around the
time of surgery,” says Dr. Goodman. “Now
we’re looking at pain and functionality in
these patients after a year.”
Dr. Goodman and Mark P. Figgie, MD, Chief of
the Surgical Arthritis Service and Attending
Orthopaedic Surgeon, are investigating flares in
RA patients after arthroplasty.
“Rheumatoid arthritis patients
who experienced flares after
arthroplasty had significantly
higher disease activity at
baseline.”
SUSAN M. GOODMAN, MD,
Director of the Integrative
Rheumatology and Orthopedic
Center of Excellence and
Attending Physician
12
Improving clinical
decision-making
in the OR in LOAD CELL SENSOR

real time
If we could customize meniscus and
cartilage repair, outcomes might improve.
That is the rationale behind our research
on “smart” sensors, which assess changes
in joint mechanics as a device applies
real-life loads to the knee. These changes,
which include how the magnitudes and
distribution of the contact forces can affect
the risk of joint degeneration, arthritis
and other injuries later in life.
“We are trying to identify
individual variations in
knee mechanics, such as
alignment, stability and
anatomical factors, in
the operating room,”
says Scott A. Rodeo,
MD, Senior Scientist and
Attending Orthopaedic
Surgeon. By gaining this
valuable information in real
time, surgeons would be better
equipped to make clinical decisions and
change course, if necessary. “If we can
identify who’s likely to have a problem
with pressures across the knee later, we
can intervene in the OR and improve the
patient’s outcome by putting a meniscus
graft or a novel scaffold in,” says Dr. Rodeo.

Currently, data from participating

meniscal allograft patients has been
analyzed, and the MRI data for two to three
years after surgery is being processed.
In the meantime, Suzanne Maher, PhD,
Associate Director of the Department of
Biomechanics and Senior Scientist, whose
research is supported by the Russell F.
Warren Research Chair, and Dr. Rodeo During surgery, researchers place a sensor in the
are trying to refine the sensor so that it’s knee joint to measure forces across the joint.
wireless and easier to deploy in the joints.
The goal is to eventually use sensors in
other joints. “The fact that surgeons can
get information about how the patient’s
knee mechanics are responding at the time
of surgery is a big advancement,” says
Dr. Maher. “In sports medicine, the ability
to have this real-time feedback is unique.”

30
13
Battling bone loss
with a promising
microRNA-
targeting therapy
“Our exciting genetic
Small non-coding RNA molecules that
evidence and outstanding
are approximately 21 to 25 nucleotides
pharmacological results
in length, or microRNAs (miRNAs),
obtained from disease
regulate gene expression and functions
models provide a proof of
in a variety of biological and pathological
a specific inhibitor targeting miR-182. “Our concept for the efficacy
settings. While miRNA-based therapies
exciting genetic evidence and outstanding of therapeutic targeting
have recently shown significant promise
pharmacological results obtained from of miR-182 to prevent
in the treatment of diseases like cancer,
disease models provide a proof of concept bone loss.”
diabetes and Hepatitis C, their use has
been underexplored in osteoporosis for the efficacy of therapeutic targeting of BAOHONG ZHAO, PhD,
and rheumatoid arthritis — until now. miR-182 to prevent bone loss and highlight Assistant Scientist in
Baohong Zhao, PhD, Assistant Scientist the translational implications of targeting the Arthritis and Tissue
in the Arthritis and Tissue Degeneration miR-182 in treating osteolytic diseases,” Regeneration Program and
Program and The David Z. Rosensweig says Dr. Zhao. “Now we are collaborating The David Z. Rosensweig
Genomics Research Center, has been with translational researchers to see if we Genomics Research Center
using miRNA-sequencing techniques to can develop more appropriate approaches
profile genome-wide changes of miRNAs to deliver a miR-182 inhibitor to patients
that are involved in the differentiation of with osteoporosis and arthritis to suppress
osteoclasts. She has identified two different bone loss.”
methods for protecting against excessive
While developing a safe and effective
osteoclast formation and bone destruction
delivery system for this therapy is a
in disease models of ovariectomy-induced
priority, Dr. Zhao hopes that this miRNA
osteoporosis and rheumatoid arthritis.
will eventually be used as a biomarker to
One approach involves using a genetic
predict the progression of these diseases
knockout of miR-182 and the other involves
to prevent bone loss early on.

31
 Scleroderma, one of the most life-
threatening rheumatic diseases, is among
the most challenging to understand

14
and treat. But breakthrough research
from the lab of Franck Barrat, PhD,
Michael R. Bloomberg Chair and Senior
Scientist, could lead to new therapeutic
possibilities. Dr. Barrat’s research focuses
on plasmacytoid dendritic cells (pDCs),

New possibilities which normally produce interferon to

combat infection. In a study published

for scleroderma in Science Translational Medicine in

January 2018, Dr. Barrat and HSS and
international colleagues revealed that pDCs
treatment are chronically activated in scleroderma
patients. They infiltrate the skin, where
they trigger fibrosis and inflammation.
“In the field of scleroderma, people have
focused on how to stop fibrosis,” says
Dr. Barrat. “But the correlation between
inflammation and the main players that
drive inflammation in fibrosis hasn’t been
explored as much. This is pointing us
in a direction that people had not looked
at before.” As a result, the finding has
ge
generated considerable excitement from
sc
scientists and industry. “Some companies
a r looking really hard at this now,” says
are
D r Barrat.
Dr.

IIn n a disease model, Dr. Barrat and

c o
colleagues showed that depleting pDCs
p r
prevented fibrosis. The research has helped
tto o delineate important mechanisms of the
a b
aberrant cell activity. It has implicated a
rreceptor
e on the surface of pDCs, called
T
TLR8,L as a culprit behind the cell activity.
A
As s a result, there may be several potential
ttherapeutic
h targets and some existing
d r
drugs as possible candidates for study in
s c
scleroderma patients. “We have identified
p
pDCsD as potentially very important in
tthe
h establishment and development of
ffibrosis,”
ib says Dr. Barrat. “Now we can
inv
investigate new therapeutic options for
targeting the cells, the ways they become
activated, and some of the product
they make.”

These findings have led to new research

funding, including nearly $1.8 million in
grants from the National Institutes of
Health and the Scleroderma Research
Foundation. “What excites me is all of
the possibilities that this research has
opened up,” says Dr. Barrat. “We’ve put
scleroderma on the map.”

Franck Barrat, PhD, Senior Scientist, and other

HSS researchers discovered that plasmacytoid
dendritic cells are chronically activated in
scleroderma patients, opening the door to
investigations of new treatments.

32
15
HSS rheumatologists and orthopaedic
surgeons are investigating health disparities
in an effort to improve outcomes for all
patients. In the latest study, published in
The Journal of Rheumatology in May 2018,
our researchers reviewed the literature on
The next step is to investigate the reasons
people in poorer communities delay care.
“Once we have a better understanding
of the barriers to care, we’ll have a better
sense of what we can do to knock them
down,” says Dr. Goodman.

Insights into quality-of-life outcomes — pain, function and

satisfaction — after total hip arthroplasty Other HSS study authors were Bella Y.
Mehta, MD, Assistant Attending Physician;
disparities (THA) for black and white adult patients.
After evaluating studies involving 1,588 Anne R. Bass, MD, Attending Physician;
Linda A. Russell, MD, Associate Attending
in orthopaedic THA patients, of whom 15 percent were
black, the team found that black patients Physician; Michael L. Parks, MD, Associate
Attending Orthopaedic Surgeon; and
experience more pain and worse functioning
care after THA than white patients. “Black Mark P. Figgie, MD, Chief of the Surgical
Arthritis Service and Attending Orthopaedic
patients tend to present for hip or knee
replacement when their arthritis is more Surgeon.
advanced, so they start from a worse
place and never really catch up,” says
Susan M. Goodman, MD, a study author and
Director of the Integrative Rheumatology
and Orthopedic Center of Excellence.
“However, in other research, when we used
geocoding and looked at black patients
in wealthy neighborhoods, we found no
Susan M. Goodman, MD, Director of the Integrative
differences in terms of when they present Rheumatology and Orthopedic Center of
for surgery and outcomes. This suggests Excellence and Attending Physician, has found that
socioeconomic factors are contributing to socioeconomic factors may play a role in better
better outcomes.” surgical outcomes among black and white patients.

33

16
Using precision
medicine to refine
RA treatment
The promise of precision medicine is to
personalize therapy for patients with
notoriously difficult-to-treat diseases
such as rheumatoid arthritis (RA). To that
end, HSS scientists and physicians are
investigating differences in RA patients’
responses to drugs as part of the five-year
Accelerating Medicines Partnership (AMP)
study, funded by the National Institutes
of Health and partnering pharmaceutical
companies. Our researchers are also
investigating molecular pathways involved
in flares. “We’re trying to discover new
pathways, which could lead to new ther-
apeutic targets,” says Lionel B. Ivashkiv,
MD, Richard L. Menschel Chair and Chief
Scientific Officer, David H. Koch Chair
for Arthritis and Tissue Degeneration
Research, and Director of the David Z.
Rosensweig Genomics Research Center.
“The ultimate goal is to use this information
to help us choose the best drug for each
patient at the beginning of treatment.”
“Using advanced genomic technologies
involving single cells, we are studying
synovial tissue samples to find out how
they relate to disease activity in the
patient,” says Vivian P. Bykerk, MD, lead
investigator of the RA study, Director of the
Inflammatory Arthritis Center of Excellence
and Associate Attending Physician. In
the first phase of the study, which is now
complete, our researchers were able to
identify eight new cell types in RA joints
using next-generation sequencing tech-
niques. “These are subsets we’d want to
target with new drugs,” says Laura Donlin,
PhD, Co-Director of the Derfner Foundation
Precision Medicine Laboratory and
Assistant Scientist.
34
“Using advanced genomic
technologies involving single
cells, we are studying synovial
tissue samples to find out how
they relate to disease activity
in the RA patient.”
VIVIAN P. BYKERK, MD,
lead investigator of the HSS
site for the NIH Accelerating
Medicines Partnership
(AMP) study, Director of the
Inflammatory Arthritis Center
of Excellence, and Associate
Attending Physician
In the second phase of the study, which
is currently underway, our researchers
are following a large cohort of RA patients
who will have tissue samples taken before
and after a new treatment is provided.
Researchers will monitor them and look
for commonalities that could serve as
biomarkers for treatment response. “HSS
is a critical player in the AMP consortium
because we provide unique scientific
expertise and patient resources,” says
Dr. Ivashkiv. “This study has changed the
way we perform translational research,
have scientific collaborations, and link
clinical data with scientific data.”
From left to right: Laura Donlin, PhD, Co-Director
of the Derfner Foundation Precision Medicine
Laboratory and Assistant Scientist, and Dr. Bykerk
review data for the AMP study.
17
Immunotherapy drugs known as
“checkpoint inhibitors” can have dramatic,
often life-saving benefits for cancer
patients. But they are also known to have
problematic side effects. “Patients are
staying on these drugs for longer periods
Defining a new of time, and we’re starting to see arthritis
as a side effect more commonly,” says
form of arthritis in Anne R. Bass, MD, Attending Physician.
“My theory is that some patients are
cancer patients genetically predisposed to arthritis and
develop it when they take these immune-
stimulating therapies.”
Collaborating with oncologists at a
major New York City cancer center,
Dr. Bass has been working to clinically
define this new form of inflammatory
arthritis, which causes joint swelling and
pain and occasionally is associated with
rheumatoid arthritis (RA) markers in
the blood. In some patients, symptoms
resemble RA and in others, they are similar
to polymyalgia rheumatica. Dr. Bass is
investigating why and how the condition
develops on an immunological level and
is establishing treatment protocols. One
key question: Is the “RA-like” form of
inflammatory arthritis the same as the RA
35
that develops in people who haven’t taken
immunotherapy drugs? “If it is, then these
patients offer an opportunity to study
RA developing over a compressed period
of time,” says Dr. Bass. This shortened
timeline “may allow us to identify predictors
for RA and figure out the immunologic
pathways that lead to arthritis. That may
allow us to target those pathways early on
and potentially prevent RA in the general
population.”
While we aim to treat the arthritis that
develops in cancer patients who are taking
immunotherapy medications, we don’t
want to interfere with the curative effects
of the drugs by suppressing the immune
system too much. Says Dr. Bass: “This
is an important opportunity for clinical
and research collaboration with our
oncology colleagues, especially now that
immunotherapy is being used for an ever-
expanding array of cancers.”
“Studying a new form of arthritis
linked to immunotherapy drugs may
help us to figure out the immunologic
pathways that lead to arthritis.
That may allow us to target those
pathways early on and potentially
prevent RA in the general population.”
ANNE R. BASS, MD,
Attending Physician
18
A promising new
target for treating
autoimmune
diseases
HSS scientists have identified a key protein
that helps to regulate inflammation and
could become a target for treating auto-
immune diseases. The protein iRhom2
appears to play a critical role in causing
kidney damage in patients with lupus and
seems to contribute to osteoporosis and
joint damage in patients with hemophilic
arthropathy.
In a study published in the April 2018 issue
of The Journal of Clinical Investigation, HSS
researchers and international colleagues
found that inactivating iRhom2 — which
regulates ADAM17, whose substrates,
such as TNF- and heparin-binding EGF
(HB-EGF), have been implicated in the
pathogenesis of chronic kidney disease —
prevented inflammation and irreversible
scarring in lupus nephritis models. These
same pathways were found to be
upregulated in kidney biopsies from lupus
patients. “The benefit of this approach
is selective and simultaneous inhibition
of two major pathological mediators of
tissue damage in lupus,” says Jane E.
Salmon, MD, Director of the Lupus and
Antiphospholipid Syndrome Center of
Excellence, Collette Kean Research Chair,
and Attending Physician.
In another study, published in Blood
in September 2018, HSS researchers
found that inactivating iRhom2/TNF-
prevented the bone erosion and joint
inflammation often seen in hemophilic
arthropathy. “This is a major break-
through because it points toward
exciting new approaches for treatment
of these two major manifestations of
hemophilic arthropathy,” says Carl P.
Blobel, MD, PhD, Director of the Arthritis
and Tissue Degeneration Program,
Virginia F. and William R. Salomon
Chair in Musculoskeletal Research,
and Senior Scientist.
HSS scientists and researchers at other institutions
have discovered that iRhom2 may be an attractive
new target for preventing osteoporosis and joint
damage in patients with hemophilic arthropathy.
In the photo, osteoclasts (red) are resorbing
bone (blue).
Copyright © 2018 American Society of Hematology
36
19
Unraveling
the molecular
mysteries of lupus
HSS Research Institute scientists are
conducting studies at the molecular level
to uncover new targets for lupus treatment.
Alessandra Pernis, MD, The Peter Jay
Sharp Chair in Lupus Research and Senior
Scientist, is identifying molecular pathways
of autoimmunity in the disease. Her work
focuses on B cells, important players in
autoimmune disease, including a subset
called age-associated B cells, also known as
ABCs. Dr. Pernis has discovered that ABC
cells play two key roles in autoimmunity.
“They can behave like B cells by making
auto-antibodies, and they can behave like
inflammatory cells by making inflammatory
cytokines,” she says. “Understanding the
pathways that regulate these cells could that in healthy people, these cells protect
represent a major advance in lupus as well the skin from UV damage. “With UV
as autoimmunity in general.” exposure, Langerhans cells normally
activate ADAM17, a molecule that activates
Using genome-wide transcriptional and epidermal growth factor receptor (EGFR)
epigenetic analysis on ABCs, Dr. Pernis and ligands, helping skin cells to survive,” says
her team have uncovered the mechanism
by which ABCs are regulated. “The majority
Dr. Lu. In lupus models, Langerhans cells
expressed less of the ADAM17 molecule,
of patients with autoimmunity are women,
but until now we have not been able to find
so they were less able to protect the skin.
However, when EGFR ligand was added
a molecular link,” says Dr. Pernis. “This is
the first time we can see clear differences in
males and females and how they behave at
to the skin in lupus models, fewer lesions
developed. More research is needed, but
“stimulating EGFR in the skin may be an
the transcriptional as well as the epigenetic approach to ameliorating photosensitivity
level.” This research will enable us to and systemic disease in lupus patients,”
uncover new treatment targets. says Dr. Lu.
Separately, Theresa Lu, MD, PhD,
Associate Scientist, whose research is
supported by the St. Giles Research Chair,
is making headway toward understanding
photosensitivity, whereby the sun’s ultra-
violet (UV) light can trigger skin rashes as
well as flares in patients. Photosensitivity
affects 30 to 60 percent of lupus patients.
Dr. Lu’s research centers on Langerhans
cells, immune cells in the top layer of skin. From left to right: Alessandra Pernis, MD, Senior
In a study published in Science Translational Scientist, is identifying molecular pathways that
play key roles in lupus, and Theresa Lu, MD, PhD,
Medicine in 2018, Dr. Lu, HSS colleagues
Associate Scientist, is gaining a better under-
and scientists at other institutions found
standing of photosensitivity in lupus patients.
37
LOCAL &
GLOBAL
LEADERSHIP

38
Improving
orthopaedic care
across the globe
China has a huge population
that needs [orthopaedic] care.
If we can disseminate some
of the information we have here,
it’s a win-win for everybody.”
HAN JO KIM, MD
Associate Attending Orthopaedic
Surgeon
At HSS, we’re committed to optimizing
orthopaedic care not only at our own
institution but also around the world.
“As the top orthopaedic hospital, it’s our
obligation to share our knowledge and
best practices,” says Laura Robbins, DSW,
Senior Vice President, Education Institute
and Global Affairs.
In 2018, HSS extended its collaboration
with Bumin Hospital Group (BHG) in
South Korea. HSS, which has partnered
with Bumin since 2014, helped BHG
achieve operating efficiencies by trans-
ferring our best practices and partnering
on education and research. In the second
phase of the collaboration, which will
continue through 2020, HSS is working
with two of the hospitals — Seoul Bumin
Hospital and Haeundae Bumin Hospital —
to strengthen their quality improvement
and infection control programs. Both
facilities are working toward achieving the
designation of HSS Center of Excellence,
a certification of advanced care delivery
accompanied by continuing development
support from and membership in the
HSS Global Orthopedic Alliance Network.
“We have the tools to help Bumin,” says
Mathias P. Bostrom, MD, Vice Chairman
of Education and Academic Affairs and
Attending Orthopaedic Surgeon. “We
developed the playbook in terms of how
to assess the needs of institutions and
help them implement areas where they
can improve.”
We are also partnering with
several Chinese institutions
to educate orthopaedic
surgeons and trainees through
the HSS-China Orthopaedic
Education Exchange. The partner-
ship involves annual symposia,
live videoconferencing and
programs that enable Chinese
orthopaedic surgeons to travel to
HSS to observe our clinicians or
conduct research. In November
2017, HSS surgeons traveled to
Zhuhai, China for the HSS-China
Symposium. They presented
courses on complex primary knee
and deformity of the cervical and
lumbar spine. More than 250
Chinese surgeons attended
the Symposium. Participating
Chinese hospitals were Peking
University People’s Hospital,
Peking University Third Hospital,
Peking Union Medical College Hospital and
Guangzhou Provincial Traditional Chinese
Medicine Hospital.
In addition, HSS physicians presented a
course on complex primary hip at the
39
12th International Congress of the Chinese
Orthopaedic Association (COA) in China
in November 2017. Douglas E. Padgett,
MD, Chief of the Adult Reconstruction and
Joint Replacement Service, Chitranjan S.
Ranawat Chair in Adult Reconstruction
and Joint Replacement, and Attending
Orthopaedic Surgeon, was Program Chair
of the COA-HSS Arthroplasty Session.
More than 500 Chinese surgeons attended
the course. “The Chinese Orthopaedic
Association invites us to run the program
every year,” says Dr. Bostrom. “We
have had a long-term commitment to
orthopaedic education in China.”
Han Jo Kim, MD, Associate Attending
Orthopaedic Surgeon and Director of
the Spine Fellowship Program, says it’s
rewarding to help educate the Chinese
physicians. “They have a huge population
that needs care,” he says. “If we can
disseminate some of the information we
have here, it’s a win-win for everybody.”
HSS is now expanding its educational
offerings in China to include our Sports
Service. “We just started livestreaming
Sports Grand Round Conferences to major
orthopaedic centers in Beijing,” says
Dr. Bostrom.
Greek Orthopaedic Surgeons also
benefit from professional education
at HSS. In November 2017, 15 Greek
surgeons traveled to HSS to learn
the latest on complex primary total hip
and knee replacement at the annual
HSS Stavros Niarchos Foundation
Orthopaedic Seminar Program. In 2017,
HSS launched the Stavros Niarchos
Foundation Academic Visitor Program.
Greek fellows traveled to HSS to train for
a two-month period, with two in the Fall
and two in the Spring. “This is unique
because it is a structured academic visitor
program,” says Dr. Bostrom. “The visitors
observe a group of HSS attendings in
clinic, operating rooms and in conferences.
They have the opportunity to see clinical
best practices.”
HSS surgeons with Chinese physicians at the
12th International Congress of the Chinese
Orthopaedic Association in November 2017. HSS
physicians, from left to right: Michael B. Cross,
MD, Assistant Attending Orthopaedic Surgeon;
Seth A. Jerabek, MD, Assistant Attending
Orthopaedic Surgeon; Douglas E. Padgett, MD,
Chief of the Adult Reconstruction and Joint
Replacement Service and Attending Orthopaedic
Surgeon; and Peter K. Sculco, MD, Assistant
Attending Orthopaedic Surgeon.
Making sports HSS may be known for best-in-class
treatment of sports injuries, but our
physicians are also committed to
safer for all preventing them from occurring in the
first place. That’s why the HSS Education
Institute developed the Sports Safety
Program, which is generously supported
by HSS Board member James Dinan
and his wife, Elizabeth Miller, through
The Dinan Family Foundation. The goal
of this community-based public health
education program is to empower
coaches, physical education teachers,
sports administrators, sports medicine
clinicians, young athletes and their
parents to reduce the risk of ACL injury.
“HSS is taking the lead in trying to keep
young athletes safe,” says Laura Robbins,
DSW, Senior Vice President, Education
Institute and Global Affairs. “We want to
reach children in all communities, not just
those who have the most resources.”
The incidence of ACL tears in pediatric
patients has steadily increased by more
than 2 percent annually over the past 20
years, according to a study published
in Pediatrics. What is concerning is that
people who sustain ACL injuries have up
to a six-fold increased risk of developing
osteoarthritis, regardless of the outcome
of their surgery.
The HSS Sports Safety Program’s inter-
active New York City-area and regional
workshops with coaches have helped to
boost knowledge
of ACL injuries and
the confidence
necessary to
implement an ACL
injury-prevention
program. “We
taught coaches how
to incorporate a
warm-up into their
training regimens
that’s been proven
to reduce the risk of
injury,” says Joseph
Janosky, Director
of HSS Sports
Safety. In addition
to training coaches,
parents of children
involved in basket-
ball, soccer, football
and lacrosse —
sports that are
associated with a
higher risk of ACL injuries — were taught
how to evaluate movement quality by
analyzing pictures or videos taken during
practices or games.
40
Research shows the results have been
favorable: Knowledge of how to reduce
ACL injuries increased by over 30 percent
among coaches, according to a pilot
study Janosky presented at the American
Public Health Association meeting
in November 2017. Another finding:
Confidence in implementing an effective
warm-up program to reduce the risk of
ACL injuries increased by 14 percent.
We are trying to teach children how
to move appropriately, such as
bending their knees and hips when
they land from a jump.”
JAMES J. KINDERKNECHT, MD
Medical Co-Director of the HSS
Sports Safety Program and
Assistant Attending Physician
The exercises are proven to reduce the
risk of ACL injuries by about two-thirds,
potentially preventing a lot of pain and
suffering, says Robert G. Marx, MD,
MSc, FRCSC, Medical Co-Director of
the Program and Attending Orthopaedic
Surgeon. “Quality movement is a big
issue,” says James J. Kinderknecht, MD,
Medical Co-Director of the Program
and Assistant Attending Physician.
“We are trying to teach children how
to move appropriately, such as bending
their knees and hips when they land
from a jump.”
In a related project, HSS and the Aspen
Institute, a nonpartisan forum for
values-based leadership, developed
the Healthy Sport Index, a tool that
identifies the relative benefits and risks
of participating in the 10 most popular
high school boys’ and girls’ sports. The
Index, found at HealthySportIndex.com,
is based on the most recent physical
activity, safety and psychosocial health
data and gives users the ability to
customize results based on their own
priorities. “Ultimately, the Index is a
tool for athletes, parents and other key
stakeholders to make better informed
decisions about which sports to play
based on physical activity, injury risk,
and social benefits data,” says Robbins.
The most trusted HSS has many reasons to be proud of
its residency program. For the fourth
consecutive year, the HSS Orthopaedic
educator in Surgery Residency Program was the
top program, according to Doximity.
orthopaedic surgery This result was informed by more than
315,000 peer nominations, ratings and
handwritten reviews. In addition, the
program has new leadership: Duretti Fufa,
MD, Assistant Attending Orthopaedic
Surgeon, is the new Director, and
Daniel W. Green, MD, MS, Attending
Orthopaedic Surgeon, is Associate
Director. “My goal is to maintain the
excellence of our program,” says Dr. Fufa.
“I want to continue recruiting the best
and brightest residents and be responsive
to their needs. I also want to be aware
of the changing educational landscape
so we can continue to be innovative
leaders in orthopaedic education.”
The HSS Residency Program currently
has 46 residents and is more diverse
than most. For instance, while women
comprise only 5 percent of board-
certified orthopaedic surgeons in the
nation, the HSS program is 24 percent
female. It is also highly competitive.
“Every year, we receive more than 600
applications,” says
Dr. Fufa. “We interview
fewer than 60 applicants,
and we accept a class
of nine residents.”
The HSS Residency
Program provides formal
leadership training
through a lecture series,
mentorship opportunities
and support for residents’
academic research —
all of which help to
advance their careers.
“We continue to produce
a high volume of some
of the highest quality
resident-led or resident-
assisted orthopaedic
research in the country
and the world,” says
Dr. Green. “Our research
scientists teach our
residents how to apply for
grants and discuss and
design experiments. By
the time the residents are
in their fifth year, many
of them are competing
at the national level for
orthopaedic surgery
grants. That’s unique to
HSS. It helps to train the
next generation of ortho-
paedic surgery leaders.”
41
Another hallmark of the HSS Residency
Program is the use of innovative training
tools. In October 2017, we held the
inaugural Surgical Games, a simulated
surgery day in our accredited and newly
renovated surgical training facility, the
Bioskills Education Laboratory. Second-
to fifth-year residents rotated through
four stations to perform carpal tunnel
release surgery on cadaver wrists,
remove foreign bodies on an arthroscopic
simulator, and stabilize ankle fractures
and perform total knee replacements
using a sawbones model. “The residents
were observed by an attending and
were given immediate feedback on their
performance,” says Dr. Fufa. “They
also received an evaluation of their
performance relative to their peers in
the same year of training, as well as
those in different years of training.”
I want to be aware of the changing
educational landscape so we can
continue to be innovative leaders in
orthopaedic education.”
DURETTI FUFA, MD
Director of the HSS Orthopaedic
Surgery Residency Program and
Assistant Attending Orthopaedic
Surgeon
The second round of the Surgical Games
took place in October 2018. The advantage
of having annual Games is that residents
can track their progress from one year to
the next. “This also gives evaluators and
faculty more objective metrics to pair with
more classic evaluation techniques, such
as direct observation in the operating
room,” says Dr. Fufa. Residents clearly
benefited from the Surgical Games: In
a survey of 32 participants, 82 percent
reported that the Games were a valuable
educational experience.
The majority of HSS residents pursue
fellowships in areas such as Hand, Foot
and Ankle, Spine and Sports Medicine,
says Dr. Green. “Fellowship programs
compete to attract these extremely
talented and bright, young physicians,”
he says. “They are probably the most
sought-after group of orthopaedic
surgery residents in the country.”
Sharing best
practices in
sports medicine
Attendees at the HSS Professional
Sports Medicine Conference were
able to learn from experts at HSS
and other organizations to achieve
the goal of better patient care
across multiple sports.”
BRYAN T. KELLY, MD
Chief of the Sports Medicine
and Shoulder Service, Attending
Orthopaedic Surgeon, and Activity
Director of the Conference
In June 2018, more than 150 sports
medicine professionals attended the 2nd
Annual HSS Professional Sports Medicine
Conference to learn about the latest
strategies for treating the professional
athlete. The Conference, which is the
largest gathering of its kind, was held at
MetLife Stadium in East Rutherford, NJ.
“Last year’s inaugural Conference was
a success, and we were thrilled by the
opportunity to once again bring together
top clinicians to share best practices
in a collaborative environment,” says
Bryan T. Kelly, MD, Chief of the Sports
Medicine and Shoulder Service, Attending
Orthopaedic Surgeon and Activity Director
of the Conference. “Attendees were able
to learn from experts at HSS and other
organizations to achieve the goal of better
patient care across multiple sports.”
HSS Sports Medicine clinicians serve as
team physicians and athletic trainers for
more than 20 professional and collegiate
teams and organizations. As a result,
they’re uniquely positioned to share their
knowledge with other professionals to
help improve the quality of patient care.
At the Conference, nearly 20 HSS physi-
cians, along with guest faculty from other
leading institutions, presented on topics
such as off-season strength training and
conditioning, complex cases and concus-
sions. Other topics included ACL, hip and
shoulder injuries, dehydration and renal
failure. Attendees
discussed
challenging
cases, the latest
treatment strat-
egies, and the
management
of professional
athletes, such as
how team physi-
cians, athletic
trainers, physical
therapists and
general managers
collaborate on
treatment plans.
The gathering
was attended by
sports medicine
physicians, ortho-
paedists, athletic
trainers, physical
therapists, phys-
ical therapist assistants, physiatrists and
primary care physicians. Also present
were medical and training personnel from
professional sports teams, such as the
Boston Celtics, New England Patriots,
New York Mets, New York Giants, New
York Jets, New York Rangers, New York
42
Islanders, New Jersey Devils, Hartford
Wolfpack, New York Knicks, Brooklyn Nets
and the New York Red Bulls. Professionals
from Iona College, Rutgers University,
St. Peter’s University and West Point
attended the Conference as well.
While medical personnel in specific
sports, such as football or hockey, have
traditionally met to discuss treatment
issues, Dr. Kelly felt there was a need
to bring together experts from multiple
sports. This enables them to compare
notes on the optimal treatment and
rehabilitation of top athletes, who are
at greater risk of injury than the general
population because of the physical
demands of professional sports. The
first conference took place in July 2017.
“The goal was to assemble a group of
sports medicine clinicians from various
professional teams and have all of them
in one room with an agenda to discuss a
variety of orthopaedic and sports-related
issues,” says Dr. Kelly, who serves as
Team Physician for the New York Rangers.
“This conference was the first time we
were able to get representation from MLB,
NFL, NHL, NBA, MLS and local collegiate
teams as well.”
With the success of the first two
conferences, Dr. Kelly is already planning
a third conference, which will take place
next summer. As an extension of these
conferences, Dr. Kelly and colleagues are
working to establish the HSS Center for
Professional Sports Medicine. “HSS has
a lot of experience with different types of
athletes and the medical management
of various teams,” says Dr. Kelly. “We want
to consolidate that knowledge into a center
and potentially share it with other teams.”
From left to right: Riley J. Williams III, MD,
Attending Orthopaedic Surgeon and Curriculum
Director of the Conference; Samuel A. Taylor,
MD, Assistant Attending Orthopaedic Surgeon
and Curriculum Director of the Conference;
Bryan T. Kelly, MD, Chief of the Sports Medicine
and Shoulder Service, Attending Orthopaedic
Surgeon and Activity Director of the Conference;
and Peter D. Asnis, MD, Chief of the Sports
Medicine Service at Massachusetts General
Hospital and Activity Director of the Conference
Providing the When Roger F. Widmann, MD, Chief of
the Pediatric Orthopaedic Service and
Attending Orthopaedic Surgeon, started
best care for working at HSS more than two decades
ago, about one-third of his fellow pediatric
all children orthopaedic surgeons participated in
Medicaid. Today, every surgeon in the
department does. “We’ve taken the
philosophical approach of ‘one level of care
for all,’” says Dr. Widmann. “As pediatric
orthopaedists, we feel we should be
providing the highest level of care for
all children.”
At HSS, all patients come to the same
waiting room and exam rooms and see
the same physicians and radiologists.
Everyone is treated at the same high
level of care for which HSS is known.”
ROGER F. WIDMANN, MD
Chief of the Pediatric Orthopaedic
Service and Attending Orthopaedic
Surgeon
At HSS, there are upwards of 3,000
pediatric outpatient visits and about
200 pediatric surgical procedures annu-
ally involving Medicaid patients, making
the program one of the largest elective
Roger F. Widmann, MD, Chief of the Pediatric
Orthopaedic Service and Attending Orthopaedic
Surgeon, with one of his patients.
43
pediatric orthopaedic surgery services
for Medicaid patients in New York. Patients
and their families travel from across the
state, with some even relocating from
countries such as Mexico, Israel and Russia,
for treatment at HSS.
Our pediatric orthopaedic surgery care is
centralized in the Lerner Children’s Pavilion
(LCP), which opened in 2012. The LCP is
quite different from most Medicaid clinics.
“A lot of institutions create Medicaid clinics
that are offsite and have different staff
members and/or residents or fellows,”
says Dr. Widmann. “At HSS, all patients
come to the same waiting room and exam
rooms and see the same physicians and
radiologists. Everyone is treated at the
same high level of care for which HSS is
known. As physicians, that’s something
we’re enthusiastic about.”
Medicaid patients tend to need more
social services than private patients,
including help navigating insurance issues,
dealing with language barriers, taking time
off from work and finding transportation
for appointments. Our nurse practitioners,
social workers and physicians assist
them. “In the last four years, we’ve raised
endowment and programmatic funds
to support nurse practitioners who help
the attendings in the clinics and provide
continuity of care,” says Dr. Widmann.
“They know the patients, and
they know the families. This
helps us to provide appropriate
resources for an under-resourced
patient population.”
These extra efforts do not go
unnoticed. Medicaid patients
and their families appreciate the
guidance and quality care they
might not receive elsewhere.
Some of these patients have the
most complex and challenging
orthopaedic problems. “It is a
privilege to provide orthopaedic
care for this underserved
population, and it is notable
that these patients are some of
the most grateful patients that
we care for,” says Dr. Widmann.
Leading HSS physicians have initiated a variety
of humanitarian efforts around the
world. Since 2012, our anesthesiologists
humanitarian have worked to educate providers in
limited-resource settings in Vietnam,
efforts to benefit Uganda, India and, most recently, Ghana,
through the Global Health Initiative at
underserved HSS. The focus of the training is on
ultrasound-guided peripheral nerve
communities blocks. “Practitioners in these areas often
do not know how to perform regional
anesthesia or don’t do it very well due
to lack of training and education,” says
Swetha Pakala, MD, Director of the
Global Health Initiative and Assistant
Attending Anesthesiologist. “Training
them is important because we know that
regional techniques lead to lower mortality
and morbidity in a lot of settings. Some
patients may be too ill to tolerate general
anesthesia, so this allows practitioners to
perform life-saving surgery on patients
who might not otherwise be able to have
surgery. It is a relatively easy skill to teach,
and practitioners are very eager to learn.
What’s more, regional anesthesia requires
less expensive equipment and medication
to provide surgical anesthesia, which is
important in limited resource settings.”
The trips have had a lasting impact in some
parts of the world. In 2017, Dr. Pakala’s
team stopped traveling to the Hospital
for Traumatology and Orthopedics in
Ho Chi Minh City,
Vietnam because data
showed that after the
annual HSS teaching
trips, physicians
were comfortable
performing regional
anesthesia techniques
and instructing others.
“Our intervention was
highly successful,”
says Dr. Pakala. “All of
the anesthesiologists
in the program were
performing the skills
that we taught. In
addition, they were
teaching other people,
thereby disseminating
the teaching and
proving that it was
sustainable.”
From left to right: Swetha Pakala, MD, Director of
the Global Health Initiative at HSS and Assistant
Attending Anesthesiologist, and World Federation
of Societies of Anesthesiologists Visiting Fellow
Faith Moyo at the Komfo Anokye Teaching
Hospital in Kumasi, Ghana.
44
Most recently, the HSS physicians traveled
to the Komfo Anokye Teaching Hospital
(KATH) in Kumasi, Ghana. In January 2018,
Dr. Pakala and colleagues introduced the
Global Regional Anesthesia Curriculum
Engagement program at KATH. This
regional anesthesia teaching curriculum is
now being measured for its effectiveness.
Team members returned in June 2018
and, at press time, were planning another
trip. Preliminary data indicate the program
has been successful. Dr. Pakala’s group is
now identifying other locations — possibly
Haiti or southern India — that need
assistance.
Training practitioners in limited-
resource settings is important because
we know that regional anesthesia
techniques often lead to lower mortality
and morbidity.”
SWETHA PAKALA, MD
Director of the Global Health Initiative
at HSS and Assistant Attending
Anesthesiologist
HSS physicians also have been involved
with the Foundation of Orthopedics and
Complex Spine (FOCOS), which provides
spine care and other services to under-
served populations in Ghana and other
parts of Africa. The President and Founder
of FOCOS is Oheneba Boachie-Adjei, MD,
Chief Emeritus of the Scoliosis Service.
Dr. Boachie-Adjei returned to his native
Ghana in 2014 to work full-time at the
FOCOS Orthopedic Hospital. The hospital
was built in Accra, Ghana in 2012, and
HSS surgeons and physicians have made
multiple journeys there since then.
Many FOCOS patients have disabling
musculoskeletal disorders, including
severe spine deformities and pediatric
orthopaedic issues. In July 2018, three
HSS physicians — Michael J. Maynard,
MD, Assistant Attending Orthopaedic
Surgeon; Paul M. Cooke, MD, Assistant
Attending Physiatrist; and Carlo J. Milani,
MD, Clinical Fellow — traveled to Ghana
to provide surgical and nonsurgical
services for spine disorders, sports
injuries and knee arthritis. “I’m trying to
bring a sports medicine competency here
to help develop arthroscopic surgery of
the shoulder and knee,” says Dr. Maynard,
who ran a clinic on ACL reconstruction
and other sports-related injuries.
Optimizing
postsurgical
outcomes
Every single patient who’s
admitted to HSS has a surgeon
and a medical physician familiar
with the perioperative care of
the orthopaedic patient.”
LINDA A. RUSSELL, MD
Director of the Division of
Perioperative Medicine and
Associate Attending Physician
Ensuring that patients are medically
ready for surgery can help improve
outcomes — and their overall experience
at HSS. “Our orthopaedic surgeons were
one of the first groups in the nation to
embrace the concept of co-management
of the patient,” says Linda A. Russell, MD,
Director of the Division of Perioperative
Medicine, Anne and Joel Ehrenkranz Chair
in Perioperative Medicine, and Associate
Attending Physician. “Every single patient
who’s admitted to HSS has a surgeon and
a medical physician familiar with the peri-
operative care of the orthopaedic patient.”
Physicians in perioperative medicine, a field up with these patients after surgery as
that has emerged over the last 15 years, are well for long-term weight management,”
assigned to follow specific patients to help says Caroline A. Andrew, MD, Assistant
ensure continuity of care. “Perioperative
medicine physicians see patients before
surgery and try to get them in as good
a shape as they can,” says Dr. Russell.
“They also see patients when they’re in the osteoarthritis, in addition to improving
hospital. Then they’re available to patients other comorbidities of obesity.”
for up to 90 days or so after the surgery
for any related medical conditions.”
Prior to surgery, HSS patients are care-
fully assessed to identify and address
any medical problems that could impact
surgical outcomes, including uncontrolled levels prior to surgery.
diabetes, cardiac issues, skin infections
and, most recently, obesity. “There’s a lot
of research that says if your BMI is 40 or
45
higher, your risk of postoperative compli-
cations is much higher,” says Dr. Russell.
In July 2018, the Division of Perioperative
Medicine added a weight-loss program
to help obese patients lose at least
5 percent of their total body weight
before surgery. “We are probably the
first hospital in the country that’s really
focused on perioperative weight loss,” says
Dr. Russell. Obese patients see a weight-
management physician and nutritionist at
HSS at least two to three months before
surgery to jumpstart healthy eating habits
and weight loss. “We continue to follow
Attending Physician, who directs the
weight management program at HSS.
“Losing weight after surgery helps with
recovery and can reduce postsurgical
Many obese patients have diabetes, so
perioperative medicine practitioners help
them get the condition under control.
These patients may work with an endo-
crinologist to achieve the healthiest A1C
Dr. Russell’s team of physicians, physician
assistants and nurse practitioners also
work to optimize the use of opioids
and other pain medications before
and after surgery. “A chronic
pain physician sees patients who
take opioids daily to taper pain
medications preoperatively and
design the postoperative pain
program,” she says.
After surgery, wound issues,
leg swelling and other
complications can be treated
by the perioperative medicine
staff, saving the patient a trip
to an urgent care facility or the
emergency room.
Over the last decade, the Division
of Perioperative Medicine has
developed numerous surgical
guidelines, including rules about
when medications should be
stopped preoperatively and
started postoperatively; which
patients with diabetes can be
cleared for the OR; and which patients are
candidates for bilateral knee replacements.
“The goal is to help decrease postoperative
complications and readmission rates,”
says Dr. Russell. “We also hope the
guidelines can provide a better patient
experience.”
2017–2018
ACHIEVEMENTS
AND FAST FACTS

46
#
1 in #
3 in Best in
the U.S. the nation New York
for Orthopaedics for nine
consecutive years by
for Rheumatology by
U.S. News & World Report City
U.S. News & World Report “Best Hospitals” for Pediatric Orthopaedics and
“Best Hospitals” (2018–2019 rankings) #21 nationally by U.S. News &
(2018–2019 rankings) World Report “Best Hospitals”
(2018–2019 rankings)

x4
consecutive Magnet®
designations
by the American Nurses Credentialing
Center. This is the highest award for
nursing excellence. HSS is the first
hospital in New York State and one of 37
hospitals in the U.S. to achieve the Magnet
designation four consecutive times.
x6 10+ years
consecutive years the the Hospital has scored in the
Hospital has received 99th percentile — the highest
the Press Ganey Guardian possible rank — on “Likelihood
of Excellence Award®, to Recommend,”
a nationally recognized symbol of a key indicator of customer satisfaction,
achievement in patient experience compared to other Magnet hospitals in the
Press Ganey® database

x4 Top
consecutive years Orthopaedic Residency
HSS has received the Program
Healthgrades Outstanding in both reputation and research
output by the professional healthcare
Patient Experience Award™ network Doximity
(2015 to 2018)

448,922 > 25,400 $43 million

Outpatient visits in the 2017–2018 Medical professionals from 130 Value of total federal research grants
academic year countries who choose HSS eAcademy® at the end of 2017
for continuing medical education

32,886 903
Surgeries performed in the 2017–2018 5.64 million Research papers published in the
academic year Unique visitors to our website (hss.edu) 2017–2018 academic year
in the 2017–2018 academic year

> 20 47
Professional and collegiate organizations 84 Active research registries at HSS, with
HSS cares for and serves as team Countries patients traveled from more than 190,000 patients enrolled
physicians for hospital services in the 2017–2018
academic year

47
Our partners in patient care
Department of
Anesthesiology
Anesthesiology can
make a big difference
for a patient when it
comes to successful
joint replacement
surgery. As a field, we
are recognizing that
the type of anesthesia
a patient receives
Gregory A. Liguori, MD,
Anesthesiologist-in-Chief
can affect his or her
and Director, Department outcome. “Recent
of Anesthesiology studies performed at
HSS show that if you use regional anesthesia
when you have your knee or hip replaced, you
can lower your risk of developing a variety of
medical complications, including death,” says
Gregory A. Liguori, MD, Anesthesiologist-
in-Chief and Director of the Department
of Anesthesiology. As a result, 98 percent
of our hip and knee replacement surgeries
are performed using spinal or epidural
anesthesia, compared to only 25 percent
nationwide. In addition, the use of regional
anesthesia may reduce the risk of a surgical
site infection. “The theory is that spinal or
epidural anesthesia increases blood flow to
the lower part of the body, which ensures
more oxygen delivery,” says Dr. Liguori. “That,
in turn, lowers the risk of infection.” One study
quantified the risk reduction as the same
order of magnitude as using prophylactic
antibiotics prior to surgery.
In light of recent concerns about the
effects of some general anesthetics on
cognitive development in young children,
our anesthesiologists minimize their use
in our pediatric surgical patients. This is
accomplished, with the cooperation of our
pediatric surgeons, by performing peripheral
nerve blocks and mild sedation whenever
possible on young children.
In addition, our anesthesiologists, mindful
of the nation’s opioid epidemic, have
adopted multimodal analgesia to treat
postoperative pain. “We administer several
different analgesic medications, such as
acetaminophen, nonsteroidal inflammatory
drugs and ketamine,” explains Dr. Liguori.
These medications, when combined with
peripheral nerve blocks and local infiltration,
enable our anesthesiologists to dramatically
reduce the amount of opioids prescribed
and administered to patients. This has led
to a reduction in opioid-induced side effects,
such as nausea, vomiting and respiratory
depression. “Opioids are there if a patient
needs them, but we only use them as a last
resort,” says Dr. Liguori.
Department of
Nursing
Improving
patient outcomes
and reducing
complications are
key goals in nursing
practice. In recent
years, we have
increased our efforts
to prevent and mitigate
Stephanie J. Goldberg,
RN, MSN, NEA-BC, Chief
skin injuries. “Skin
Nursing Officer and Senior injuries can be painful
Vice President, Patient for patients and may
Care Services
lead to additional
complications and longer lengths of stay,”
says Stephanie J. Goldberg, RN, MSN,
NEA-BC, Chief Nursing Officer and Senior
Vice President, Patient Care Services. “Our
goal is to try to prevent them.” To that end,
we recently hired a nurse practitioner (NP)
with specialized certification in wound care
management. His expertise and prescribing
capabilities allow for greater accuracy
in wound classification and appropriate
treatment and serve as an educational
resource. To further support the NP role,
40 of our nurses completed a Wound
Treatment Associate (WTA) certification
course that prepares them to collaborate
with the NP as clinical extenders to provide
continuous surveillance and education at
the unit level.
In a separate effort to improve patient care
and outcomes, we have launched a new
initiative to identify and manage complex
patients who require intensified clinical
treatment plans. “We hired five complex
care navigators to help identify patients
who, for example, are obese or have a health
condition such as Type 2 diabetes or severe
depression before they come in for surgery,”
says Goldberg. “This helps us to proactively
work with the surgeons and other providers
to anticipate patient needs and to design
a patient-centered treatment plan in which
we provide the best possible, cost-effective
quality care.”
48
Department of Pathology
and Laboratory Medicine
Pathology plays
an important role
in musculoskeletal
care, whether it’s
diagnosing a rare
disease, perfecting
implants or reporting
accurate results of
blood tests. As we
Thomas W. Bauer, MD,
PhD, Pathologist-in-Chief
move toward more
personalized medicine,
Pathology is helping to refine implants,
bone grafts, biomarkers and treatment
with regenerative biologics. “We are very
familiar with bone graft substitutes and
bioactive materials, so we can recognize the
advantages and disadvantages of certain
interventions,” says Thomas W. Bauer,
MD, PhD, Pathologist-in-Chief. “Working
with the departments of Radiology and
Biomechanics, we can also help investigate
the mechanisms of success and failure
of reconstructive orthopaedic procedures.
If we are able to identify benefits or
complications associated with one type
of implant or biologic, we can help patients,
the surgeons and the Hospital.”
Digital technology is starting to emerge
in pathology departments around the
world, and ours is no exception. Dr. Bauer
is continuing the Department’s history
of innovation by developing its digital
capabilities. “We are gradually implementing
the use of high-resolution microscope
slide scanners that let you navigate an
image like Google Earth,” says Dr. Bauer.
“The quality is just as good as microscope
slides, and you can view these slides from
anywhere, which is extremely useful for
consultation diagnoses and multicenter
research projects.”
The Department of Pathology and
Laboratory Medicine also works closely with
the HSS Research Institute to help identify
mechanisms of musculoskeletal disease and
document the efficacy of new treatments.
Performing nearly two million laboratory
tests per year, the Department of Pathology
touches virtually every patient at HSS.
Department of
Physiatry
Providing efficient,
value-based patient
care is a top priority.
To improve access
to spine care, we
have developed a
triage system to
refer patients to the
appropriate provider —
Joel M. Press, MD,
Physiatrist-in-Chief
whether a nurse
practitioner, physical
therapist, medical physician or surgeon —
quickly. “Many patients who call us don’t
need to see a surgeon,” says Joel M. Press,
MD, Physiatrist-in-Chief and Anne and
Joel Ehrenkranz Chair in Physiatry. “For
example, someone who presents with
back pain but no red or yellow flags can be
seen and treated within 48 to 72 hours by
an appropriately trained spine clinician,
such as a nurse practitioner or physical
therapist. The goal is to identify and treat
these patients with acute pain early so they
don’t develop chronic problems.” So far,
over 500 patients have been evaluated
through the program, and more than half
have been appropriately managed and
treated by a physical therapist or nurse
practitioner. We are currently expanding
the program to include knee patients.
Over the last year, we have been
collaborating with the departments of
Neurology and Sports Medicine and
Primary Care Sports Medicine to develop
comprehensive programs to address
prevention, wellness and performance
for our patients, including a Youth Sports
Concussion Program for the main campus
and HSS Westchester in White Plains, NY.
Our goal is to extend the full continuum of
musculoskeletal services around prevention,
wellness and performance for our patients.
Department of
Radiology and Imaging
Technology is
revolutionizing the
field of musculo-
skeletal radiology
and imaging. At HSS,
we are constantly
evaluating new
imaging techniques
to bring precision to
Hollis G. Potter, MD,
Chairman of the
patient care. “We take
Department of Radiology our unique research
and Imaging techniques, validate
them with grant funding, and bring them
from bench to bedside,” says Hollis G.
Potter, MD, Chairman of the Department of
Radiology and Imaging and Coleman Chair
in Magnetic Resonance Imaging Research.
The Department uses imaging to create
3-D models of tissue. “If a patient has a
bone or cartilage lesion in his or her joint,
we can use digital imaging to facilitate tissue
transfer, assessing the lesion size and also
the biochemistry of both the surrounding
tissue and subsequent repair tissue with
quantitative MRI,” says Dr. Potter. “If we
create a three-dimensional model, it takes
the guesswork away from surgeons. They
know exactly where to harvest the tissue.”
Imaging plays a crucial role in enhancing
musculoskeletal care. “The whole concept
of personalized medicine starts with an
appropriate diagnosis,” says Dr. Potter.
Protocols are often modified to refine their
diagnostic accuracy pertinent to a patient’s
individual condition. Once a diagnosis is
made by MRI, ultrasound-guided injections
provide an effective means to directly treat
the condition, often obviating the need for
more invasive surgical techniques.
49
Rehabilitation
The field of
rehabilitation is
moving in the
direction of pre-
and virtual rehab.
Research indicates
that pre-surgical
rehabilitation
training, also called
JeMe Cioppa-Mosca,
Senior Vice President,
“prehab,” cuts down
Rehabilitation on the number of
rehab sessions
needed postoperatively. In a study in which
HSS joint replacement patients underwent
a one-on-one prehab session with a physical
therapist in addition to receiving educational
materials and exercises using our digital
microsite platforms (hss.edu/LATHR
and hss.edu/RATHR), patients met their
rehabilitation discharge criteria half a
day sooner.
In addition, patients undergoing rehabili-
tation may soon be doing their exercises
at home. They will use wearable devices,
such as accelerometers, that attach to
limbs and can record data on a patient’s
progress. The data can be downloaded and
shared with the physical therapist. “Instead
of someone traveling two or three times a
week for physical therapy, the patient would
be able to augment their therapy sessions
by doing a greater proportion of them at
home using a smartphone or computer
with a built-in accelerometer,” says JeMe
Cioppa-Mosca, Senior Vice President,
Rehabilitation. “We’ll be able to prescribe
standardized procedures patients can
follow on their own — and ensure they are
performing the exercises correctly.”
To refine our approaches to rehabilitation,
HSS recently purchased a portable gait
lab, which can analyze a patient’s walking
patterns in the first few weeks after surgery.
One way it’s being used is to compare
the early outcomes of surgical procedures.
“We can find out, for instance, if patients
who had an anterior surgical approach walk
differently from those who had the standard
posterior approach and adjust rehab
protocols accordingly,” says Michael M.
Alexiades, MD, Director and Chief of
Rehabilitation.
REPORTS
FROM THE
FIELD
The latest advances in patient care, research and education
from our 10 Orthopaedic Surgery Services and Department
of Biomechanics, plus our five Rheumatology Centers of
Excellence and Division of Pediatric Rheumatology.

50
Orthopaedic
Surgery
Message from the Surgeon-in-Chief 52

Adult Reconstruction and

Joint Replacement Service 53

Foot and Ankle Service 56 Rheumatology

Hand and Upper Extremity Service 58

Hip Preservation Service 60 Message from the Physician-in-Chief 80

Limb Lengthening and Complex Bone Health and Osteoporosis

Reconstruction Service 62 Center of Excellence 81

Metabolic Bone Disease/ Inflammatory Arthritis Center of Excellence 83

Musculoskeletal Oncology Service 64

Integrative Rheumatology and

Orthopaedic Trauma Service 66 Orthopedic Center of Excellence 86

Pediatric Orthopaedic Service 68 Lupus and Antiphospholipid Syndrome

Center of Excellence 88
Spine Service 72
Division of Pediatric Rheumatology 90
Sports Medicine and Shoulder Service 74
Scleroderma, Vasculitis & Myositis
Department of Biomechanics 78 Center of Excellence 92

51
Message from the
Surgeon-in-Chief
At HSS, well over a century of specialization
enables our surgical and nonsurgical physicians
to deliver unrivaled care. Unmatched volume
and complexity of cases have led to superior
technical expertise, as well as a unique
capability to personalize treatment. For those
who need surgery, we optimize patients’ health
prior to the procedure so they can achieve
the best possible outcomes. After surgery,
we provide rehabilitation services and assess
patients’ pain, mobility, function and overall
health status. We use the information we
collect to inform future treatments. We are
also looking to enhance the environment for
our physicians, as we know this impacts the
care we deliver. We have undertaken several
new initiatives focusing on both patient safety
and physician well-being.
OPIOID EDUCATION
HSS is taking the lead in reducing opioid use
and misuse. We have created Service- and
procedure-specific guidelines for prescribing
pain medication postoperatively, which are
expected to result in 500,000 fewer opioid
pills prescribed. Our healthcare providers
receive mandatory training on proper opioid
use, and we have created patient-provider
agreements that establish expectations for
opioid therapy in order to avoid overuse and
misuse. HSS is also engaging the medical
community in discussions on the topic. We
convened a national forum on opioid-free
arthroplasty regimens in June 2018. We have
also produced webinars on best practices for
opioid prescribing and provided information
for the public on our website and through
social media.
HSS TEAM TRAINING
Even the safest hospitals can improve,
and HSS is no exception. We have partnered
with LifeWings, an organization that helps
healthcare providers adopt and implement
safety practices from aviation and other high-
reliability industries. Through our work with
the organization, we developed HSS Team
Training, a Hospital-wide effort to improve
teamwork and strengthen communication
for optimal patient care and safety and to
improve our efficiencies. In the past year,
more than 1,100 perioperative and procedural
area leaders, physicians and team members
have received the training, which focuses
on addressing barriers to communication,
52
developing effective team skills, and creating
safety tools, such as checklists, with the goal
of zero patient harm. As part of the effort to
improve our culture of safety, team members
are encouraged to speak up if they have
any concerns.
PHYSICIAN WELLNESS
Hospitals nationwide are experiencing
an epidemic of physician burnout due to
many factors, such as a growing number
of bureaucratic tasks, regulation and a loss
of autonomy. Orthopaedic surgeons report
some of the highest rates of burnout — close
to 60 percent. As leaders in the field, we are
committed to addressing the physical and
mental needs of our medical community.
In June 2018, we launched a Wellness Task
Force, and we recently appointed Anne M.
Kelly, MD, Associate Attending Orthopaedic
Surgeon, as Director of Physician Wellness.
In the meantime, we are developing a
program for our surgeons, which will likely
include lectures from nationally recognized
leaders in physician wellness and burnout;
psychologists and life or career coaches for
counseling; and opportunities for physicians
to exercise and participate in events that
foster camaraderie. By tending to the needs
of our physicians, we hope to do the same
for our patients.
I’m proud of the work we are doing outside
the surgical suite to improve patient care
and advance the field. These efforts will
allow HSS to do what we have always done,
only better.
TODD J. ALBERT, MD, FACS
Surgeon-in-Chief and Medical Director
Korein-Wilson Professor of
Orthopaedic Surgery
Adult Reconstruction and
Joint Replacement Service

Physicians in the Adult Reconstruction and Joint Replacement ACHIEVEMENTS

(ARJR) Service perform more joint replacement procedures than • Douglas E. Padgett, MD, Chief of the ARJR Service and Attending
any other hospital in the country. Our surgeons are at the forefront Orthopaedic Surgeon, is President of the Hip Society.
of developing novel techniques and process improvements that
enable our patients to return to a pain-free, active lifestyle quickly. • Michael L. Parks, MD, Associate Attending Orthopaedic Surgeon, is
President of the Orthopaedic Research and Education Foundation.
Chief: Douglas E. Padgett, MD • Paul M. Pellicci, MD, Chief Emeritus of the Hip Service and Attending
Orthopaedic Surgeon, received the HSS Lifetime Achievement Award
Chief, Hip Service: Mathias P. Bostrom, MD at the Hospital’s 35th Tribute Dinner in June 2018.
Chief, Knee Service: Steven B. Haas, MD • Eduardo A. Salvati, MD, Attending Orthopaedic Surgeon, was
the keynote speaker and honorary Chair at the 5th Annual World
Chief, Surgical Arthritis Service: Mark P. Figgie, MD Congress of Orthopaedics, sponsored by the global conference
organizer BIT Congress Inc., in Milan, Italy.
• Michael M. Alexiades, MD, Associate Attending Orthopaedic Surgeon,
PATIENT VISITS PUBLISHED STUDIES ACADEMIC VISITORS
received the ARJR Teaching Award for the 2017–2018 academic year.
51,772 140 50 • Peter K. Sculco, MD, Assistant Attending Orthopaedic Surgeon,
received the Richard S. Laskin, MD, Young Attending Award.
SURGERIES PRESENTATIONS AT PATENTS • Bradford Waddell, MD, Assistant Attending Orthopaedic Surgeon, was
CONFERENCES named Chair of the Young Arthroplasty Group Committee, which he
11,001 170 2 co-founded, of the American Association of Hip and Knee Surgeons.
• Mark P. Figgie, MD, Chief of the Surgical Arthritis Service and
FELLOWS ATTENDINGS Attending Orthopaedic Surgeon, and Robert N. Hotchkiss, MD,
NEW HSS eACADEMY®
9 MODULES
29 Associate Attending Orthopaedic Surgeon, received a patent for a
drug delivery device, a novel approach to medical therapy for the
25 management of musculoskeletal conditions for select patients.
• Nine books and/or chapters were published by the following Service
members: Dr. Figgie; Steven B. Haas, MD, Chief of the Knee Service
and Attending Orthopaedic Surgeon; Alejandro Gonzalez Della
Valle, MD, Attending Orthopaedic Surgeon; Russell E. Windsor,
Attending Orthopaedic Surgeon; Friedrich Boettner, MD, Associate
Attending Orthopaedic Surgeon; David J. Mayman, MD, Associate
Attending Orthopaedic Surgeon; Dr. Parks; Edwin P. Su, MD,
Associate Attending Orthopaedic Surgeon; Seth A. Jerabek, MD,
Assistant Attending Orthopaedic Surgeon; and Alexander S.
McLawhorn, MD, MBA, Assistant Attending Orthopaedic Surgeon.

PATIENT CARE

• In collaboration with Perioperative Medicine, Anesthesiology and

Physician Assistant leaders, the Service assessed and revised
perioperative protocols and pain medication prescriptions issued
at discharge. The goal was to reduce opioid prescriptions and
consumption. The Service focused on alternative medications and
remedies, including blocks and multimodal approaches to pain
management.
• The Service is excited to offer outpatient diagnostic and postoperative
joint replacement care at multiple locations in Fairfield County, CT.
In 2017, we began offering joint replacement surgery in Stamford, CT,
as part of a collaboration with Stamford Health, which includes
independent Magnet® accredited Stamford Hospital. The program is
led by Charles N. Cornell, MD, Medical Director of HSS Orthopedics
at Stamford Health and Attending Orthopaedic Surgeon who also
serves as Chairman, Department of Orthopedic Surgery, at Stamford
Health. As part of this collaboration, we expanded our ARJR patient
pathways and best practices to Stamford Health. The benefit to
patients is assurance of the highest quality of care.

53
Adult Reconstruction and Joint
Replacement Service (cont.)
• Some patients who are having problems after joint replacement
surgery see a local, non-HSS physician or go to their local emergency
room. As a result, the Service has created a postoperative care
program in which patients can be seen not only at the main HSS
campus but also at any of the HSS sites in Paramus, NJ; White Plains,
NY; Stamford, CT; and Uniondale, NY. They can call any one of these
locations or be seen by a Nurse Practitioner.
RESEARCH INITIATIVES
• Dr. Padgett, Timothy M. Wright, PhD, Director of the Department of
Biomechanics, and colleagues have found that a small but significant
percentage of patients who seem to have an uncomplicated hip
• Using the New York State Department of Health database,
replacement procedure develop a variety of symptoms, such as
pain, limp and altered function. Several years ago, while looking at
retrieved implants in the lab, we noticed corrosion at the junction
between the ball and the stem. Some implant systems appeared to
be more susceptible to this phenomenon than others. To investigate
further, we developed a corrosion chamber and a simulator. We took
seemingly well-performing implants and not-so-well-performing
implants and tested combinations of different types of stems
with varying geometries and different materials for the head. In a
study published in the Journal of Orthopaedic Research in 2018,
we reported that some ceramic materials seemed to reduce the risk
of corrosion. Another study is in the works, but in the meantime, our
findings have resulted in a change in clinical practice. At this point,
they support the use of ceramic heads in total hip replacement.
• Dislocation and wear in total hip replacement continue to be among
the leading causes of revision surgery. For years, we have been
54
FROM LEFT TO RIGHT:
Bradford S. Waddell, MD*
Friedrich Boettner, MD
Chitranjan S. Ranawat, MD
Eduardo A. Salvati, MD
Edwin P. Su, MD
Charles N. Cornell, MD
Thomas P. Sculco, MD
Michael M. Alexiades, MD
Amar S. Ranawat, MD
Michael P. Ast, MD*
Douglas E. Padgett, MD
David J. Mayman, MD
Steven B. Haas, MD
Alberto V. Carli, MD*
Alexander S. McLawhorn,
MD, MBA
*new physician
unable to understand why hip replacement patients have problems
despite standard radiographs that indicate a person’s alignment is
fine. Dr. Mayman and Christina Esposito, PhD, Assistant Scientist
in the Department of Biomechanics, found that imaging patients
preoperatively from a standing to a sitting position to measure spino-
graphic alignment parameters and acetabular component orientation
can indicate which ones are at higher risk of dislocation. The study
was published in the Journal of Arthroplasty in 2018. We have been
at the cutting edge of trying to better understand the mechanical
relationship between the spine and the pelvis and want to be able to
anticipate the functional position of the implants. To that end, we will
continue to perform several types of analyses in the future.
Geoffrey H. Westrich, MD, Attending Orthopaedic Surgeon; Stephen
Lyman, PhD, Associate Scientist; and colleagues analyzed 22,076
readmissions from total knee arthroplasty (TKA) within 30 days of
discharge between 1997 and 2014. In the study, which was published
in The Journal of Bone and Joint Surgery in 2017, they found that
only 11 percent of all readmissions were due to TKA-specific compli-
cations. Patients with a greater number of comorbid conditions,
such as coagulopathies, renal disease, heart disease, obesity and
mental health problems, were at increased risk for TKA readmission.
These findings have called attention to the issue of coexisting
medical conditions as well as the need to more closely monitor
patients. They are one of the key reasons the Service has begun to
hire Nurse Practitioners (NPs); we now have 10. These healthcare
professionals can help us to manage patients with congestive heart
failure, postoperative swelling, deep vein thrombosis and a variety of
conditions not related to joint replacement.
 FROM LEFT TO RIGHT:
Paul M. Pellicci, MD
Daniel S. Rich, MD
Jose A. Rodriguez, MD
Geoffrey H. Westrich, MD
Seth A. Jerabek, MD
Robert L. Buly, MD
Mathias P. Bostrom, MD
Allan E. Inglis, Jr., MD
Mark P. Figgie, MD
Michael L. Parks, MD
Michael B. Cross, MD
Alejandro Gonzalez Della
Valle, MD
Peter K. Sculco, MD
Russell E. Windsor, MD

EDUCATION
Orthopaedic Surgeon, gave presentations and moderated sessions.
Nearly 1,000 orthopaedic surgeons attended, and the sessions were
• The annual HSS-China Symposium was held in Zhuhai, China on live-streamed to another 2,000 people.
November 14, 2017. We partnered with Peking University People’s
Hospital; Peking University Third Hospital; Peking Union Medical • Dr. Parks presented as a Visiting Professor at UCSF School of
College Hospital; and Guangzhou Provincial Traditional Chinese Medicine and Yale School of Medicine in 2018.
Medicine Hospital. The Arthroplasty Symposium, which focused on • Service members lectured more than 40 courses in the 2017–2018
complex primary knee, was chaired by Mathias P. Bostrom, MD, Chief academic year.
of the Hip Service and Attending Orthopaedic Surgeon, along with
Michael B. Cross, MD, Assistant Attending Orthopaedic Surgeon;
NOTABLE REFERENCES
and Drs. Jerabek and Peter Sculco.
• Carli AV, Bhimani S, Yang X, Shirley MB, de Mesy Bentley KL, Ross FP,
• The 12th International Congress of the Chinese Orthopaedic
Bostrom MP. Quantification of Peri-Implant Bacterial Load and in Vivo
Association (COA) was held in Zhuhai, China in November 2017.
Biofilm Formation in an Innovative, Clinically Representative Mouse
Drs. Padgett, Cross, Jerabek and Peter Sculco presented a course
Model of Periprosthetic Joint Infection. J Bone Joint Surg Am. 2017
on complex primary hip. Dr. Padgett was Program Chair of the
Mar 15;99(6):e25
COA-HSS Arthroplasty Session. More than 500 Chinese surgeons
attended the course, which included didactic lectures and case • Lange JK, Lee YY, Spiro SK, Haas SB. Satisfaction Rates and
discussions. Quality of Life Changes Following Total Knee Arthroplasty
in Age-Differentiated Cohorts. J Arthroplasty. 2018
• Dr. Haas lectured as a visiting surgeon at Anhui Medical University in
May;33(5):1373-1378
China in 2017.
• Soeters R, White PB, Murray-Weir M, Koltsov JCB, Alexiades MM,
• The 16th Winter Meeting of the Ranawat Orthopaedic Conference
Ranawat AS. Preoperative Physical Therapy Education Reduces Time
was held in Mumbai, India, in January 2018. The focus was
to Meet Functional Milestones After Total Joint Arthroplasty. Clin
on “Advances & Techniques in Joint Replacement Surgery &
Orthop Relat Res. 2018 Jan;476(1):40-48
Arthroscopy.” The three-day meeting was chaired by Chitranjan S.
Ranawat, MD, Attending Orthopaedic Surgeon, along with Anil S. • Pitta M, Esposito CI, Li Z, Lee YY, Wright TM, Padgett DE. Failure
Ranawat, MD, Associate Attending Orthopaedic Surgeon, and After Modern Total Knee Arthroplasty: A Prospective Study of 18,065
Amar S. Ranawat, MD, Associate Attending Orthopaedic Surgeon. Knees. J Arthroplasty. 2018 Feb;33(2):407-414
Dr. Cross and Peter D. Fabricant, MD, MPH, Assistant Attending

55
Foot and Ankle Service

The Foot and Ankle Service is the largest ACHIEVEMENTS

program of its kind in the United States. • Scott J. Ellis, MD, Associate Attending Orthopaedic Surgeon, is
Its surgeons have expertise in deformity President of the Board of Directors of the Orthopaedic Foot & Ankle
correction, trauma, sports injuries and Foundation, the fundraising arm of the American Orthopaedic Foot &
arthritis. Ankle Society (AOFAS).

Chief: Matthew M. Roberts, MD • Anne Holland Johnson, MD, Assistant Attending Orthopaedic
Surgeon, was elected to the AOFAS Board of Directors.
• Mark C. Drakos, MD, Assistant Attending Orthopaedic Surgeon, is
PATIENT VISITS PRESENTATIONS AT Executive Board Member for The Thomas B. Quigley Society and
CONFERENCES
24,303 50
serves on the Advisory Board of the Concussion Legacy Foundation.
• In May 2018, we celebrated the investiture of Jonathan T. Deland, MD,
as the Susan W. Rose and Jonathan T. Deland Chair for Research in
SURGERIES
Foot and Ankle Surgery. This is the first endowed chair in the Service,
NEW HSS eACADEMY®
2,718 MODULES and it supports the Rose Registry, one of the largest foot and ankle
registries in the nation. The Rose Registry is dedicated to evaluating

FELLOWS
10 patient outcomes following treatment of foot and ankle conditions
and supporting vital research initiatives of the Service.

3 ACADEMIC VISITORS • The paper “Influence of Tibial Component Position on Altered

Kinematics Following Total Ankle Arthroplasty During Simulated Gait”

PUBLISHED STUDIES
32 received the Award for Excellence from the International Federation
of Foot & Ankle Societies for best international paper presented at

47 the AOFAS Annual Meeting in Boston in July 2018. Drs. Deland and
Ellis, Constantine A. Demetracopoulos, MD, Assistant Attending
Orthopaedic Surgeon, and Daniel Sturnick, MS, Research Engineer
in the Department of Biomechanics, were the HSS recipients.

56

OPPOSITE PAGE, David S. Levine, MD John G. Kennedy, MD
FROM LEFT TO RIGHT:
Andrew J. Elliott, MD Scott J. Ellis, MD
Anne Holland Johnson,
Matthew M. Roberts, MD Harvey Strauss, DPM,
MD*
Constantine A. FACFAS
Jonathan T. Deland, MD
Demetracopoulos, MD
Martin J. O’Malley, MD
Mark C. Drakos, MD *new physician
PATIENT CARE
• The Service has devised guidelines that limit overprescribing of
narcotics. For years, we have used a novel pain protocol. Now, in
perhaps one of the first studies of narcotics use in foot and ankle
patients, we have measured the protocol’s benefit by prospectively
counting the number of narcotic tablets required for patients after
major foot and ankle surgery. In the study, which was published in
Foot & Ankle International, we found that 95 percent of patients rarely
require more than 26.8 tablets of narcotics after surgery. As a result,
we recommend that the number of narcotic pills prescribed at the
time of outpatient surgery should not exceed 30.
• We have published several studies on the use of hamstring autografts
in foot and ankle patients. Dr. Drakos completed fellowship training in
both orthopaedic sports and orthopaedic foot and ankle surgery and
is considered a leader in this innovative approach to reconstructing
tendon and ligament pathology. With a hamstring autograft, tissue
quality is better and the risk of infection is lower because the patient’s
own tendon is used instead of that of a cadaver. Also, in the case of
tendon pathology, autograft reconstruction maintains the use of the
muscles and prevents potential weakness.
• Dr. Demetracopoulos, a national leader in the use of patient-specific
implants, is studying the INFINITY™ prosthesis for total ankle
arthroplasty. The components of this system are available in different
sizes to match a patient’s anatomy.
• The weight-bearing 3-D CT scan — which allows us to visualize how
joints and bones interact in a weight-bearing state — is enabling us to
detect deformities we never saw before.
• We have developed a Fast Track initiative to discharge Total Ankle
Replacement patients the next day. This enables us to optimize
patient care in terms of pain management, mobilization and early
physical therapy.
• The HSS ASC (Ambulatory Surgery Center) of Manhattan opened in
2017. David S. Levine, MD, Associate Attending Orthopaedic Surgeon,
is the medical director.
RESEARCH INITIATIVES
• The award-winning paper “Influence of Tibial Component Position
on Altered Kinematics Following Total Ankle Arthroplasty During
Simulated Gait” improves our understanding of the critical nature of
component position when performing ankle replacements. The study
was conducted in real time using our state-of-the-art gait simulator,
which enables us to check pressures and loads in an active situation
without the need for patients. Dr. Demetracopoulos was the Principal
Investigator.
• In the first study of its kind, Dr. Ellis, Carol A. Mancuso, MD, Attending
Physician, and colleagues investigated the effect of diagnosis on
preoperative expectations of elective foot and ankle surgery. In
the study, which was the lead article and podcast in Foot & Ankle
57
International in June 2018, the researchers found that patients
with ankle instability or osteochondral lesions had the highest
expectations, while those with mid- and hindfoot arthritis had the
lowest. If surgeons can identify patients with high — and potentially
unattainable — expectations and address them in preoperative
discussions, they may be able to improve postoperative satisfaction.
• In another lead article and podcast published in Foot & Ankle
International in 2018, Drs. Ellis and Deland and colleagues studied
flatfoot reconstruction patients undergoing Cotton osteotomy for
residual forefoot supination. In attempting to predict the size of
the osteotomy graft needed, the researchers determined that the
preoperative cuneiform articular angle, as determined by radiograph,
was most useful.
EDUCATION
• HSS was a host site for the AOFAS Traveling Fellowship Program.
In July 2018, we hosted six fellows from China, Turkey, the United
Kingdom, South Korea, India and Japan for three days. They spent
time with us in the clinics and observed in the OR.
• Dr. Roberts chaired the AOFAS Postgraduate Education and Training
Committee, a two-year leadership role. In this role, he completed
the AOFAS Resident Lecture Series and hosted an onsite teaching
session for residents at the annual meeting in Boston.
• Dr. Drakos was Chair of the Foot and Ankle Education Committee at
the AAOS Annual Meeting in New Orleans in March 2018.
• Dr. Ellis taught at the AOFAS Surgical Complications of the Foot and
Ankle Course in Austin, TX, in October 2017 and at the AAOS/AOFAS
Total Ankle Arthroplasty Course in Rosemont, IL, in May 2018.
• John G. Kennedy, MD, Co-Founder of the International Society on
Cartilage Repair of the Ankle, hosted the International Consensus
Meeting on Cartilage Repair of the Ankle in Pittsburgh in
November 2017.
• Dr. Ellis teaches medical students with Juliet Aizer, MD, MPH,
Assistant Attending Physician, at Weill Cornell Medical College.
NOTABLE REFERENCES
• Gupta, M., Jones, A. Sanders, K. Kumar, M. Roberts, D. Levine, M.
Drakos, M. O’Malley, A. Elliott, J. Deland, S.J. Ellis. Pain Management
After Outpatient Foot and Ankle Surgery. Foot & Ankle International.
39(2). February 2018. 149-154.
• G. Kunas, H. Do, T. Aiyer, J.T. Deland, S.J. Ellis. The Contribution of
Medial Cuneiform Osteotomy to Correction of Longitudinal Arch
Collapse in Stage IIb Adult Acquired Flatfoot Deformity. Foot & Ankle
International.
• E.A. Cody, H. Do, J. Burket, C. Mancuso, S.J. Ellis. Patients’
Expectations of Foot and Ankle Surgery: Diagnosis Matters. Foot &
Ankle International. 39(6). June 2018. 641-648.
• Techniques with Guidance. Techniques in Foot and Ankle Surgery.
Guest Editor. Chapters on Lapiplasty, Prophecy Infinity Total Ankle,
PARs Achilles Repair, and Flatfoot Reconstruction with Equations.
Wolters Kluwer. Guest Editorial. 16(4). December 2017.
• Novel Hamstring Autograft Techniques. Techniques in Foot and
Ankle Surgery. Chapters on Peroneus Brevis, Anterior Tibial Tendon,
Chronic Achilles, and Ankle Instability. Wolters Kluwer 2017. Guest
Editorial. 17(1). March 2018.
Hand and Upper Extremity Service

The Hand and Upper Extremity Service is ACHIEVEMENTS

internationally renowned for its treatment • Steve K. Lee, MD, Associate Attending Orthopaedic Surgeon, is Chair
of adults and children suffering from bone of the American Society for Surgery of the Hand Corporate Advisory
and soft-tissue conditions of the hand, wrist, Council and President of the New York Society for Surgery of the Hand.
forearm, elbow and shoulder.
• Michelle G. Carlson, MD, Attending Orthopaedic Surgeon, is Treasurer
Chief: Edward A. Athanasian, MD of the American Society for Surgery of the Hand.
• Duretti T. Fufa, MD, Assistant Attending Orthopaedic Surgeon, was
named Director of the HSS Residency Program.
PATIENT VISITS PRESENTATIONS AT
CONFERENCES • In 2018, Dr. Fufa became a member of the American Orthopaedic
24,318 52
Association’s Emerging Leaders Program.

SURGERIES PATIENT CARE

NEW HSS eACADEMY®
2,892 MODULES • Scott W. Wolfe, MD, Chief Emeritus, Hand and Upper Extremity
Service and Attending Orthopaedic Surgeon, is working with Joseph

FELLOWS
5 Lipman, MS, Director of Device Development in the Department
of Biomechanics, to customize surgical reconstruction of the

4 ACADEMIC VISITORS
fragmented scaphoid proximal pole. Using high-resolution computed
tomography (CT), we are able to visualize the shape of the scaphoid,

PUBLISHED STUDIES
16 then rebuild it with a 3-D model. The model enables us to determine
the exact geometry of a patient’s damaged bone so we can
reconstruct it in one of three ways:
41 PATENTS
1. We can compare the shape of the scaphoid to the ipsilateral hamate,
1 and if there is a match we can perform an osteochondral autograft.
2. We can shape a new scaphoid proximal pole from the costochondral
portion of the patient’s rib.
3. We can transplant a vascularized osteoarticular graft from the
medial femoral condyle.

58

OPPOSITE PAGE,
FROM LEFT TO RIGHT:
Samir K. Trehan*, MD
Andrew J. Weiland, MD
Scott W. Wolfe, MD
Robert N. Hotchkiss, MD
Lana Kang, MD
Daniel A. Osei, MD, MSc
intraoperative punctate bleeding and histopathological examination
Edward A. Athanasian, MD
showed substantial degrees of ischemia, but none correlated with
Aaron Daluiski, MD
time to healing or union. Dr. Wolfe and team removed sclerotic
Michelle G. Carlson, MD
and necrotic bone and replaced it with fresh, non-vascularized
Steve K. Lee, MD
autogenous bone graft and rigid fixation. Thirty-three of the patients
Duretti T. Fufa, MD healed by 12 weeks, and lengthy, expensive vascular grafts were
unnecessary. In the study, which was published in the Journal of Hand
*new physician Surgery (European Volume) in 2018, we concluded that proximal pole
infarction is rare and vascularized bone grafting is seldom required
for internal fixation of a scaphoid nonunion.

• Dr. Wolfe and his radiology colleagues are making significant strides
in managing Parsonage-Turner Syndrome (PTS), which leads to
residual muscle paralysis or pain in up to 60 percent of patients.
Using high-resolution MRI and ultrasound, we routinely identify
hourglass constrictions in the affected nerves of PTS patients with
persistent motor paralysis. In a recent study of eight PTS patients
with chronic, persistent motor palsy and hourglass constrictions,
we performed microsurgical neurolysis of the affected nerves.
This resulted in significant electrical and strength improvements in
previously denervated muscles in seven out of eight patients. Based
on these findings, surgical management of hourglass constrictions
in PTS patients appears to be a viable treatment alternative for
recalcitrant disease.
• Robert N. Hotchkiss, MD, Associate Attending Orthopaedic Surgeon,
is making progress using 3-D printing and additive manufacturing
to design elbow implants for patients. Over the past year, he has
created — in collaboration with the Department of Biomechanics
and Italy-based LimaCorporate S.p.A. — approximately six implants
using these technologies. CT imaging of a patient’s anatomy enables
Dr. Hotchkiss to perform predictive stress analysis, and he uses a
3-D printer to create a model of a patient’s bone for a more accurate
picture of the problem. He uses additive manufacturing to tailor the
implant’s stiffness and porosity to a patient’s needs.
• Dr. Hotchkiss recently used the Compress® implant system to create
an elbow implant for a patient with limited bone stock. The system is
traditionally used in the femur.
• The Service experienced an impressive drop in opioid prescriptions
over the past year, according to new research published in the
Journal of Hand Surgery. In 2016, HSS mandated a one-hour opioid
education program for employees qualified to prescribe controlled
substances. The Hospital also formulated prescribing guidelines for
the Hand and Upper Extremity Service based on literature review and
expert opinion. The new guidelines, which recommended a specific
number of pills based on the type of hand surgery performed,
were distributed to staff members in February 2017. To determine
whether these efforts resulted in a change in prescribing practices,
investigators reviewed postoperative opioid prescriptions for patients
who underwent ambulatory hand and upper-extremity surgery four
months before the mandatory education session and twice after the
guidelines were disseminated. Researchers found that there was a
52.3 percent mean reduction in oral morphine equivalents prescribed
after the education session and distribution of guidelines.
RESEARCH INITIATIVES
• Dr. Wolfe, Dr. Lee and colleagues challenged the accepted beliefs
that the proximal pole of the scaphoid becomes ischemic after a
fracture — and that a vascular graft is required for the bone to heal.
In a recent study of 35 patients with scaphoid nonunions, MRI,
• In an effort to reduce opioid use, we have initiated a prospective
patient education study led by Dr. Fufa. The goal is to determine
whether educating patients on how to manage postoperative pain
appropriately can help decrease opioid use. Our Patient Education
team created a video presentation that patients view one week prior
to surgery. Then, after their procedures, they are given a laminated
card with reminders to ice, elevate and rest their hand. They are
also advised to try acetaminophen or ibuprofen before turning to
an opioid. Currently, about 250 patients have enrolled in the study,
and we are recruiting around 70 more. We hope to identify what
factors contribute to higher opioid use to prevent excessive opioid
prescribing and consumption.
EDUCATION
• Dr. Fufa fosters a cooperative effort between the Hand and Trauma
services, enhancing patient care and the resident education program.
• Daniel A. Osei, MD, MSc, Assistant Attending Orthopaedic Surgeon,
and Samir K. Trehan, MD, Assistant Attending Orthopaedic
Surgeon, renewed the Service’s emphasis on resident training,
including instruction on how to take patient histories and conduct
physical exams.
• We hosted eight international Fellows through the American Society
for Surgery of the Hand’s International Traveling Fellows Program in
September 2017.
• Martin Boyer, MD, the Carol B. and Jerome T. Loeb Professor of
Orthopaedic Surgery at Washington University in St. Louis, was the
Lee Ramsay Straub Hand lecturer in 2018.
NOTABLE REFERENCES
• Stepan J, Sacks HA, Lovecchio F, Premkumar A, Fu M, Osei D, Fufa D.
Opioid Prescriber Education and Guidelines for Ambulatory Upper
Extremity Surgery: Evaluation of an Institutional Protocol. J Hand
Surg Am. 2018 Jul; S0363-5023(17)31857-9.PMID: 30033347
• Schreiber JJ, Kang L, Hearns KA, Pickar T, Carlson MG. Micro screw
fixation for small proximal pole scaphoid fractures with distal radius
bone graft. J Wrist Surg. 2018 Jun; doi: 10.1055/s-0038-1660445
[eFirst ahead of print]
• Swanstrom MM, Morse KW, Lipman J, Hearns KA, Carlson MG.
Effect of screw perpendicularity on compression in scaphoid waist
fractures. J Wrist Surg. 2017 Aug; 6(3):178-182. PMID 28725497
• Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW.
Success of scaphoid nonunion surgery is independent of proximal
pole vascularity. J Hand Surg Eur Vol. 2018; 43(1):32-40.

59
Hip Preservation Service
The Hip Preservation Service and the
Center for Hip Preservation provide a
multidisciplinary approach to diagnosing
and treating patients’ complex hip pain.
Service and Center members include
specialists trained in Orthopaedic Surgery,
Sports Medicine, Physiatry, Physical
Therapy, Radiology and Biomechanics.
Chief: Robert L. Buly, MD
SURGERIES PRESENTATIONS AT
CONFERENCES
1,663 64
FELLOWS
ACADEMIC VISITORS
1 6
PUBLISHED STUDIES
78
60
ACHIEVEMENTS
• Robert L. Buly, MD, Chief of the Hip Preservation Service and
Associate Attending Orthopaedic Surgeon, wrote the chapter entitled
“Proximal Femoral Derotational Osteotomy” for the forthcoming
book Hip Surgery: Tricks of the Trade, edited by Allston Stubbs, MD,
and published by Thieme Publishers.
• Anil S. Ranawat, MD, Associate Attending Orthopaedic Surgeon,
is Editor-in-Chief of the journal Current Reviews in Musculoskeletal
Medicine.
• Dr. Ranawat is a reviewer for HSS Journal, Clinical Orthopaedics and
Related Research, and The American Journal of Sports Medicine.
• Edwin P. Su, MD, Associate Attending Orthopaedic Surgeon, is a
member of the Editorial Board of Techniques in Orthopaedics.
• Danyal H. Nawabi, MD, Assistant Attending Orthopaedic Surgeon,
is an author of the paper “Becoming Proficient at Hip Arthroscopy
Harder than Expected,” which was featured in the Star Paper Session
at the 18th ESSKA Congress in Glasgow, Scotland, UK, in May 2018.
• Dr. Nawabi is an author of “Defining the Learning Curve for Hip
Arthroscopy: A Threshold Analysis of the Volume-Outcomes
Relationship,” a video abstract for The American Journal of Sports
Medicine.
PATIENT CARE
• The Hip Preservation Registry was designed to capture and evaluate
the outcomes of surgical and nonsurgical treatment for non-arthritic
hip pain in patients. The Registry, which was established in 2010,
currently contains information on more than 5,500 hip patients and

OPPOSITE PAGE, David L. Helfet, MD
FROM LEFT TO RIGHT:
Struan H. Coleman, MD
Edwin P. Su, MD Anil S. Ranawat, MD
Douglas N. Mintz, MD Danyal H. Nawabi, MD
Peter J. Moley, MD
Robert L. Buly, MD
NOT PICTURED:
David S. Wellman, MD
Dean G. Lorich, MD
Bryan T. Kelly, MD
Ernest L. Sink, MD
is enabling clinicians to evaluate the effectiveness of the diagnosis
and treatment of hip pain; monitor patient outcomes for five, 10 and
20 years after treatment; and determine whether early interventions
will delay — or even prevent — the onset of osteoarthritis. This data
will help us to identify which patients are the best candidates for
specific surgical techniques and will aid in the development of optimal
standards for hip care.
• In collaboration with the Department of Radiology and Imaging,
Department of Biomechanics, and the Computer Assisted Surgery
Center Research Laboratory, Hip Preservation Service members
are identifying the factors that contribute to hip osteoarthritis and
learning how structural abnormalities of the hip cause early cartilage
deterioration. This knowledge will help specialists across a range of
efforts, from identifying various hip conditions to developing and
validating a robotic navigation program for hip preservation surgery.
• The Service is studying the biomolecular cause of early cartilage
failure with the goal of developing new and innovative methods
for repair. HSS is at the forefront of translating basic and clinical
research into patient care, and we are using that expertise to develop
techniques that generate new cartilage and promote healing.
• Our specialists are working to identify strong, objective measures
to better evaluate hip pain and validate many non-operative or
minimally invasive procedures. The team is building a true functional
assessment to gauge mobility of the spine, hips and lower kinetic
chain. This effort will involve looking at a patient’s strength,
neurological factors and movement during everyday activities.
Capturing this crucial data will help advance hip pain diagnostics.
RESEARCH INITIATIVES
• One of the Service’s key research initiatives is focused on evaluating
the outcomes of hip arthroscopy procedures. We are trying to answer
the following questions:
– When can patients expect to be better? Patient-reported outcome
scores from our Registry are being used to measure Minimal
Clinical Important Difference (MCID) and Substantial Clinical
Benefit (SCB) over time.
– Is hip arthroscopy useful as an adjunct to open hip procedures?
– Does hip arthroscopy jeopardize the blood supply to the
femoral head?
– Does prior hip arthroscopy jeopardize the outcome of open hip
procedures or total hip replacement?
– Why does hip arthroscopy fail in some cases?
• We are studying the outcomes of periacetabular osteotomy (PAO)
to determine if blood loss can be minimized; if there is a role for
61
“salvage” PAO; if concomitant hip arthroscopy is necessary; and if
femoral or acetabular version affects the outcome of PAO.
• An additional research focus is treating hip disorders in athletes. We
are investigating whether hip disorders predispose athletes to other
musculoskeletal problems and which hip disorders are commonly
seen in athletes.
EDUCATION
• Dr. Buly presented “Version Problems in the Hip” at the 9th Annual
Meeting of the International Society for Hip Arthroscopy in Santiago,
Chile, in October 2017.
• Dr. Buly gave a podium presentation entitled “Prior Hip Arthroscopy
Does Not Affect Clinical Outcomes Following Total Hip Arthroscopy:
An Institutional, Matched Cohort Study” at the American Academy of
Orthopaedic Surgeons (AAOS) Annual Meeting in New Orleans, LA,
in March 2018.
• Dr. Buly gave a poster presentation entitled “Acetabular Version
and Acetabular Coverage Measurements have Clinically Relevant
Associations with Pelvic Incidence and Pelvic Tilt in Patients Treated
for Femoroacetabular Impingement” at the AAOS Annual Meeting in
March 2018.
• Dr. Ranawat gave a presentation on soft-tissue reconstruction at
the Hip Orthopaedic Technology & Innovation Forum in Naples, FL,
in June 2018.
• Dr. Nawabi was the Faculty Speaker at the 44th Annual Meeting
of the International Skeletal Society. He spoke about complex hip
preservation.
• Dr. Nawabi gave an HSS webinar entitled “Direct Anterior Approach
for THR/Complications and Complex Cases” in June 2018.
NOTABLE REFERENCES
• Lazaro LE, Nawabi DH, Klinger CE, Sculco PK, van der List JP,
Dyke JP, Helfet DL, Kelly BT, Lorich DG. Quantitative Assessment
of Femoral Head Perfusion Following Arthroscopic Femoral
Osteochondroplasty: A Cadaveric Study. J Bone Joint Surg Am.
2017Dec 20;99(24):2094-2102.
• Time Required to Achieve Minimal Clinically Important Difference
and Substantial Clinical Benefit After Arthroscopic Treatment of
Femoroacetabular Impingement. Nwachukwu BU, Chang B, Adjei J,
Schairer WW, Ranawat AS, Kelly BT, Nawabi DH. Am J Sports Med.
2018 Aug 1:363546518786480. doi: 10.1177/0363546518786480.
PMID:30067064
• The Effect of Prior Hip Arthroscopy on Patient-Reported Outcomes
After Total Hip Arthroplasty: An Institutional Registry-Based, Matched
Cohort Study. Konopka JF, Buly RL, Kelly BT, Su EP, McLawhorn AS.
J Arthroplasty. 2018 Jun;33(6):1806-1812.
• Degen RM, Pan TJ, Chang B, Mehta N, Chamberlin PD, Ranawat
AS, Nawabi D, Kelly BT, Lyman S. Risk of failure of primary hip
arthroscopy — a population-based study. J Hip Preserv Surg. 2017
Aug; 4(3):214-223.
• Ricciardi BF, Fields KG, Wentzel C, Kelly BT, Sink EL. Early Functional
Outcomes of Periacetabular Osteotomy After Failed Hip Arthroscopic
Surgery for Symptomatic Acetabular Dysplasia. Am J Sports Med.
2017 Sep;45(11):2460-2467.
Limb Lengthening and Complex
Reconstruction Service
FROM LEFT TO RIGHT:
Austin T. Fragomen, MD
S. Robert Rozbruch, MD

The Limb Lengthening and Complex ACHIEVEMENTS

Reconstruction Service (LLCRS) is the • S. Robert Rozbruch, MD, Chief of the Limb Lengthening and Complex
only comprehensive limb lengthening Reconstruction Service and Attending Orthopaedic Surgeon, and
and deformity program that is part of an Austin T. Fragomen, MD, Associate Attending Orthopaedic Surgeon,
academic orthopaedic surgery department published the following book chapter: Motorized Intramedullary
in the United States. Lengthening Nail for Limb Reconstruction, in Browner et al., Skeletal
Trauma, 6th Edition, 2018.
Chief: S. Robert Rozbruch, MD
• Drs. Rozbruch and Fragomen were selected as Top Doctors in
Orthopaedic Surgery by “Castle Connolly Top Doctors” and New York
PATIENT VISITS PRESENTATIONS AT magazine in 2018.
CONFERENCES
2,764 42
• At the Limb Lengthening and Reconstruction Society (LLRS)
Specialty Day at the American Academy of Orthopaedic Surgeons
(AAOS) conference in 2018, Dr. Rozbruch presented: Feasibility of
SURGERIES Correcting the Mechanical Axis in Large Varus Deformities with Medial
NEW HSS eACADEMY® Unicompartmental Knee Arthroplasty. The presentation was included
564 MODULES
in the “Best Papers from the LLRS 26th Annual Meeting” Session.

FELLOWS
4 • Dr. Rozbruch is Membership Chair, Executive Board Member and
President Emeritus of the LLRS.

2 ACADEMIC VISITORS • Dr. Rozbruch is Associate Editor of the Journal of Limb Lengthening
and Reconstruction.

PUBLISHED STUDIES
11 • Dr. Fragomen is Second Vice President and Executive Board Member
of the LLRS.
20 • In 2018, Dr. Fragomen was named an International Committee
Member of the Fracture-Related Infection Consensus Group at the
AO Foundation.

62
PATIENT CARE
• Dr. Rozbruch is a national leader in a groundbreaking procedure
called osseointegration amputation reconstructive surgery,
which is designed to make prosthetics for amputee patients more
comfortable and functional. The procedure is most commonly used
for the femur, but Dr. Rozbruch performed the first tibia case in
the U.S. recently. He plans to work with Scott W. Wolfe, MD, Chief
Emeritus of the Hand and Upper Extremity Service and Attending
Orthopaedic Surgeon, on a humerus and forearm case, which
will involve Targeted Muscle Reinnervation (TMR). This innovative
surgical procedure uses the brain and residual muscles to power the
elbow and hand of an upper extremity amputation.
• We are taking a new approach to recalcitrant nonunions, which
have traditionally been repaired using a static nail or external fixator.
At the 2018 LLRS meeting, Dr. Fragomen presented data on the use
of the magnetic internal compression nail — which is traditionally
used for lengthening — for gradual compression of nonunions. We
have performed about a dozen cases so far using this technique,
and it appears promising. In our study of patients with a long bone
nonunion treated with the magnetic internal compression nail, all
patients achieved union in an average of 23.7 weeks.
• Dr. Rozbruch is a pioneer in bone transport, in which bone with
a defect is lengthened, sparing the patient amputation. Initially,
patients wore an external fixator during treatment. Several years
ago, Dr. Rozbruch introduced integrated fixation, in which both
external and internal fixators are used. This lessens the amount of
time patients need to spend in the external fixator. The next step
in improving bone transport is to eliminate the external fixator
completely. Drs. Rozbruch and Fragomen are currently developing
an internal bone transport intramedullary (IM) nail. They expect that
it will become available in the next one to two years.
• Drs. Rozbruch and Fragomen compared the costs of lengthening
over a nail and internal lengthening in a study accepted for
publication in the Journal of the American Academy of Orthopaedic
Surgeons. Although the internal lengthening nail is more expensive,
the higher cost is offset by the fewer surgeries needed when
compared with the lengthening-over-nail technique.
RESEARCH INITIATIVES
• We have been studying survival and patient outcomes following the
joint preservation technique ankle distraction arthroplasty. Our most
recent results are very compelling: Five years after the procedure was • Kleeblad LJ, van der List JP, Pearle AD, Fragomen AT, Rozbruch SR:
performed, there was an 85 percent survival rate. Seven years later,
there was a 78 percent survival rate. The technique has been shown
to delay the need for ankle fusion and replacement.
• Drs. Rozbruch and Fragomen collaborated with Andrew D. Pearle,
MD, Associate Attending Orthopaedic Surgeon, who specializes
in Sports Medicine, to devise an algorithm for determining when
a deformity correction can be optimally treated with unicompart-
mental knee arthroplasty. Drs. Rozbruch and Pearle came up with
an equation to help surgeons predict the amount of deformity
correction that can be achieved in an arthritic knee by performing a
unicompartmental knee replacement. The study, called “Feasibility
of Correcting the Mechanical Axis in Large Varus Deformities with
Medial Unicompartmental Knee Arthroplasty Research,” won the
LLRS “Best Paper” Award in 2017.
• As part of our effort to move away from the use of external fixators,
we are using the intramedullary (IM) nail for deformity correction and
lengthening. This new approach, which includes the use of blocking
screws, enables us to effectively lengthen and correct deformity without
the need for an external fixator. To better understand the accuracy
of internal fixation, we recently published two studies on the use of
osteotomy, IM nails and blocking screws for correcting deformity. These
findings will help us to decrease our use of external fixation without
compromising our ability to accurately lengthen and correct deformity.
EDUCATION
• The first-ever HSS Limb Deformity Course was held in February 2018.
In February 2019, there will be an endowed Course called the Bobby
Menges Memorial HSS Limb Deformity Course.
• Drs. Rozbruch and Fragomen gave a webinar in January 2018 called
“New Technologies in Limb Lengthening and Deformity Correction.”
• In February 2018, Raymond Liu, MD, Associate Professor of
Orthopaedic Surgery at Case Western Reserve University, served
as the Annual Dr. Bonnie Reichman Visiting Limb Lengthening and
Complex Reconstruction Professor.
• Dr. Fragomen and Scott J. Ellis, MD, Associate Attending Orthopaedic
Surgeon, chaired the combined LLRS/American Orthopaedic Foot &
Ankle Society (AOFAS) session at the AAOS Annual Meeting in New
Orleans in March 2018. Dr. Rozbruch participated and lectured in
the session.
• Dr. Rozbruch was the Keynote Speaker at the British Limb
Reconstruction Society meeting in Southampton, England, in
March 2018.
• Dr. Fragomen was the Keynote Speaker for Grand Rounds at the
University of Calgary in Alberta, Canada, in March 2018.
• Dr. Fragomen was the Keynote Speaker at the Peking University
2017 Osteoarthritis International Forum in Hangzhou, China, in
September 2017.
NOTABLE REFERENCES
• Fragomen AT, Kurtz A, Barclay JR, Nguyen J, Rozbruch SR: A
comparison of femoral lengthening methods favors the magnetic
internal lengthening nail when compared with lengthening over a nail.
HSS J. 2018 Jul;14(2):166-176. doi: 10.1007/s11420-017-9596-y. Epub
2018 Jan 5.
Feasibility of correcting the mechanical axis in large varus deformities
with medial unicompartmental knee arthroplasty. J Arthroplasty. 2018
Feb;33(2):372-378. doi: 10.1016/j.arth.2017.09.052. Epub 2017 Oct 5.
• Iobst CA, Rozbruch SR, Nelson S, Fragomen AT: Simultaneous Acute
Femoral Deformity Correction and Gradual Limb Lengthening Using
the Retrograde Precice Femoral Nail: Technique and Clinical Results.
J Am Acad Orthop Surg. 2018 Apr 1;26(7):241-250. doi: 10.5435/
JAAOS-D-16-00573.
• Fragomen AT, Rozbruch SR: Does the surgical correction of tibial
torsion with genu varum produce outcomes similar to those in
varus correction alone? J Knee Surg. 2018 Apr;31(4):359-369. doi:
10.1055/s-0037-1603797. Epub 2017 Jun 24.
• Hamdy RC, Bernstein MA, Fragomen AT, Rozbruch SR: What’s New in
Limb Lengthening and Deformity Correction. J Bone Joint Surg Am.
2017 Aug 16;99(16):1408-1414. doi: 10.2106/JBJS.17.00464.
63
Metabolic Bone Disease/
Musculoskeletal Oncology Service
The Metabolic Bone Disease/
Musculoskeletal Oncology Service is
focused on the prevention and treatment
of musculoskeletal disorders, including
osteoporosis and fragility fractures.
Practitioners are dedicated to enhancing
orthopaedic surgery outcomes for patients
with bone disease. The Service unites
physicians from multiple disciplines,
including Orthopaedics, Rheumatology,
Physiatry, Endocrinology, Nephrology
and Pediatrics.
Chief: Joseph M. Lane, MD
PATIENT VISITS PRESENTATIONS AT
CONFERENCES
7,330 27
FELLOWS
ACADEMIC VISITORS
4 4
PUBLISHED STUDIES
9 • Linda A. Russell, MD, Director of the Bone Health and Osteoporosis
64
FROM LEFT TO RIGHT:
Emily M. Stein, MD, MS
Richard S. Bockman, MD,
PhD
Marci Anne Goolsby, MD
Dorothy A. Fink, MD
Linda A. Russell, MD
Alana C. Serota, MD
Juliet B. Aizer, MD, MPH
Kevin Math, MD
Joseph M. Lane, MD
Douglas N. Mintz, MD
Robert Schneider, MD
NOT PICTURED:
Azeez M. Farooki, MD
ACHIEVEMENTS
• Joseph M. Lane, MD, Chief of the Metabolic Bone Disease/
Musculoskeletal Oncology Service and Attending Orthopaedic
Surgeon, is a member of the National Institutes of Health (NIH)/
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) AMS Review Study Section.
• Dr. Lane serves on the Board of Directors for the Switzerland-based
ON (Orthoregeneration Network) Foundation, a new international
nonprofit group in the field of orthopaedic tissue regeneration
that drives the development and understanding of new treatment
strategies for patients.
• Dr. Lane is a member of the Editorial Board and a Reviewer for the
following journals: Osteoporosis International; Journal of Bone and
Mineral Research; Journal of Orthopaedic Trauma; Journal of Bone
and Joint Surgery; and Clinical Orthopaedics and Related Research.
• Richard S. Bockman, MD, PhD, Chief of the Endocrine Service and
Attending Physician, is a member of the Ethics Advisory Committee
of The American Society for Bone and Mineral Research (ASBMR).
• Dr. Bockman served on the Board of Directors for “Advances in
Mineral Metabolism,” a combined research mentoring group for the
10 to 12 ASBMR Haddow Fellows held annually in Aspen, CO.
• Dr. Bockman is a member of the Editorial Board of the Journal of
Clinical Endocrinology and Metabolism. He has reviewed more than
100 submitted articles.
Center of Excellence, was appointed by the American College of
Rheumatology as a member of its Committee on Rheumatologic Care.
• Emily M. Stein, MD, MS, Associate Attending Physician, is a Fellow of
the ASBMR. She is also a member of the Development Committee.
• Dr. Stein is a member of the Scientific Advisory Council for the
International Society for Clinical Densitometry.
• Dr. Stein is Associate Editor of BMC Rheumatology.
• Juliet B. Aizer, MD, Assistant Attending Physician, received a Dean’s
Award from Weill Cornell Medical College for her role in curriculum
development for clinical training of first- and second-year medical
students.
PATIENT CARE
• While oral steroids are known to have a negative impact on the
skeleton, less is known about inhaled steroids. In a study of
postmenopausal women who chronically used inhaled steroids,
Dr. Stein and colleagues found substantial abnormalities in
volumetric bone mineral density, microarchitecture and stiffness
compared to controls. The abnormalities were most severe at the
radius. The study was published in Osteoporosis International in 2018.
• Drs. Stein, Lane and Bockman and colleagues have launched a study
to define the abnormalities associated with avascular necrosis (AVN)
on a cellular level. To do this, they will use biopsies from patients at
different stages of the condition. The goal is to identify a target for
drug therapy.

• Dorothy A. Fink, MD, Assistant Attending Physician, oversees the

Diabetes Program for all inpatients. EDUCATION

• New research shows that the risk of complications increases if • Drs. Stein and Fink established a monthly Interdisciplinary Metabolic
an elderly patient who suffers a hip fracture is not operated on Bone Case Conference, in which the management of challenging
quickly. In the study, which was published in The Bone & Joint metabolic bone cases is discussed. The sessions are attended by
Journal, Drs. Russell, Lane and colleagues found that having surgery rheumatology trainees as well as faculty from several disciplines.
within 24 hours of admission was associated with lower odds of Twice a month, we hold the Metabolic Bone Disease Grand Rounds/
respiratory complications, including pneumonia; failure to extubate Journal Club, in which we discuss diagnostic and therapeutic
or reintubation; and shorter length of stay. As a result, HSS now dilemmas.
mandates that all hip fracture patients have surgery within 24 hours • For first-year residents, there is a dedicated rotation on the Metabolic
of admission. Bone Service. The goal is to provide early exposure to metabolic
• We are now offering patients bone density scans prior to spinal bone disease.
fusion procedures. If a patient has osteoporosis, we will recommend • In May 2018, Drs. Lane and Bockman conducted a webinar
delaying surgery and prescribe an anabolic agent for three months to called “Recent Advances Toward the Clinical Application of PTH
improve bone mass. We will also continue treatment after surgery (Parathyroid Hormone Analogues) in Fracture Healing or Anabolic
to ensure the best outcome. Agents: What is Beyond Osteoporosis?”
• We are working with the Foot and Ankle and Sports Medicine services • Dr. Lane served as a faculty member at the American Academy
to improve outcomes for patients with metatarsal and calcaneal of Orthopaedic Surgeons (AAOS) Annual Meeting. He was also a
fractures. We are prescribing anabolic agents to reduce recovery presenter at meetings for the following organizations: Orthopaedic
time and prevent a recurrence. Trauma Association, North American Spine Society and the
• We are studying the use of anabolic agents in improving pelvic American Orthopaedic Association.
fracture healing. Now we are extending that research to include sacral
fractures. We will study whether the agents, combined with calcium
NOTABLE REFERENCES
and vitamin D, can enhance healing.
• Fu MC, Boddapati V, Guasden EB, Samuel AM, Russell LA, Lane
• Dr. Lane and colleagues are examining the relationship between
JM: Surgery for a fracture of the hip within 24 hours of admission is
HbA1c control and bone quality in patients with diabetes who are
independently associated with reduced short-term operative compli-
undergoing total hip replacement. The researchers hypothesize that
cations. Bone Joint J 2017:1216-1222/doi: 10.1302/0301-620x.99B9.
tighter control of HbA1c will correlate with better bone quality.
BJJ220-0101
• The journal Osteoporosis International asked Dr. Lane and colleagues
• Liu Y, Carrino JA, Dash AS, Chukir T, Do H, Bockman RS, Hughes AP,
to write a review and recommendation on the use of anabolic
Press JM, Stein EM. Lower spine volumetric bone density in patients
agents in an orthopaedic setting. The article can be found at:
with a history of epidural steroid injections. J Clin Endocrinol Metab.
https://doi.org/10.1007/s00198-018-4507-8.
2018 Jul 2. doi: 10.1210/jc.2018-00558
• Liu Y, Dimango E, Bucovsky M, Agarwal S, Nishiyama K, Guo XE,
RESEARCH INITIATIVES Shane E, Stein EM. Abnormal microarchitecture and stiffness in
• In what may be the first study of its kind, Dr. Bockman, Dr. Stein postmenopausal women using chronic inhaled glucocorticoids.
and colleagues found that epidural injections for low back pain can Osteoporos Int. 2018 Jun 11. doi: 10.1007/s00198-018-4591-9
lead to a small loss of bone and can put people at risk for spinal • Liu Y, Levack AE, Marty E, Or O, Samuels BP, Redko M, Lane J:
fracture. In the study, which was published in The Journal of Clinical Anabolic agents: what is beyond osteoporosis? Osteoporosis Int
Endocrinology & Metabolism in 2018, patients who received more 2018:1009–22. https://doi.org/10.1007/s00198-018-4507-8
epidurals experienced a greater loss of lower spine volumetric
bone density. As a result, HSS patients who are receiving epidural
injections are advised to have bone density scans to monitor the
effects on the spine.

65
Orthopaedic Trauma Service

The Orthopaedic Trauma Service (OTS) ACHIEVEMENTS

collaborates with NewYork-Presbyterian/ • William M. Ricci, MD, is President of the Orthopaedic Trauma
Weill Cornell Medical Center to provide Association (OTA). He also serves on the Board of Directors. Dr. Ricci
unrivaled orthopaedic trauma care. presided over the OTA Annual Meeting as President in Vancouver,
Canada, in October 2017.
Chief: William M. Ricci, MD
• Dr. Ricci was guest speaker at the German Orthopaedic Society
meeting in Berlin in October 2017. The German Trauma Society
PATIENT VISITS PUBLISHED STUDIES presented Dr. Ricci with an honorary membership. He was also a
special guest at the SIGN Fracture Care International Meeting in
9,064 53 Richland, WA, in September 2017 and at the Dutch Orthopaedic
Society Meeting in Amsterdam in November 2017.
SURGERIES PRESENTATIONS AT • David L. Helfet, MD, Chief Emeritus of the Orthopaedic Trauma
CONFERENCES Service and Attending Orthopaedic Surgeon, received the Society of
1,936* 23 Honorary Police Surgeons of the City of New York Inaugural Award in
May 2018. The award recognizes Dr. Helfet’s continued and untiring
FELLOWS efforts, skill and support to the members of the New York Police
ACADEMIC VISITORS Department (NYPD) and their families. He has been an Honorary
3 18
Surgeon for the NYPD and Assistant Division Physician for the New
York State Police since 1999; and Honorary Medical Officer and
Honorary Fire Officer for the Fire Department of the City of New York
since 2009.
• Joseph M. Lane, MD, Chief of the Metabolic Bone Disease/
Musculoskeletal Oncology Service and Attending Orthopaedic
Surgeon, serves on the Board of Directors for the Switzerland-based
ON (Orthoregeneration Network) Foundation, a new international
nonprofit group in the field of orthopaedic tissue regeneration
*Surgical volume is inclusive of procedures performed that drives the development and understanding of new treatment
at NewYork-Presbyterian/Weill Cornell Medical Center. strategies for patients.

66
OPPOSITE PAGE, NOT PICTURED:
• Dr. Lane is leading an NIH-supported, randomized, double-blind,
FROM LEFT TO RIGHT: placebo-controlled trial to determine if parathyroid hormone, an
Dean G. Lorich, MD
David S. Wellman, MD
injectable medication, can augment healing of geriatric patients with
David E. Asprinio, MD
pelvic fractures treated non-operatively. The drug has the potential
David L. Helfet, MD Andrew Grose, MD to reduce healing time and pain, as well as accelerate recovery. There
William M. Ricci, MD
is no other known medication that can accelerate fracture healing.
John P. Lyden, MD
Gregory S. DiFelice, MD • Dr. Lane has determined that an INR — a measure of blood thinning —
under 2 is safe to perform fracture surgery, even if a patient has
Duretti T. Fufa, MD
mildly thinned blood. While conventional wisdom says an INR needs
Joseph M. Lane, MD
to return to near-normal before surgery can be performed, this
can lead to delays. The more expeditiously we can get a patient to
surgery, the bigger the benefit. The patient will experience less pain,
can start rehabilitation sooner, and will have a lower risk of blood
clots, pneumonia, bed sores and other complications.

EDUCATION

• The Service now provides educational conferences directed toward

every stage of learning. Some are geared toward junior residents,
while others are focused on more complex issues for Chief Residents
and Fellows. We are ensuring that every learner’s educational needs
are addressed.
• We reorganized the residents’ rotation to maximize their experience.
One important change is that we increased their operative exposure.
• We initiated a daily educational conference to review all new
Orthopaedic Trauma cases.
• We plan to improve our educational program and patient care
through increased collaboration with other Services, such as Foot
and Ankle, Limb Lengthening and Complex Reconstruction, Pediatric
PATIENT CARE Orthopaedics, and Hand and Upper Extremity.

• We have combined forces with the Foot and Ankle and Limb
Lengthening and Complex Reconstruction services to create a multi- NOTABLE REFERENCES
disciplinary team caring for inpatients. This enables us to provide
• DiFelice GS, Van der List JP. Clinical Outcomes of Arthroscopic
better continuity of care and gives us more expertise in managing
Primary Repair of Proximal Anterior Cruciate Ligament Tears
complex patients, such as those in external fixators.
are Maintained at Mid-term Follow-up. Arthroscopy. 2018
• We are using an enhanced communication tool to help facilitate Apr;34(4):1085-1093.
patient transfers from other institutions to HSS for our
• Lazaro LE, Nawabi DH, Klinger CE, Sculco PK, van der List JP,
multidisciplinary care.
Dyke JP, Helfet DL, Kelly BT, Lorich DG. Quantitative Assessment
• To determine the ideal treatment pathways for the most complex of Femoral Head Perfusion Following Arthroscopic Femoral
patients, we have instituted a monthly complex case conference Osteochondroplasty: A Cadaveric Study. J Bone Joint Surg Am.
with other Services, including Pediatric Orthopaedics and Limb 2017;99(24):2094-102.
Lengthening and Complex Reconstruction. At the conference,
• Verbeek DO, van der List JP, Villa JC, Wellman DS, Helfet DL.
we discuss both preoperative and postoperative complex cases.
Postoperative CT Is Superior for Acetabular Fracture Reduction
Multiple opinions from different specialties enable us to deliver the
Assessment and Reliably Predicts Hip Survivorship. J Bone Joint Surg
highest quality patient care.
Am. 2017;99(20):1745-52.
• We recently launched a new patient access program in collaboration
• Gausden EB, Nwachulwu BU, Schreiber JJ, Lorich DJ, Lane JM:
with the Foot and Ankle Service. We are aiming to ensure that any
Opportunistic use of CT imaging for osteoporosis screening and bone
patient with an ankle fracture will see a physician within 24 hours of
density assessment: A qualitative systemic review. J Bone Joint Surg
calling HSS.
Am. 2017: 1580-1590. Doi: 10.2106/JBJS.16.00749. Review
• Cosgrove CT, Putnam SM, Cherney SM, Ricci WM, Spraggs-Hughes
RESEARCH INITIATIVES A, McAndrew CM, Gardner MJ. Medial Clamp Tine Positioning Affects
• We have continued to perform anatomic studies of the vasculature Ankle Syndesmosis Malreduction. J Orthop Trauma. 2017;31(8):440-
of the distal femur, which will potentially yield insight into improved 446. https://www.ncbi.nlm.nih.gov/pubmed/28471914
treatment approaches to fractures. Minimizing disruption of the
blood supply can help maximize healing potential.

67
Pediatric Orthopaedic Service

The Lerner Children’s Pavilion-Hospital for Special Surgery was ACHIEVEMENTS

named a best children’s hospital for orthopaedics in the most • Roger F. Widmann, MD, Chief of the Pediatric Orthopaedic Service
recent U.S. News & World Report rankings. Key to our high-quality and Attending Orthopaedic Surgeon, is the American Academy
care for children is the Pediatric Orthopaedic Service. Members of Orthopaedic Surgeons (AAOS) representative on the American
of this Service work in a collaborative manner with pediatricians, College of Radiology Appropriateness Criteria® Expert Panel on
anesthesiologists and other clinical specialists to provide best- Pediatric Imaging.
in-class care for children. The Lerner Children’s Pavilion has been
providing specialized musculoskeletal care for children since 2012. • Daniel W. Green, MD, MS, Attending Orthopaedic Surgeon, received
the EPOS Research Award — The Jurgen Baumann Award for
Chief: Roger F. Widmann, MD “Return to Sport and Reoperation Rates in Patients Under the Age
of 20 Following Primary Anterior Cruciate Ligament Reconstruction:
Risk Profile Comparing Three Patient Groups Predicated Upon
PATIENT VISITS PUBLISHED STUDIES NEW HSS eACADEMY® Skeletal Age.”
MODULES
37,122 46 1
• Dr. Green was named Associate Director of the HSS
Residency Program.
• David M. Scher, MD, Associate Attending Orthopaedic Surgeon, was
SURGERIES PRESENTATIONS AT named Co-Chair of the HSS Residency Selection Committee.
CONFERENCES ACADEMIC VISITORS
3,242* 77 12
• Shevaun M. Doyle, MD, Associate Attending Orthopaedic Surgeon,
received the Healthcare Chaplaincy Network’s Wholeness of Life
Award, which recognizes an individual who provides compassionate
FELLOWS
care and helps patients to balance physical, mental and spiritual

1** well-being.
• Ernest L. Sink, MD, Associate Attending Orthopaedic Surgeon, is
Chair of the AAOS Pediatric Program Committee.

*Surgical volume is inclusive of procedures performed

at NewYork-Presbyterian/Weill Cornell Medical Center.
**Four other Fellows also support the Program.

68
OPPOSITE PAGE, Samir K. Trehan, MD*
FROM LEFT TO RIGHT: Daniel W. Green, MD, MS
Matthew E. Cunningham, MD, PhD Han Jo Kim, MD
Shevaun M. Doyle, MD Emily R. Dodwell, MD, MPH
David M. Scher, MD Peter D. Fabricant, MD, MPH
Aaron Daluiski, MD S. Robert Rozbruch, MD
Ernest L. Sink, MD Cathleen L. Raggio, MD
Austin T. Fragomen, MD
John S. Blanco, MD
*new physician
Roger F. Widmann, MD
• Emily R. Dodwell, MD, Assistant Attending Orthopaedic Surgeon,
received a Pediatric Orthopaedic Society of North America (POSNA)
Directed Research Grant for $50,000 for “Alpha-Defensins &
Synovial Proteins to Improve Detection of Pediatric Septic Arthritis.”
• Peter D. Fabricant, MD, MPH, Assistant Attending Orthopaedic
Surgeon, is a member of the Pediatric Sports Medicine Registry
Steering Committee at the Pediatric Research in Sports Medicine
Society (PRiSM).
PATIENT CARE
• The Service is using Tantalum Beads to document the timing of
growth plate closure after epiphysiodesis. Developed by Dr. Widmann
and Dr. Dodwell, this method gives the surgeon precise feedback
at three-, six- and 12-month intervals after surgery to correct
deformities and limb length discrepancies.
• We are using surgical navigation and intraoperative three-
dimensional imaging for a variety of complex foot and ankle, sports
and spinal procedures. For tarsal coalition procedures, three-
dimensional surgical navigation helps to facilitate more accurate
resection of abnormal bone and cartilage. Intraoperative three-
dimensional imaging allows us to verify the adequacy and completion
of the surgery, improving success rates and patient outcomes.
We are also using three-dimensional surgical navigation for closed
reduction and internal fixation of transitional ankle fractures. This
technique, which was developed by Dr. Widmann, allows for a
minimally invasive approach to common ankle fractures that have
historically required open surgical approaches for visualizing bone
and joint surfaces. Dr. Green plans and verifies the placement of ACL
tunnels using three-dimensional imaging techniques, which decrease
the risk of injury to the growth plate. Both technologies are used to
improve the safety and accuracy of spinal implant placement.
• The Leon Root, MD, Pediatric Outreach Program provides free injury
prevention screenings for children from diverse communities who
participate in sports. HSS orthopaedic surgeons, physical therapists,
orthopaedic residents and nurses perform the screenings, which
are held at New York City schools. In the 2017-2018 academic year,
112 children were screened, and 32 musculoskeletal disorders were
diagnosed.
69
RESEARCH INITIATIVES
• With a grant from The Pediatric Orthopaedic Society of North
America, Dr. Dodwell is investigating the sensitivity and specificity
of alpha defensins, leukocyte esterase and other synovial biomarkers
to improve the diagnosis of pediatric bacterial joint infections.
She hypothesizes that alpha defensins alone or in combination with
other synovial biomarkers will more accurately and rapidly diagnose
bacterial arthritis than standard tests. Dr. Dodwell, HSS colleagues
and researchers at other institutions will determine the normal values
of these biomarkers in children, then compare how well they perform
in differentiating septic bacterial arthritis from other causes of joint
pain and inflammation, such as Lyme disease, rheumatoid arthritis
and transient synovitis. Enrollment in the multi-center study, which
HSS is leading, has begun, and it is expected to be completed within
two years. The following Service physicians are involved in the study:
John S. Blanco, MD, Associate Attending Orthopaedic Surgeon;
Dr. Widmann, Dr. Green, Dr. Doyle, Dr. Scher, Dr. Fabricant and
resident Joseph Ruzbarsky, MD.
• We are participating in five multicenter pediatric sports medicine
study groups. Service members are collecting patient-reported
outcomes for the following groups: Justifying Patellar Instability
Treatment by Early Results (JUPITER), a study of patellar dislocation;
Medial Epicondyle: Measuring Outcomes (MEMO), which aims to
evaluate and compare treatment outcomes for displaced medial
humeral epicondyle fractures; Pediatric ACL: Understanding
Treatment Options (PLUTO) study of patients who are skeletally
immature and have a complete ACL tear; Research in Osteochondritis
of the Knee (ROCK), which is investigating osteochondritis
dissecans; and Sports Cohort Outcomes Registry (SCORE), which
is focused on understanding the best ways to minimize treatment
complications of sports knee injuries in children and adolescents.
• Dr. Fabricant, Aaron Daluiski, MD, Associate Attending Orthopaedic
Surgeon, and resident Christine Johnson, MD, are studying osteo-
chondritis dissecans (OCD) of the capitellum, a leading cause of
elbow disability in adolescents who participate in throwing sports like
baseball and upper-extremity, weight-bearing sports like gymnastics.
To gain a better understanding of the lesions’ location — which
affects symptoms, surgical management and outcomes — we have
developed a novel clock-face localization method for describing
capitellar OCD lesion location on MRI imaging. We have also analyzed
capitellar OCD lesion location on 104 elbows. In a study published
in The Journal of Hand Surgery (American) in 2018, we identified
a broader region of the capitellum affected by OCD lesions than
previously reported. Subsequently, our team has assessed the
surgical implications of these findings. We determined the region
of the capitellum accessible for orthogonal graft placement for
three different surgical approaches. The study was published in
Journal of Shoulder and Elbow Surgery. Our data may help inform
clinical decisions regarding the surgical approach for resurfacing
the capitellum.
• Under the leadership of Drs. Green, Dodwell and Fabricant,
the Service has embraced the routine use of patient-reported
outcome measures for all patients. These physicians are using a
streamlined digital mechanism for patient data input that presents
the information in real time to the treating physician as well as
the researchers.
Pediatric Orthopaedic Service
(cont.)
EDUCATION
• Dr. Scher has developed a comprehensive training and evaluation
system for residents. One of the goals is to standardize, improve
and evaluate intern and resident manual skills acquisition in the
important but often neglected demanding techniques for safe cast
and splint application. The program combines didactic lectures,
active demonstrations, expert instruction, practical supervision and
evaluations by Attendings and experienced Cast Room technicians.
• We are training HSS orthopaedic residents via surgical simulation
in the Bioskills Education Laboratory (BSEL), our state-of-the-art
facility.
• Dr. Sink participates in the Annual International Pediatric Orthopaedic
Symposium (IPOS) and serves on the IPOS Advisory Board. He also
is a member of the CME Course Committee at the AAOS.
• Drs. Green and Dodwell are faculty members of AO North America.
70
NOTABLE REFERENCES
• Chen C, Kaushal N, Scher DM, Doyle SM, Blanco JS, Dodwell ER.
Clubfoot Etiology: A Meta-Analysis and Systematic Review of
Observational and Randomized Trials. J Pediatr Orthop. 2018 Jun 18.
• Fabricant PD, Suryavanshi JR, Calcei JG, Marx RG, Widmann RF,
Green DW. The Hospital for Special Surgery Pediatric Functional
Activity Brief Scale (HSS Pedi-FABS): Normative Data and Activity
Attrition in Healthy US Adolescents. Am J Sports Med. 2018 Mar 1.
• Swarup I, Derman P, Sheha E, Nguyen J, Blanco J, Widmann R.
Relationship between thoracic kyphosis and neural axis abnor-
malities in patients with adolescent idiopathic scoliosis. J Child
Orthop. 2018 Feb 1. 12(1): 63-69. doi: 10.1302/1863-2548.12.170163.
PMID: 29456756
• Citron, K., Veneziale, C., Marino, J., Carter, E.M., Jepsen, K.J. and
Raggio, C., 2017. Bone robusticity in two distinct skeletal dysplasias
diverges from established patterns. Journal of Orthopaedic Research,
35(11), pp.2392-2396.
• Ricciardi, B.F., Fields, K.G., Wentzel, C., Kelly, B.T. and Sink, E.L., 2017.
Early functional outcomes of periacetabular osteotomy after failed
hip arthroscopic surgery for symptomatic acetabular dysplasia. The
American journal of sports medicine, 45(11), pp.2460-2467.
 FROM LEFT TO RIGHT: Front row: NOT PICTURED:
Back row: H. Susan Cha, MD Victor M. Zayas, MD
Eric Bogner, MD Douglas N. Mintz, MD
Austin T. Fragomen, MD Aaron Daluiski, MD
Alyson Insull, NP Matthew E. Cunningham,
MD, PhD
Danielle Gorelick, NP
Jordan Ruby, MD
Ernest L. Sink, MD
Daniel O’Neill, MD
David M. Scher, MD
Alexa Adams, MD
Grace Solomon, NP
Lisa S. Ipp, MD
Daniel W. Green, MD, MS
Theresa T. Lu, MD, PhD
Roger F. Widmann, MD
Melanie C. Prior, MD
John S. Blanco, MD
Kathryn DelPizzo, MD
Alexandra Farrell, NP
Sarah Taber, MD
Emily R. Dodwell, MD,
MPH Pamela K. Wendel, MD
Peter D. Fabricant, MD, Naomi Dong, MD
MPH Nancy Pan, MD
Arkady Blyakher Stephanie L. Perlman, MD
Shevaun M. Doyle, MD Cathleen L. Raggio, MD
Lucia Fabrizio, NP Karen B. Onel, MD
Han Jo Kim, MD Chris R. Edmonds, MD
Erin M. Carter, MS, CGC Andrew C. Lee, MD
S. Robert Rozbruch, MD
Samir K. Trehan, MD

71
Spine Service

The Spine Service is world-renowned for its ACHIEVEMENTS

innovative and research-based treatment
of children and adults with all levels of
spine disease and deformity. It is a leader
in complex spinal reconstruction and
minimally invasive spine procedures.
Chief: Frank J. Schwab, MD
PATIENT VISITS PRESENTATIONS AT
CONFERENCES
• “Does Lumbar Spine Pathology Affect Bone Mineral Density
Measurement by Quantitative Computed Tomography (QCT)?”
received the Best Paper Award at the 11th Annual Meeting of the
Lumbar Spine Research Society (LSRS) in 2018. The authors
included Andrew A. Sama, MD, Associate Attending Orthopaedic
Surgeon; Frank P. Cammisa Jr., MD, Chief Emeritus of the Spine
Service and Attending Orthopaedic Surgeon; Federico P. Girardi,
MD, Attending Orthopaedic Surgeon; Alexander P. Hughes, MD,
Assistant Attending Orthopaedic Surgeon; and John A. Carrino, MD,
MPH, Attending Radiologist.

19,787 260
• Todd J. Albert, MD, Surgeon-in-Chief, Medical Director and Attending
Orthopaedic Surgeon, is President of the Scoliosis Research Society.
SURGERIES • Dr. Albert is a member of the Clinical Orthopaedics and Related
NEW HSS eACADEMY® Research (CORR) Board of Trustees.
3,730 MODULES
• Frank J. Schwab, MD, Chief of the Spine Service and Attending

FELLOWS
25 Orthopaedic Surgeon, is an Executive Committee Member of the
International Spine Study Group (ISSG).

4 ACADEMIC VISITORS • Dr. Schwab is a member of the Scoliosis Research Society’s Board
of Directors.

PUBLISHED STUDIES
43 • Sheeraz Qureshi, MD, MBA, Associate Attending Orthopaedic
Surgeon, is a member of the Minimally Invasive Spine Study Group’s
133 ATTENDINGS Board of Directors.

20 • Matthew E. Cunningham, MD, PhD, Assistant Attending Orthopaedic

Surgeon, was named Chair of the Scoliosis Research Society’s
Awards & Scholarship Committee.

72

OPPOSITE PAGE, Roger F. Widmann, MD Russel C. Huang, MD
FROM LEFT TO RIGHT:
Frank J. Schwab, MD Patrick F. O’Leary, MD
John S. Blanco, MD
James C. Farmer, MD Han Jo Kim, MD
Steven J. McAnany, MD Todd J. Albert, MD Alexander P. Hughes, MD
Andrew A. Sama, MD Matthew E. Cunningham, Joseph M. Lane, MD
Harvinder S. Sandhu, MD MD, PhD
Bernard A. Rawlins, MD Charles B. Goodwin, MD
NOT PICTURED:
Sheeraz Qureshi, MD, Frank P. Cammisa, Jr., MD
MBA Federico P. Girardi, MD
Darren R. Lebl, MD
• Dr. Cunningham is Chair of the Education/Fellowship Committee at
the International Society of Orthopaedic Centers.
PATIENT CARE
• In the 2017–2018 academic year, the Service performed more spine
surgery using a skin-based navigation array than any other institution
in the world. As a result, it has earned its position as the international
leader in minimally invasive spine surgery. In 2019, we are launching
the Patty and Jay Baker Minimally Invasive Spine Surgery Program.
Led by Dr. Qureshi, the Program’s goal is to advance clinical care,
education and research in the field.
• In 2017, the Service launched a program called Fast Track to ensure
that patients are referred to the most appropriate provider and begin
treatment as soon as 24 to 48 hours after the initial appointment
request. Patients are evaluated by a Nurse Practitioner who works
with the Spine Care team to refer them to the most appropriate
provider. Over the last year, about 40 percent of patients were sent to
Physiatry; 30 percent went to Physical Therapy only; 10 percent were
referred to Spine surgeons; and 20 percent were referred to other
Services, such as Neurology.
• All spinal fusion patients are undergoing DXA and quantitative CT
scans before surgery. If a person has osteoporosis, we prescribe
teriparatide for three months prior to surgery and keep him or her on
it afterward. For urgent and emergent cases, we start patients on the
drug in the Hospital before or after surgery.
• The incidence of postsurgical blood clots in Spine patients dropped
by approximately 60 percent between 2016 and 2017. Patients
identified as high risk are placed on a 30-day, low-dose, postoperative
course of anticoagulants.
RESEARCH INITIATIVES
• Low back pain is the leading and most costly cause of work-related
disability in the U.S. To address this, the Service is developing a
predictive model for return to work (RTW), which can provide realistic
probabilities of postoperative functional status and optimize patient
outcomes and satisfaction after minimally invasive surgery.
• Our research has pointed to the importance of assessing a patient’s
psychosocial status during a preoperative visit. In a study published
in Spine in 2018, Carol A. Mancuso, MD, Attending Physician; Chad M.
Craig, MD, Assistant Attending Physician; Dr. Girardi and a colleague
found that patients who had less social support and worse functional
status were more likely to have a length of stay greater than three
days. We aim to provide patients with personalized consultations
before surgery in order to maximize the benefits.
73
• We have discovered that the quality of a person’s soft tissue may
affect spinal alignment postoperatively, just as bone quality can.
In one study, Dr. Schwab, Han Jo Kim, MD, Associate Attending
Orthopaedic Surgeon, and Virginie Lafage, PhD, Senior Director
of Spine Research, found that having larger muscles, greater
fat infiltration and lower bone quality was associated with larger
postoperative changes in the thoracic spine in patients undergoing
surgery for spinal deformity. In a related study, Drs. Schwab, Kim
and Lafage found that anterior malalignment was associated with
increased fat infiltration in the upper thoracic, lower thoracic and
lumbar spine. In the future, we will investigate physical therapy’s
effect on muscle quality and its ability to help restore alignment.
EDUCATION
• The Service reduced the number of fellowship spots to ensure
that each fellow has the opportunity to spend more time with the
Attendings on the Service and develop deeper mentor/mentee
relationships. The four Spine fellowship spots were matched by the
top applicants to the program.
• Service members created four webinars, which were attended by
hundreds of participants. Many of our Attendings participated
by giving lectures and participating in case discussions.
• In November 2017, the annual HSS-China Symposium was held
in Zhuhai, China. We partnered with Peking University People’s
Hospital; Peking University Third Hospital; Peking Union Medical
College Hospital; and Guangzhou Provincial Traditional Chinese
Medicine Hospital to host the Spine Symposium. The program chairs
were Drs. Kim and Qureshi, and topics focused on degeneration and
deformity of the cervical and lumbar spine.
NOTABLE REFERENCES
• Yang J, Lafage V, Lafage R, Smith J, Klineberg EO, Shaffrey CI,
Mundis G Jr, Hostin R, Burton D, Ames CP, Bess S, Kim HJ, Schwab
F; International Spine Study Group (ISSG). Determinants of Patient
Satisfaction Two Years after Spinal Deformity Surgery: A Latent
Class Analysis. Spine (Phila Pa 1976). 2018 Jun 21. doi: 10.1097/
BRS.0000000000002753. PMID: 29933336
• McAnany SJ, Merrill RK, Overley SC, Kim JS, Brochin RL, Qureshi
SA. Investigating the 7-Year Cost-Effectiveness of Single-Level
Cervical Disc Replacement Compared to Anterior Cervical
Discectomy and Fusion. Global Spine J. 2018 Feb;8(1):32-39. doi:
10.1177/2192568217726283. Epub 2017 Aug 17. PMID: 29456913
• Lafage R, Pesenti S, Lafage V, Schwab FJ. Self-learning computers
for surgical planning and prediction of postoperative alignment.
Eur Spine J. 2018 Feb;27(Suppl 1):123-128. doi: 10.1007/s00586-018-
5497-0. Epub 2018 Feb 9. PMID: 29427011
• Mancuso CA, Duculan R, Cammisa FP, Sama AA, Hughes AP, Lebl DR,
Girardi FP. Successful lumbar surgery results in improved psycho-
logical well-being: a longitudinal assessment of depressive and
anxiety symptoms. Spine J. 2018 Apr;18(4):606-613. doi: 10.1016/
j.spinee.2017.08.260. Epub 2017 Sep 4. PMID: 28882527
• Lafage R, Liabaud B, Diebo BG, Oren JH, Vira S, Pesenti S,
Protopsaltis TS, Errico TJ, Schwab FJ, Lafage V. Defining the Role of
the Lower Limbs in Compensating for Sagittal Malalignment. Spine
(Phila Pa 1976). 2017 Nov 15;42(22):E1282-E1288. doi: 10.1097/
BRS.0000000000002157. PMID: 28306639
Sports Medicine and
Shoulder Service

Members of the Sports Medicine and Shoulder Service are ACHIEVEMENTS

dedicated to providing the highest level of musculoskeletal care • Bryan T. Kelly, MD, Chief of the Sports Medicine and Shoulder Service
for active and athletic patients of all abilities, including those and Attending Orthopaedic Surgeon, is Head Team Physician for the
affiliated with local high school, collegiate and professional teams New York Rangers and Head Consulting Orthopaedic Surgeon for
and organizations. the UFC.
Chief: Bryan T. Kelly, MD • Answorth A. Allen, MD, Attending Orthopaedic Surgeon, is Medical
Consultant for the National Basketball League (Liga Nacional de
Chief, Primary Care Sports Medicine: John P. DiFiori, MD*
Baloncesto, or LNB) in Santo Domingo, Dominican Republic. HSS is
the Official Hospital of the LNB for the second consecutive year.
PATIENT VISITS NEW HSS eACADEMY® PHYSIATRISTS
• Jo A. Hannafin, MD, PhD, Attending Orthopaedic Surgeon and a
MODULES
76,644 15 4 Director of the Women’s Sports Medicine Center, was appointed to
a five-year term as a member of the American Orthopaedic Society
for Sports Medicine (AOSSM) Medical Publishing Board, which
SURGERIES NUMBER OF CENTERS
ACADEMIC VISITORS AND SPECIALIZED oversees American Journal of Sports Medicine, Sports Health and the
10,217 40
SERVICES open access Orthopedic Journal of Sports Medicine. She also served
on the OREF Grant review board, which selected recipients for the
FELLOWS
5 Russell F. Warren Soft Tissue Research Grants.
PATENTS • Women’s Sports • Robert G. Marx, MD, MSc, FRCSC, Attending Orthopaedic Surgeon,
11 1
Medicine Center
• Institute for
is a co-author of “Hardware Complications after Anterior Cruciate
Cartilage Repair
Ligament Reconstruction,” a chapter in The Anterior Cruciate
PUBLISHED STUDIES Ligament: Reconstruction and Basic Science, Second Edition
ATTENDINGS • Patellofemoral Center
(Elsevier, 2018).
189 30
• Sports
Rehabilitation and • Stephen J. O’Brien, MD, MBA, Attending Orthopaedic Surgeon,
Performance Center is an author of “Superior Labrum Anterior-Posterior Lesion:
PRESENTATIONS AT • Non-Surgical Foot and
CONFERENCES PRIMARY CARE
A Reconstruction of the Superior Labrum and Biceps Anchor,”
Ankle Service
ATTENDINGS which appeared in the new textbook Operative Techniques: Shoulder
133 13
and Elbow Surgery, 2nd Edition (Elsevier, 2018).

74
 • Lisa R. Callahan, MD, Medical Director of the Women’s Sports
OPPOSITE PAGE, Samuel A. Taylor, MD BELOW, FROM LEFT
FROM LEFT TO RIGHT: TO RIGHT: Medicine Center and Associate Attending Physician, completed her
Jo A. Hannafin, MD, PhD
Karen M. Sutton, MD*
14th season as Team Physician for the New York Knicks and served as
Andrew D. Pearle, MD Russell F. Warren, MD
Vice President of the NBA Team Physicians Association.
Andreas H. Gomoll, MD* Beth E. Shubin-Stein, MD Anil S. Ranawat, MD
Lawrence V. Gulotta, MD Answorth A. Allen, MD Sabrina M. Strickland, MD • Struan H. Coleman, MD, PhD, Associate Attending Orthopaedic
Riley J. Williams III, MD Surgeon, is President of the Major League Baseball Team Physicians
Stephen Fealy, MD Thomas L. Wickiewicz,
Jennifer L. Solomon, MD MD Association. He is also Head Team Physician for the New York Mets.
Frank A. Cordasco, MD,
Howard A. Rose, MD MS Danyal H. Nawabi, MD • Stephen Fealy, MD, Associate Attending Orthopaedic Surgeon, is
Robert G. Marx, MD, MSc, Joel M. Press, MD Scott A. Rodeo, MD part of a team of researchers that received the Fellow Research
FRCSC Hollis G. Potter, MD Stephen J. O’Brien, MD Award — Clinical Science at the AOSSM Annual Meeting in 2018.
Anne M. Kelley, MD David M. Dines, MD David W. Altcheck, MD • Andreas H. Gomoll, MD, Associate Attending Orthopaedic Surgeon,
John D. MacGillivray, MD Joseph H. Feinberg, MD is an editor of the textbook Cartilage Restoration: Practical Clinical
Bryan T. Kelly, MD *new physician Moira M. McCarthy, MD Application, 2nd Edition (Springer, 2018).
Struan H. Coleman, MD
Peter J. Moley, MD • Lawrence V. Gulotta, MD, Associate Attending Orthopaedic Surgeon,
Michael J. Maynard, MD was a Grand Rounds speaker at Massachusetts General Hospital and
Joshua S. Dines, MD
Johns Hopkins Hospital in 2017.
• Anil S. Ranawat, MD, Associate Attending Orthopaedic Surgeon, is
an author of “Knee Rotation: The HSS School,” a chapter in Rotatory
Knee Instability (Springer International Publishing, 2017). Other
authors include Russell F. Warren, MD, Attending Orthopaedic
Surgeon; Thomas L. Wickiewicz, MD, Attending Orthopaedic Surgeon;
and Andrew D. Pearle, MD, Associate Attending Orthopaedic Surgeon.
• Beth E. Shubin Stein, MD, Associate Attending Orthopaedic Surgeon,
• Scott A. Rodeo, MD, Attending Orthopaedic Surgeon, received is co-leading the first national, multicenter patella instability study
the Arthur C. Rettig Award for Academic Excellence from the NFL group called JUPITER. She is also a member of the Fellowship
Physicians Society in March 2018 for the paper “Current Update on Education Committee for the American Orthopaedic Society for
Clinical Use of Biologics in Musculoskeletal Injury.” Sports Medicine.
• Riley J. Williams III, MD, Attending Orthopaedic Surgeon, was a Guest • Karen M. Sutton, MD, Associate Attending Orthopaedic Surgeon,
Faculty Member at the Kaiser Permanente SCPMG Dale Daniel, MD was named Chief Medical Officer of the Federation of International
Orthopaedic Symposium in 2018. Lacrosse in 2018.

75
Sports Medicine and
Shoulder Service (cont.)

PRIMARY CARE Osric S. King, MD PATIENT CARE

SPORTS MEDICINE, James J. Kinderknecht,
FROM LEFT TO RIGHT: • Our patients include more than 400 professional athletes per year
MD
from more than 80 professional teams and more than 100 Collegiate
William W. Briner, Jr., MD Marci A. Goolsby, MD
programs. Our physicians care for individual players from more than
Jordan D. Metzl, MD Warren K. Young, MD half of the teams in the NFL, NBA, MLB and NHL combined.
Daphne A. Scott, MD Ryan J. Lingor, MD*
Brett G. Toresdahl, MD
• The Service has supported HSS’s continued growth and expansion
John P. DiFiori, MD*
in local and regional markets. In 2017, we began offering Sports
Lisa R. Callahan, MD
Medicine care at the new HSS Westchester outpatient center in White
David A. Wang, MD *new physician Plains, NY, and operating at the Tully Health Center in Stamford,
Brian C. Halpern, MD
CT, as part of a collaboration with Stamford Health. In addition, our
surgeons are now operating out of the HSS ASC of Manhattan. In
2019, they will also be treating patients and performing procedures at
• Marci A. Goolsby, MD, Assistant Attending Physician and a member a new sports-focused location on the West Side of New York City.
of the Women’s Sports Medicine Center, was a Team Physician for
the U.S. Biathlon Team at the 2018 Winter Olympics in Pyeongchang, • For the second consecutive year, Drs. Kelly and Williams provided
South Korea. She completed her 8th season as a Team Physician for free sports-related knee and hip procedures for patients in Santo
the WNBA New York Liberty, where she works with Dr. Hannafin and Domingo, Dominican Republic (DR). They provided follow-up
Dr. Callahan. consultations for the patients who underwent knee and shoulder
surgery last year, then performed five procedures on new patients.
• Danyal H. Nawabi, MD, Assistant Attending Orthopaedic Surgeon, The Surgical Sports Mission was a partnership between HSS and
is Medical Director/Head Orthopaedic Surgeon for the New York Hospital General de la Plaza de la Salud in the DR.
Cosmos. He presented “Workup of the Multiligament Injured Knee”
at the 12th Annual HSS Sports Medicine Symposium in March 2018. • We are using the Boston Biomotion Proteus Device, a three-
dimensional strength training and physical assessment system. The
• Daphne A. Scott, MD, Assistant Attending Physician, served as Team Device produces real-time, automated performance and strength
Physician for USA Track & Field during the 2017 World Championships measurements. It has the potential to allow us to determine exactly
in London, England. She also serves as a Consultant for UFC. when a patient is ready to return to play (based on his or her
• Brett G. Toresdahl, MD, Assistant Attending Physician, was a Team pre-injury level) and may be used in research on pre- and post-injury
Physician for the U.S. Biathlon Team at the 2018 Winter Olympics in movement assessments.
Pyeongchang, South Korea.

76
• The Women’s Sports Medicine Center led the first-ever training
series for the New York Road Runners (NYRR) New York Women’s
Mini 10k. We have also hosted 27 free educational seminars at the
NYRR RunCenter. Topics have included strength training, foam rolling
and nutrition. In addition, we have provided pre-race warm-ups at
10 races.
RESEARCH INITIATIVES
• The Service received approximately $550,000 in federal, internal,
foundation and industry grants in 2017.
• In 2018, we held a Sports Research Retreat. The Service decided to
evaluate research in terms of the following questions: Do interventions
improve patient symptoms and function? Do interventions allow
patients to return to their sport? Do interventions change the natural
course of joint deterioration?
• Sports research initiatives are focused on the following areas: clinical
outcomes of knee, shoulder and hip procedures for inclusion in
patient registries; biomechanics; soft tissue and biologics research;
and ACL repair consensus.
• We are studying a novel patch and instrumentation for arthroscopic
rotator cuff repair, as well as the use of platelet-rich plasma (PRP)
or stem cells to enhance healing. We are investigating whether
adding stem cells to the injured area during surgery could enhance
tissue repair.
• We are studying AGelity-OCI, a non-degradable implant that uses our • Nwachukwu BU, Chang B, Adjei J, Schairer WW, Ranawat AS, Kelly BT,
patented hydrogel technology to treat articular cartilage defects. The
goal is to enhance patient function and mobility and prolong the need
for more invasive procedures.
• David W. Altchek, MD, Attending Orthopaedic Surgeon; Christopher
Mendias, PhD, Associate Scientist; and Drs. Rodeo, Williams and
Allen are searching for biomarkers that may predict the onset of knee • Mahony GT, Werner BC, Chang B, Grawe BM, Taylor SA, Craig EV,
osteoarthritis after arthroscopic procedures for meniscal injuries.
Our goal is to identify biomarkers of cartilage degeneration and joint
inflammation and determine how they relate to clinical factors and
alterations in cartilage composition and morphology after primary
arthroscopic meniscal repair and partial meniscectomy. This will
enable us to develop novel therapeutic targets or orthobiologics to
promote tissue regeneration.
• We are also assessing circulating biomarkers used to identify the
presence and progression of osteoarthritis in patients with a history
of shoulder dislocations. If we are able to show that two or more
dislocations results in significantly higher levels of biomarkers,
surgeons may want to consider stabilizing the shoulder arthroscopically
after a single dislocation. The researchers are Joshua S. Dines, MD,
Associate Attending Orthopaedic Surgeon; Samuel A. Taylor, MD,
Assistant Attending Orthopaedic Surgeon; Frank A. Cordasco, MD,
MS, Attending Orthopaedic Surgeon; and Drs. Mendias, Rodeo,
Williams, Allen, Warren, Gulotta and Altchek.
EDUCATION
• Service members have trained more than 150 Sports Medicine
leaders in institutions across the world.
• In March 2018, we hosted the 12th Annual Sports Medicine
Symposium in New York City.
• In June 2018, we hosted the 2nd Annual Professional Sports Medicine
Conference to provide latest strategies for treating the professional
athlete. More than 150 Sports Medicine professionals — including
orthopaedists, primary care physicians, sports medicine physicians,
physiatrists, physical therapists and athletic trainers — attended
the Conference, which was held at MetLife Stadium in NJ. Also in
attendance were medical and training personnel from professional
sports teams and organizations, such as the Boston Celtics, New
England Patriots, New York Mets, New York Giants, New York Jets
and New York Rangers. Nearly 20 HSS physicians, along with guest
faculty from other leading institutions, presented on topics such as
offseason strength training and conditioning, complex cases and
concussions.
• In May 2018, HSS and Liga Nacional de Baloncesto hosted a Sports
Rehabilitation and Performance Seminar in Santo Domingo focused
on HSS strategies for injury prevention, evaluations and clinical
recommendations.
• Rock G. Positano, DPM, MSc, MPH, Director and Founder of the
Non-Surgical Foot and Ankle Service, is an editor of the newly released
book Pocket Foot and Ankle Medicine and Surgery (Wolters Kluwer,
2018). It was a collaboration between the Non-Surgical Foot and
Ankle Service at HSS and the Foot & Ankle Center at Massachusetts
General Hospital/Harvard Medical School.
NOTABLE REFERENCES
Nawabi DH. Time Required to Achieve Minimal Clinically Important
Difference and Substantial Clinical Benefit After Arthroscopic
Treatment of Femoroacetabular Impingement. Am J Sports Med.
2018 Aug 1:363546518786480. doi: 10.1177/0363546518786480.
[Epub ahead of print] PMID:30067064
Warren RF, Dines DM, Gulotta LV. Risk factors for failing to achieve
improvement after anatomic total shoulder arthroplasty for glenohu-
meral osteoarthritis. J Shoulder Elbow Surg. 2018 Jun;27(6):968-975.
doi: 10.1016/j.jse.2017.12.018. Epub 2018 Feb 23. PMID: 29482959
• Wang D, Jones KJ, Eliasberg CD, Pais MD, Rodeo SA, Williams RJ
3rd. Condyle-Specific Matching Does Not Improve Midterm Clinical
Outcomes of Osteochondral Allograft Transplantation in the Knee.
J Bone Joint Surg Am. 2017 Oct 4;99(19):1614-1620. doi: 10.2106/
JBJS.16.01542.
• Grawe B, Burge A, Nguyen J, Strickland S, Warren R, Rodeo,
Shubinstein B. Cartilage regeneration in full-thickness patellar
chondral defects treated with particulated juvenile articular allograft
cartilage: An MRI analysis. Cartilage. 2017 Oct;8(4):374-383. doi:
10.1177/1947603517710308. Epub 2017 Jun 12.
• Camp CL, Zajac JM, Pearson DB, Sinatro AM, Spiker AM, Werner BC,
Altchek DW, Coleman SH, Dines JS. Decreased Shoulder External
Rotation and Flexion Are Greater Predictors of Injury Than Internal
Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional
Baseball. Arthroscopy.2017Sept;33(9):1629-1636.doi:10.1016/
j.arthro.2017.03.025.
77
Department of Biomechanics

Engineers in the Department of Biomechanics collaborate with ACHIEVEMENTS

Orthopaedic Surgeons, Radiologists, Pathologists and Basic • Timothy M. Wright, PhD, Director of the Department of
Scientists to perform research and develop orthopaedic devices and Biomechanics, served as an ad hoc member of the Bioengineering,
instrumentation with the goal of improving patient care. Technology and Surgical Sciences Study Section at the National
Institutes of Health (NIH) in the 2017–2018 academic year. He was
Director: Timothy M. Wright, PhD
also an ad hoc member of the NIH review panel for the Clinical and
Translational Science Awards Program and a reviewer of applications
to the NIH Loan Repayment Programs.
SURGEON REQUESTS FELLOWS NEW HSS eACADEMY®
FOR ASSISTANCE MODULES • Suzanne Maher, PhD, Associate Director of the Department of
WITH COMMERCIAL
PRODUCTS
4 1
Biomechanics, is a permanent member of the Musculoskeletal Tissue
Engineering Study Section at the NIH.

96 PUBLISHED STUDIES
ACADEMIC VISITORS
• Dr. Maher is a Board Member-at-Large for the Orthopaedic Research
Society (ORS) and Chair-Elect of the Society’s Meniscus Section.
PATIENT- SPECIFIC
28 5 • Carl Imhauser, PhD, Assistant Scientist, received a Traveling
IMPLANT DESIGNS Fellowship from the ACL Study Group, which is composed of
CREATED PRESENTATIONS AT approximately 100 renowned ACL surgeons from around the world.

41
CONFERENCES PATENTS
The Fellowship provides travel funds for Dr. Imhauser to exchange

35 5 ideas with key opinion leaders in knee surgery over the next
two years.
DEPARTMENT
ENGINEERS • Dr. Imhauser is a co-investigator on a $2.6 million multi-institutional
grant from the NIH to study computational modeling of the knee
19 joint. The goal is to establish computational models that simulate
the loading and motion of the knee as important components of
improving clinical care.

78
OPPOSITE PAGE,
FROM LEFT TO RIGHT:
Carl W. Imhauser, PhD
Joseph D. Lipman, MS
Timothy M. Wright, PhD
Christina Esposito, PhD
Suzanne Maher, PhD
NOT PICTURED:
• We have conducted an investigation of total knee arthroplasty failure.
Nelly Andarawis-Puri, PhD
Christopher J. Hernandez, PhD
Marjolein van der Meulen, PhD
Department engineers
Using a unique registry of more than 18,000 HSS patients who had
primary total knee arthroplasties, we explored the most common
failure modes and the preoperative risk factors for failure. In the
study, which was published in the Journal of Arthroplasty in 2018,
the patients provided valuable feedback on their outcomes at least
five years after their procedures. The most common reasons for
failure within two years were infection and stiffness. Preoperative risk
factors for failure included a history of drug use and a preoperative
diagnosis of post-traumatic arthritis or knee trauma. These findings
may help inform strategies for improving outcomes following total
knee arthroplasty.

EDUCATION

• Dr. Wright taught Biomechanics and Wear at the Maine Orthopaedic

PATIENT CARE
• We have developed a treatment algorithm for hip instability following
total hip arthroplasty. It involves the use of improved imaging
and modeling tools for patients needing revision procedures for
dislocation. We followed a series of patients for two years and found
that the algorithm markedly improved patient outcomes.
• We are integrating computational modeling of each patient’s unique
knee joint structure and movement patterns into surgical planning
in order to enhance the objective value of clinical examinations and
enable surgeons to personalize ligament reconstructive surgery.
• In 2018, we met with the U.S. Food and Drug Administration (FDA)
and the National Standards Authority of Ireland (NSAI) to obtain
clarity on the regulatory pathway for the commercialization of a
novel device for cartilage repair developed by HSS researchers. If
approved, this device will provide a reliable treatment for patients
suffering from painful and disabling articular cartilage defects.
RESEARCH INITIATIVES
• We are continuing to develop personalized approaches to knee
ligament reconstruction, with a focus on ACL reconstruction. Our
long-term goal is to identify patient-specific information about
the knee’s structure and laxity to determine who is at high risk of
having a poor outcome after tearing his or her ACL. We want to use
this personalized approach to restore patients to optimal function.
Ultimately, it will improve clinical practice, drive down medical costs
by reducing the need for revision surgeries, eliminate unnecessary
and follow-up treatments, and mitigate the burden of post-traumatic
osteoarthritis.
• We are developing a pediatric total hip replacement system in
collaboration with Wishbone Medical, Inc., a new global pediatric
orthopaedic company. The system will be geared primarily to the
needs of children with juvenile idiopathic arthritis and those with
congenital dysplastic hip disease.
• We have discovered that the forces acting on the menisci are highly
variable during daily activities, such as walking. Differences between
the mechanics of patients who heavily load their menisci versus
those who do not might explain the variability in outcomes after
medial meniscus surgery. Our findings were presented at the 2018
ORS meeting.
Review Course in June 2018. The Course was geared to orthopaedic
surgeons preparing for their American Board of Orthopaedic Surgery
certification and recertification examinations. It was the 38th time
that Dr. Wright has participated in the annual Course.
• Dr. Maher was an Invited Keynote speaker at the 8th World Congress
of Biomechanics in July 2018 in Dublin, Ireland.
• Dr. Imhauser was Guest Lecturer at the Cleveland Clinic Foundation
in December 2017. The topic of his lecture was “Computational
Modeling: An Important Tool for Personalized Knee Reconstruction.”
NOTABLE REFERENCES
• Imhauser CW, Kent RN, 3rd, Boorman-Padgett J, Thein R, Wickiewicz
TL, Pearle AD. New parameters describing how knee ligaments
carry force in situ predict interspecimen variations in laxity during
simulated clinical exams. J Biomech. 2017;64:212-8.
• Ma QL, Lipman JD, Cheng CK, Wang XN, Zhang YY, You B. A
Comparison Between Chinese and Caucasian 3-Dimensional Bony
Morphometry in Presimulated and Postsimulated Osteotomy for
Total Knee Arthroplasty. J Arthroplasty. 2017 Sep;32(9):2878-2886.
• Donnelly PE, Chen T, Finch A, Brial C, Maher SA, Torzilli PA.
Photocrosslinked tyramine-substituted hyaluronate hydrogels with
tunable mechanical properties improve immediate tissue-hydrogel
interfacial strength in articular cartilage. J Biomater Sci Polym Ed.
2017 Apr;28(6):582-600.
• Pitta M, Esposito CI, Li Z, Lee YY, Wright TM, Padgett DE. Failure
After Modern Total Knee Arthroplasty: A Prospective Study of 18,065
Knees. J Arthroplasty. 2018 Feb;33(2):407-414.
• Esposito CI, Carroll KM, Sculco PK, Padgett DE, Jerabek SA,
Mayman DJ. Total Hip Arthroplasty Patients With Fixed Spinopelvic
Alignment Are at Higher Risk of Hip Dislocation. J Arthroplasty. 2018
May;33(5):1449-1454.

79

HSS rheumatologists have a long history
of commitment to advancing our field through
our many leadership roles, our engagement
in the education of future physicians, and
our contributions to unraveling the complex
mechanisms responsible for autoimmune and
inflammatory rheumatic diseases.
I want to congratulate Anne R. Bass, MD,
Attending Physician, on completing her
term as Chair of the American College of
Rheumatology’s (ACR) Training and Workforce
Committee. In view of the acknowledged need
to grow the number of adult rheumatologists
and pediatric rheumatologists in the U.S. in
particular, recruiting and training physicians is
a high priority nationally and at HSS. Dr. Bass
has done an outstanding job in her ACR role
and as Director of the HSS Rheumatology
Training Program.
HSS rheumatologists also have high visibility
and critical roles in the programs at our
academic partner institution, Weill Cornell
Medicine. Jane E. Salmon, MD, Attending
Physician, serves as Associate Dean for
Faculty Affairs. Juliet B. Aizer, MD, Assistant
Attending Physician, and Edward J. Parrish,
MD, Assistant Attending Physician, have
designed significant portions of the curriculum
for first- and second-year medical students
and guide nearly all members of our faculty in
teaching activities at the medical school.
Perhaps only second to our focus on expert
patient care is our commitment to studying
the mechanisms of lupus, scleroderma,
myositis and other rheumatic diseases: Why
do they occur? Why do they affect some
people and not others? Why are they more
common in women than men?
Message from the
Physician-in-Chief
HSS has a long history of supporting
physician-scientists. Over the last five years,
we’ve recruited seven junior faculty members
who are pursuing careers in clinical and
translational research. We also founded the
HSS Rheumatology Council, a committee
of supporters and donors dedicated to raising
the Rheumatology Division’s visibility and
enabling research.
Working in partnership with the Development
Department, we have initiated a research
grant program and were pleased to award
the first Rheumatology Council Grants to the
following physicians:
• Karmela K. Chan, MD, Assistant Attending
Physician
• Jessica K. Gordon, MD, Assistant Attending
Physician
• Nathalie Burg, MD, Instructor
• David R. Fernandez, MD, PhD, Assistant
Attending Physician
Other grant recipients include Bella Mehta,
MBBS, MD, Assistant Attending Physician,
who received the C. Ronald MacKenzie Young
Scientist Endowment Award. Michela Manni,
PhD, Instructor, has received the Lockshin
Fellowship Award from the Barbara Volcker
Center for Women and Rheumatic Disease.
Our five Centers of Excellence and Division of
Pediatric Rheumatology facilitate collaboration
among physicians with disease-related
academic interests. Clinical care, research
and patient support are organized through
most of the Centers. Dr. Salmon, Director of
the Lupus and Antiphospholipid Syndrome
Center of Excellence, and colleagues oversee
the recruitment of patients for translational
research studies in lupus and APS and prioritize
interventional clinical trials of candidate
therapeutics. The Center of Excellence also
works closely with HSS Social Workers to lead
support groups and educational programs for
patients. HSS has been dedicated to advancing
understanding of the immunopathogenesis of
systemic lupus erythematosus for many years,
and we continue to identify biomarkers that
predict complications of disease and molecular
targets that hold the promise of leading to
new drug therapies.
In systemic sclerosis, Dr. Gordon and Robert F.
Spiera, MD, Director of the Scleroderma,
Vasculitis & Myositis Center of Excellence
80
and Attending Physician, have worked closely
with Franck Barrat, PhD, Senior Scientist
at the HSS Research Institute, to study the
role of plasmacytoid dendritic cells in the
disease. They have identified Toll-like receptor
8 as a novel pathway for immune system
activation in patients with systemic sclerosis.
Drs. Gordon and Spiera are also designing
investigator-initiated studies of novel
therapeutics and participating in multi-
center sponsored clinical trials.
HSS Rheumatologists recognize the value
of close collaboration with basic scientists
in the laboratory as well as with orthopaedic
surgeons. With the rich patient resources
available at HSS, clinical data and synovial
tissue samples collected at the time of
arthroplasty have been studied to characterize
the cell populations that are associated with
flares in activity of rheumatoid arthritis.
Vivian P. Bykerk, MD, Director of the
Inflammatory Arthritis Center of Excellence
and Attending Physician, and Susan M.
Goodman, MD, Director of the Integrative
Rheumatology and Orthopedic Center of
Excellence and Attending Physician, have
established protocols that provide the clinical
data necessary for productive analysis of
tissue samples. These researchers and their
collaborators are using machine learning
to analyze gene expression data from synovial
tissue cells in relation to pathologic patterns
of tissue histology in rheumatoid arthritis
patients. In our Bone Health and Osteoporosis
Center of Excellence, Emily M. Stein, MD, MS,
Associate Attending Physician and Associate
Scientist, is working closely with the HSS
Spine Service to study bone quality.
Our commitment to young investigators and
the success of their academic careers will
ensure that we sustain our long tradition of
leadership in rheumatology and our history
of advancing patient care. Our application
of current technologies to characterize the
molecular mechanisms that underlie the
diseases we treat exemplifies our commitment
to achieve better lives for our patients.
MARY K. CROW, MD
Physician-in-Chief
Chair, Department of Medicine
Chief, Rheumatology Division
Bone Health and Osteoporosis
Center of Excellence
The Bone Health and Osteoporosis Center of Excellence, which
educates, tests and treats patients with bone health disorders, is
the oldest of its kind in the country — and the only New York City-
based center that is accredited by the International Society for
Clinical Densitometry. Our novel and collaborative studies focus
on optimizing bone quality and health.
DIRECTOR: Linda A. Russell, MD
ACHIEVEMENTS
• Linda A. Russell, MD, Director of the Bone Health and Osteoporosis
Center of Excellence and Associate Attending Physician, was
appointed by the American College of Rheumatology as a member
of its Committee on Rheumatologic Care.
• Dr. Russell is a reviewer for Arthritis Care & Research and The New
England Journal of Medicine.
• Joseph M. Lane, MD, Chief of the Metabolic Bone Disease/
Musculoskeletal Oncology Service and Attending Orthopaedic
Surgeon, is a member of the National Institutes of Health (NIH)/
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) AMS Review Study Section.
• Dr. Lane is a member of the Editorial Board and a reviewer for the
following journals: Osteoporosis International; Journal of Bone and
Mineral Research; Journal of Orthopaedic Trauma; Journal of Bone
and Joint Surgery; and Clinical Orthopaedics and Related Research.
• Richard S. Bockman, MD, PhD, Chief of the Endocrine Service, is a
member of the Ethics Advisory Committee of The American Society
for Bone and Mineral Research (ASBMR).
• Dr. Bockman served on the Board of Directors for “Advances in
Mineral Metabolism,” a combined research mentoring group for the
10 to 12 ASBMR Haddow Fellows held annually in Aspen, CO.
• Dr. Bockman is a member of the Editorial Board of the Journal of
Clinical Endocrinology and Metabolism.
• Emily M. Stein, MD, MS, Associate Attending Physician, is a Fellow
of the ASBMR. She is also a member of the Development Committee.
• Dr. Stein is a member of the Scientific Advisory Council for the
International Society for Clinical Densitometry.
• Dr. Stein is Associate Editor of BMC Rheumatology.
• Juliet B. Aizer, MD, Assistant Attending Physician, received a Dean’s
Award from Weill Cornell Medical College for her role in curriculum
development for clinical training of first- and second-year medical
students.
PATIENT CARE
• Our Center incorporates contributions from Endocrinologists,
Rheumatologists and Orthopaedic Surgeons in the clinical evaluation
and management of patients with osteoporosis and related bone
disorders.
• We screen patients for bone loss so that we can treat them
proactively and possibly prevent fractures. We are among just a few
centers nationwide and the only center in New York City that goes
beyond DXA scanning to perform the most advanced testing, such
as Body Composition, Vertebral Fracture Assessment, Trabecular
81
Bone Score and QCT. Since 2016, we have been getting patients’
Trabecular Bone Score, which measures the strength of the vertebral
body. We also perform a body composition analysis, which measures
a patient’s fat-to-muscle ratio and can help diagnose sarcopenia, as
well as a vertebral fracture assessment to check for back fractures.
We are conducting femur fracture assessments, which are especially
helpful for patients who take bisphosphonates or denosumab. These
medications have been shown to increase the risk of atypical femur
fracture. Early changes of this condition can be detected by the
femur fracture assessment, which is done at the time of the bone
density test.
RESEARCH INITIATIVES
• We recently published novel observations by Dr. Stein and colleagues
on the impact of two types of steroids on bone density and quality. In a
study of the impact of epidural steroid injections on bone quality, which
was published in The Journal of Clinical Endocrinology & Metabolism,
Dr. Stein found lower bone density in patients who cumulatively
received higher doses of epidural steroids. She also found lower bone
quality in postmenopausal women who used inhaled steroids. The
study was published in Osteoporosis International in 2018.
• Dr. Stein is engaged in a study of bone quality in patients undergoing
spine surgery. She is collaborating with orthopaedic surgeons to
establish the most effective protocols for optimizing the outcomes
of spine surgery.
• Dr. Russell and colleagues published a study in The Bone & Joint
Journal demonstrating the significance of performing surgery
for hip fracture in elderly patients within 24 hours of admission to
minimize medical complications. They found that having surgery
within 24 hours of admission was associated with lower odds of
respiratory complications, including pneumonia; failure to extubate
or reintubation; and shorter length of stay. As a result, HSS hip
fracture patients now undergo surgery within 24 hours of admission.
EDUCATION
• Dr. Stein and Dorothy A. Fink, MD, Assistant Attending Physician,
established a monthly Interdisciplinary Metabolic Bone Case
Conference, in which the management of challenging metabolic bone
cases is discussed. Rheumatology trainees and faculty from several
disciplines attend these conferences.
• Twice a month, we discuss diagnostic and therapeutic dilemmas at
the Metabolic Bone Disease Grand Rounds/Journal Club. Recent
topics have included “Romosozumab or Alendronate for Fracture
Prevention in Women with Osteoporosis” and “Opportunistic
Use of CT Imaging for Osteoporosis Screening and Bone Density
Assessment.”
• In May 2018, Drs. Lane and Bockman conducted a webinar
called “Recent Advances Toward the Clinical Application of PTH
(Parathyroid Hormone Analogues) in Fracture Healing or Anabolic
Agents: What is Beyond Osteoporosis?”
Bone Health and Osteoporosis
Center of Excellence (cont.)

NOTABLE REFERENCES FROM LEFT TO RIGHT: Emily M. Stein, MD, MS

• Liu Y, Carrino JA, Dash AS, Chukir T, Do H, Bockman RS, Hughes AP, Catherine Sutton, RT Patricia Donohue, NP
Press JM, Stein EM. Lower spine volumetric bone density in patients Joseph M. Lane, MD Huma Morel
with a history of epidural steroid injections. J Clin Endocrinol Metab. Dorothy A. Fink, MD Kevin Math, MD
2018 Jul 2. doi: 10.1210/jc.2018-00558. Jonathan Cheah, MD Douglas N. Mintz, MD

• Liu Y, Dimango E, Bucovsky M, Agarwal S, Nishiyama K, Guo XE, Richard S. Bockman, MD,
PhD
Shane E, Stein EM. Abnormal microarchitecture and stiffness in NOT PICTURED:
postmenopausal women using chronic inhaled glucocorticoids. Linda A. Russell, MD
Taryn Griswold
Osteoporos Int. 2018 Jun 11. doi: 10.1007/s00198-018-4591-9. Tomas Esparra, RT

• Fu MC, Boddapati V, Gausden EB, Samuel AM, Russell LA, Lane

JM. Surgery for a fracture of the hip within 24 hours of admission is
independently associated with reduced short-term post-operative
complications. Bone Joint J. 2017 Sep;99-B(9):1216-1222.
• Park-Min KH. Mechanisms involved in normal and pathological
osteoclastogenesis. Cell Mol Life Sci. 2018 Jul;75(14):2519-2528.

82
Inflammatory Arthritis Center
of Excellence
The Inflammatory Arthritis Center of Excellence has established
cohorts of patients with early inflammatory arthritis and other
rheumatic diseases and is collaborating with basic scientists to
discover new therapeutic targets. The Center also provides patient
care, support and education.
Director: Vivian P. Bykerk, MD
ACHIEVEMENTS
• Vivian P. Bykerk, MD, Director of the Inflammatory Arthritis Center of • Dr. Donlin is the lead author of the first methods manuscript detailing
Excellence and Associate Attending Physician, is the lead investigator
of a rheumatoid arthritis (RA) study funded by the National Institutes
of Health (NIH) as part of the Accelerating Medicines Partnership
(AMP). The study is focused on identifying molecular processes that
occur in patients with active RA who have failed different therapies.
The goal is to investigate the differences in patients’ responses to
drugs to inform treatment decisions and directions for new therapies.
HSS physicians contribute clinical and technological resources, as well • We are using machine learning to identify the molecular basis of
as research expertise, to this consortium. Co-Principal Investigators
are Lionel B. Ivashkiv, MD, Chief Scientific Officer and Attending
Physician; Laura Donlin, PhD, Co-Director, Derfner Foundation
Precision Medicine Laboratory and Assistant Scientist; Alessandra
Pernis, MD, Senior Scientist; Edward F. DiCarlo, MD, Attending
Pathologist; John A. Carrino, MD, MPH, Attending Radiologist; and
Susan Goodman, MD, Attending Physician.
• Dr. Bykerk and Mary K. Crow, MD, Physician-in-Chief and Chief,
Division of Rheumatology, are responsible for the introductory chapter
on inflammatory arthritis published in the widely read Cecil Textbook
of Medicine.
• Our study of the impact of overweight and obesity on sustained
remission in RA patients won the HSS Residents Research Prize.
Results from this study have been highlighted by the press and were
featured in Rheumatology Now. In 2017, we presented research based
on 982 patients whom we had followed since they were diagnosed
with RA. We found that overweight patients were 25 percent less likely • We have developed three educational webinars for patients with
to achieve sustained remission and obese patients were 47 percent
less likely to do so in the three years after diagnosis despite similar
treatment. This is the largest study demonstrating the negative
impact of excess weight on RA disease activity in patients with new
onset RA. The study was published in Arthritis Care & Research.
PATIENT CARE
• We provide 16 educational and support programs for patients with
inflammatory arthritis in collaboration with the Department of Social
Work Programs.
• In a recent patient focus group, we learned that more RA patients
than expected experience significant and distressing effects from
their medication. Center members are working with the Outcome
Measures in Rheumatology (OMERACT) international steering
committee to develop a means to systematically capture the negative
effects of treatment. This will be used in clinical trials, observational
studies and, ultimately, in care to better assess the benefits and risks
of medications and improve treatment adherence.
• The Center is collaborating with Anne R. Bass, MD, Attending
Physician, to study the effects of immune checkpoint inhibitors (ICI),
which are prescribed to some cancer patients, on the musculoskeletal
system. With the support of our research group, we have created
a registry of ICI-treated patients who have developed autoimmune
reactions and arthritis. Now we have a formal study in place to examine
the underlying cytokine and antibody profiles of these patients.
We plan to compare the data to our early arthritis cohort patients.
RESEARCH INITIATIVES
standardized procedures on procuring and managing synovial
tissue for the purposes of cellular profiling and transcriptomics.
These techniques were employed to generate sequencing data on
RA patients’ synovial tissue, which was obtained via biopsy or after
a knee arthroplasty. We have published a way to use RNA sequencing
data to predict histologic features common to RA and clinical metrics.
distinct pathologic patterns of synovitis, including a gene expression
profile that is associated with pain.
• In collaboration with the New York Genome Center, we developed
a sequencing technology using fluidics to sort and sequence freshly
obtained and disaggregated synovial tissue cells. This technique,
known as Dropseq, had never been applied to synovial tissue
previously. It could help to identify novel cellular subsets in synovial
tissue not seen using older technologies.
EDUCATION
• We have created a structured education program for Rheumatology
Fellows. They participate in a weekly IAC-focused clinic conference
and courses in physical exams, outcome measures and immunology.
Each of our clinicians teaches at least one session on physical
examination of the joints.
inflammatory arthritis in collaboration with the Department of Social
Work Programs, the HSS Education Institute, the Arthritis Foundation
and Spondylitis Association of America. We also created a webinar
for primary care and rheumatology providers in collaboration with
the Department of Social Work Programs. The webinars are available
on the IAC website.
• In 2018, Dr. Bykerk moderated two panels at the European League
Against Rheumatism (EULAR) Meeting in Amsterdam.
• Dr. Bykerk presented findings from her early RA study on the
widespread pain that develops and persists in some in the first year
of the disease at the EULAR Meeting in June 2018.
83
Inflammatory Arthritis Center
of Excellence (cont.)

NOTABLE REFERENCES
• Stephenson W, Donlin LT, Butler A, Rozo C, Bracken B, Rashidfarrokhi
A, Goodman SM, Ivashkiv LB, Bykerk VP, Orange DE, Darnell RB,
• Donlin LT, Rao DA, Wei K, Slowikowski K, McGeachy MJ, Turner JD, Swerdlow HP, Satija R. Single-cell RNA-seq of rheumatoid arthritis
Meednu N, Mizoguchi F, Gutierrez-Arcelus M, Lieb DJ, Keegan J, synovial tissue using low-cost microfluidic instrumentation. Nat
Muskat K, Hillman J, Rozo C, Ricker E, Eisenhaure TM, Li S, Browne EP, Commun. 2018 Feb 23;9(1):791.
Chicoine A, Sutherby D, Noma A; Accelerating Medicines Partnership
RA/SLE Network, Nusbaum C, Kelly S, Pernis AB, Ivashkiv LB, • Chan K, Bass AR. Checkpoint inhibitor-induced polymyalgia
Goodman SM, Robinson WH, Utz PJ, Lederer JA, Gravallese EM, rheumatica controlled by cobimetinib, a MEK 1/2 inhibitor. Annals
Boyce BF, Hacohen N, Pitzalis C, Gregersen PK, Firestein GS, of the Rheumatic Diseases. May 2018, annrheumdis-2018 213672;
Raychaudhuri S, Moreland LW, Holers VM, Bykerk VP, Filer A, Boyle DOI: 10.1136/annrheumdis-2018-213672.
DL, Brenner MB, Anolik JH. Methods for high-dimensional analysis
of cells dissociated from cyropreserved synovial tissue. Arthritis Res
Ther. 2018 Jul 11;20(1):139.
• Fields TR, Batterman A. How Can We Improve Disease Education in
People with Gout? Curr Rheumatol Rep. 2018 Mar 8;20(3):12.
• Schulman E, Bartlett SJ, Schieir O, Andersen KM, Boire G, Pope
JE, Hitchon C, Jamal S, Thorne JC, Tin D, Keystone EC, Haraoui
B, Goodman SM, Bykerk VP; CATCH Investigators. Overweight,
Obesity, and the Likelihood of Achieving Sustained Remission in
Early Rheumatoid Arthritis: Results From a Multicenter Prospective
Cohort Study. Arthritis Care Res (Hoboken). 2017 Nov 30. doi:
10.1002/acr.23457.

84
 FROM LEFT TO RIGHT: NOT PICTURED:
Karmela Chan, MD Joan Westrich, LCSW
Ludis Williams-Mitchell
Theodore R. Fields, MD
Aidan Tirpack
Vivian Bykerk, MD
Caroline Reidy
Caroline Benson
Carey Ford
Laura Donlin, PhD
Gregory Vitone
Dalit Ashany, MD
Adena Batterman, LCSW
Lionel B. Ivashkiv, MD

85
Integrative Rheumatology and
Orthopedic Center of Excellence
The new Integrative Rheumatology and Orthopedic Center of RESEARCH INITIATIVES
Excellence is a unique group of rheumatologists, basic scientists • We are trying to gain a better understanding of the clinical
and orthopaedic surgeons who collaborate to improve the outcomes characteristics of RA patients undergoing arthroplasty. To achieve
of patients with rheumatic diseases and minority populations this, we have designed protocols to establish the infrastructure for
undergoing hip and knee arthroplasty. tissue acquisition at the time of arthroplasty, facilitating translational
research. This has led to multiple publications and collaborations
Director: Susan M. Goodman, MD
with other investigators in the field.
• To investigate health disparities in the utilization and outcomes
ACHIEVEMENTS of total joint replacement surgery, we have analyzed the HSS
Arthroplasty Registry in a series of studies. We have determined
• Susan M. Goodman, MD, Director of the Integrative Rheumatology
that racial healthcare disparities may be mediated by poverty and
and Orthopedic Center of Excellence and Attending Physician,
education. Race alone is not a factor in poor outcomes, but patients
led the expert panel that created the first-ever Guideline for the
of color from low-income communities tend to delay seeking care,
Perioperative Management of Antirheumatic Medication in Patients
which can contribute to worse outcomes. We are initiating a study
With Rheumatic Diseases Undergoing Elective Total Hip or Total
with the Long Island City Community Health Center to better under-
Knee Arthroplasty. The Guideline, which was published in The
stand the barriers to care in this community and enable us to design
Journal of Arthroplasty in 2017, is sponsored by the American College
an intervention to improve access and outcomes.
of Rheumatology (ACR) and the American Association of Hip and
Knee Surgeons (AAHKS). • We are studying arthritis in cancer patients treated with immune
checkpoint inhibitor drugs.
• Dr. Goodman is Co-Chair of the Glucocorticoid Impact Special
Interest Group in the Outcome Measures in Rheumatology
(OMERACT) Network. EDUCATION

• Dr. Goodman is Clinical Rheumatology Section Editor of BMC
Rheumatology and Perioperative Medicine Section Editor of Current
Rheumatology Reports.
• Anne R. Bass, MD, Attending Physician, served as Chair of the ACR
Committee on Training and Workforce Issues.
• Bella Mehta, MBBS, MD, Assistant Attending Physician, received the
ACR Distinguished Fellow Award in 2018.
PATIENT CARE
• We are studying the patient’s perspective on glucocorticoid
toxicity and glucocorticoid side effects to better assess potential
benefits in contrast to potential harms for use in evaluating
treatment strategies. Our research has found that the medications
are beneficial in controlling rheumatoid arthritis (RA) patients’
symptoms, but there are side effects, such as weight gain,
depressive symptoms and moodiness.
• We are characterizing RA subtypes using clinical data, gene
expression and histopathology to better understand disease
activity and treatment response. In a study published in Arthritis
& Rheumatology in 2018, we identified three distinct molecular
subtypes, including a “low inflammatory” subtype that expressed
neuronal genes.
• Dr. Bass is an author of a paper on supply and demand projections
of the adult rheumatology workforce. The study, which was
published in Arthritis Care & Research in 2018, found that by 2030,
the supply of rheumatology clinical providers is projected to drop
by 25 percent from 2015 baseline levels. Demand is projected to
exceed supply by 4,133 clinical full-time practitioners. Regional and
innovative strategies are needed to ensure continued access to care.
• In a related study published in Arthritis & Rheumatology in 2018,
Dr. Bass and colleagues found that while the number of adult
Rheumatology fellowship training programs — and the number of
available positions — increased over the last decade, some positions
remain vacant each year. The current adult rheumatology workforce
is in jeopardy of accelerated decline at a time when there will likely
be increased demand. More rheumatologists must be trained, and
innovative graduate medical education funding mechanisms are
necessary to create incentives for pursuing rheumatology training.
NOTABLE REFERENCES
• Bass AR, Fields KG, Goto R, Turissini G, Dey S, Russell LA. Clinical
Decision Rules for Pulmonary Embolism in Hospitalized Patients:
A Systematic Literature Review and Meta-analysis. Thromb Haemost.
2017 Nov;117(11):2176-2185.
• Gage BF, Bass AR, Lin H, Woller SC, Stevens SM, Al-Hammadi N, Li J,
Rodríguez T Jr, Miller JP, McMillin GA, Pendleton RC, Jaffer AK, King
CR, Whipple BD, Porche-Sorbet R, Napoli L, Merritt K, Thompson
AM, Hyun G, Anderson JL, Hollomon W, Barrack RL, Nunley RM,
Moskowitz G, Dávila-Román V, Eby CS. Effect of Genotype-Guided
Warfarin Dosing on Clinical Events and Anticoagulation Control
Among Patients Undergoing Hip or Knee Arthroplasty: The GIFT
Randomized Clinical Trial. JAMA. 2017 Sep 26;318(12):1115-1124.

86
• Goodman SM, Bykerk VP, DiCarlo E, Cummings RW, Donlin LT,
FROM LEFT TO RIGHT: Linda A. Russell, MD
Orange DE, Hoang A, Mirza S, McNamara M, Andersen K, Bartlett SJ,
Emily M. Stein, MD, MS Mark P. Figgie, MD
Szymonifka J, Figgie MP. Flares in Patients with Rheumatoid Arthritis
Michael L. Parks, MD Iris Navarro-Millan, MD
after Total Hip and Total Knee Arthroplasty: Rates, Characteristics,
Anne R. Bass, MD Bella Mehta, MBBS, MD*
and Risk Factors. J Rheumatol. 2018 May;45(5):604-611.
Susan M. Goodman, MD
• Goodman SM, Mandl LA, Mehta B, Navarro-Millan I, Russell LA, Parks
Laura T. Donlin, PhD *new physician
ML, Dey SA, Crego D, Figgie MP, Nguyen JT, Szymonifka J, Zhang M,
Bass AR. Does Education Level Mitigate the Effect of Poverty on Total
Knee Arthroplasty Outcomes? Arthritis Care Res (Hoboken). 2018
Jun;70(6):884-891.
• Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George
M, Gewurz-Singer O, Giles JT, Johnson B, Lee S, Mandl LA, Mont
MA, Sculco P, Sporer S, Stryker L, Turgunbaev M, Brause B, Chen
AF, Gililland J, Goodman M, Hurley-Rosenblatt A, Kirou K, Losina
E, MacKenzie R, Michaud K, Mikuls T, Russell L, Sah A, Miller AS,
Singh JA, Yates A. 2017 American College of Rheumatology/
American Association of Hip and Knee Surgeons Guideline for the
Perioperative Management of Antirheumatic Medication in Patients
With Rheumatic Diseases Undergoing Elective Total Hip or Total
Knee Arthroplasty. J Arthroplasty. 2017 Sep;32(9):2628-2638.

87
Lupus and Antiphospholipid
Syndrome Center of Excellence
The Lupus and Antiphospholipid
Syndrome Center of Excellence provides
multidisciplinary care, education and
support to patients with lupus and APS and
works closely with scientists in the Mary
Kirkland Center for Lupus Research to
support research on these diseases.
Director: Jane E. Salmon, MD
88
ACHIEVEMENTS
• Jane E. Salmon, MD, Director of the Lupus and Antiphospholipid
Syndrome Center of Excellence and Attending Physician, and Mary K.
Crow, MD, Physician-in-Chief and Chief, Division of Rheumatology,
were named Honorary Members of the European League Against
Rheumatism (EULAR) in 2018 and 2017, respectively. They are among
the first four Americans to achieve this honor, which recognizes their
contributions to research, education and service to EULAR.
• Dr. Crow received the Presidential Gold Medal from the American
College of Rheumatology in 2018. It is awarded in recognition
of outstanding achievements in rheumatology over the course of
a career.
• Dr. Salmon was named a Master of the American College of
Rheumatology in 2017.
• Dr. Salmon is Associate Dean, Faculty Affairs, Weill Cornell
Medical College.
• Dr. Salmon is a member of the Steering Committee of the Lupus
Clinical Investigators Network (LuCIN) and the Scientific Advisory
Board of the Lupus Research Alliance.
• Dr. Salmon is Associate Editor of Lupus, Science and Medicine and
serves on the editorial board of the Annals of the Rheumatic Diseases.
• Dr. Crow is Co-Chair of the Scientific Advisory Board of the Lupus
Research Alliance and a member of the Executive Committee of the
Lupus Clinical Investigators Network (LuCIN).
• Dr. Crow serves on the Organizing Committee of the Lupus 2018
Research Conference.
 NOT PICTURED:
• We have established a reproductive health program for patients with
OPPOSITE PAGE, Mavis Seehaus, MS,
FROM LEFT TO RIGHT: LCSW SLE or APS who are pregnant, considering pregnancy or concerned
Albairis Rosa, LMSW
Michael D. Lockshin, MD Doruk Erkan, MD, MPH about contraception.
My-Lan Tran, LCSW
Carol A. Mancuso, MD Alessandra Pernis, MD
Jo-Ann Vega
• We conduct a weekly meeting with our multidisciplinary team,
Alexandra Jurenko, LCSW Lisa R. Sammaritano, MD including rheumatologists, other medical specialists, trainees, social
Medha Barbhaiya, MD Mary Peng workers and nurses, to discuss complex patients.
Roberta Horton, LCSW, Julia Davis-Porada • We have SLE patient support and education programs, including
ACSW Melissa Flores, LMSW, Charla de Lupus, which is offered in English and Spanish, and
Priscilla Toral, LCSW MPH LANtern® (Lupus Asian Network), which provides resources in
Juliette Kleinman, LCSW, David Fernandez, MD English and Chinese.
ACSW Marta Guerra
Theresa Lu, MD, PhD Ann Marie Rakowicz
RESEARCH INITIATIVES
Susan Rodriguez, LMSW Mary K. Crow, MD
Kyriakos Kirou, MD Jillian Rose, LCSW, MPH • Drs. Crow and Kirou have identified type I interferon as a key
Tricia Dougherty pathogenic mediator in SLE in studies over the past 15 years. This has
Lindsay S. Lally, MD
Jane E. Salmon, MD supported therapeutic targeting of that molecular pathway. Dr. Kirou
was the site investigator for the Phase II and III trials of anifrolumab
(anti-type I interferon receptor monoclonal antibody).
• Dr. Crow is a member of the National Institute of Dental and • Dr. Salmon has discovered that tumor necrosis factor (TNF) is a
Craniofacial Research Board of Scientific Counselors. mediator of fetal loss, placental insufficiency and low birth weight in
• Dr. Crow is Associate Editor of the Annals of the Rheumatic Diseases pre-clinical and clinical studies of patients with SLE and APS. This
and Goldman’s Cecil Medicine; and Section Editor of Dubois’ Lupus finding supports the first trial of a biologic, a TNF blocker, to prevent
Erythematosus and Related Syndromes. preeclampsia and placental insufficiency in high-risk pregnancies in
• Michael D. Lockshin, MD, Director of the Barbara Volcker Center patients with APS. It has been initiated by Dr. Salmon and her team.
for Women and Rheumatic Disease and Attending Physician, and • Dr. Salmon is studying whether targeting iRhom2, a means to
Doruk Erkan, MD, MPH, Associate Attending Physician and Clinical simultaneously prevent signaling by two mediators of irreversible
Co-Director of the Mary Kirkland Center for Lupus Care, are editors kidney injury, TNF and HB-EGF, can protect from nephritis and death.
of Antiphospholipid Syndrome: Current Research Highlights and • The Center collaborates with Orthopaedic Surgeons. Susan M.
Clinical Insights 1st ed. 2017 Edition. Goodman, MD, Director of the Integrative Rheumatology and
• Dr. Erkan is Executive Committee Chair of the international APS Orthopedic Center of Excellence and Attending Physician; David R.
research network APS ACTION (Antiphospholipid Syndrome Alliance Fernandez, MD, Assistant Attending Physician; and Comprehensive
for Clinical Trials and International Networking). He organized the Arthritis Program Orthopaedic Surgeons are leading studies of
8th APS ACTION Annual Summit in November 2017 in San Diego. medical complications in SLE patients undergoing arthroplasty.
• Dr. Lockshin is author of The Prince at the Ruined Tower: Time,
Uncertainty & Chronic Illness, which was published in 2017. NOTABLE REFERENCES
• Lisa R. Sammaritano, MD, Associate Attending Physician, was • Garcia D, Erkan D. Diagnosis and Management of the Antiphospholipid
Principal Investigator of the American College of Rheumatology Syndrome. N Engl J Med. 2018 May 24;378(21):2010-2021.
Reproductive Health in Rheumatic Diseases Guideline.
• Kim MY, Guerra MM, Kaplowitz E, Laskin CA, Petri M, Branch DW,
• Kyriakos A. Kirou, MD, DSc, Assistant Attending Physician, is the HSS Lockshin MD, Sammaritano LR, Merrill JT, Porter TF, Sawitzke A,
Site Director of the Lupus Clinical Investigators Network (LuCIN). Lynch AM, Buyon JP, Salmon JE. Complement activation predicts
adverse pregnancy outcome in patients with systemic lupus
PATIENT CARE
erythematosus and/or antiphospholipid antibodies. Ann Rheum
Dis. 2018 Apr;77(4):549-555.
• We are the referral site for rheumatologists who need help
caring for patients with systemic lupus erythematosus (SLE) and/ • Manni M, Gupta S, Ricker E, Chinenov Y, Park SH, Shi M, Pannellini T,
or antiphospholipid syndrome (APS). Patients have come to HSS Jessberger R, Ivashkiv LB Pernis AB. Regulation of age-associated
from Arkansas, Connecticut, Illinois, New Jersey, New York and B cells by IRF5 in systemic autoimmunity. Nat Immunol. 2018
Pennsylvania. Patients seen by other rheumatologists also seek Apr;19(4):407-419.
care and second opinions through our “Fast Track” program, which • Mavragani CP, Nezos A, Sagalovskiy I, Seshan S, Kirou KA, Crow
provides rapid appointments. MK. Defective regulation of L1 endogenous retroelements in primary
• We have established a network of subspecialists, including Sjogren’s syndrome and systemic lupus erythematosus: Role of
nephrologists, dermatologists, obstetricians, cardiologists and methylating enzymes. J Autoimmun. 2018 Mar;88:75-82.
hematologists, to provide multidisciplinary care for SLE and APS • Qing X, Chinenov Y, Redecha P, Madaio M, Roelofs JJ, Farber G,
patients. Issuree PD, Donlin L, Mcllwain DR, Mak TW, Blobel CP, Salmon JE.
• We have launched a free app called LupusMinder to help patients iRhom2 promotes lupus nephritis through TNF- and EGFR signaling.
monitor their disease, learn about signs and symptoms, review J Clin Invest. 2018 Apr 2;128(4):1397-1412.
medications and track medical appointments.

89
Division of Pediatric Rheumatology
The Division of Pediatric Rheumatology
provides many aspects of care for children
with rheumatic disease, including the most
up-to-date medical interventions and social
services, child life programs and nutrition
counseling.
Chief: Karen B. Onel, MD
90
ACHIEVEMENTS
• Karen B. Onel, MD, Chief of the Division of Pediatric Rheumatology
and Attending Physician, is Chair of the Childhood Arthritis and
Rheumatology Research Alliance (CARRA) Ethics Committee. She
is Co-Chair of the CARRA Systemic Juvenile Idiopathic Arthritis
working group.
• Dr. Onel is a member of the Advisory Council of the Pediatric
Rheumatology Collaborative Study Group (PRCSG).
• Dr. Onel is a member of the Juvenile Arthritis Committee of the
Arthritis Foundation.
• Sarah F. Taber, MD, Assistant Attending Physician, is a co-author of
the chapter on Systemic Lupus Erythematosus in Childhood and
Adolescence in the 2018 edition of Dubois’ Lupus Erythematosus and
Related Syndromes.
• Dr. Taber is a member of the CARRA Localized Scleroderma and
Systemic Sclerosis work group.
• Theresa T. Lu, MD, PhD, Associate Scientist, was awarded a research
grant from the Lupus Research Alliance to study the involvement of
the lymphatic system in ultraviolet light-induced cutaneous lupus.
• Natalie Rosenwasser, MD, Clinical Fellow, was awarded a CARRA
Arthritis Foundation Fellow Small Grant. The grant will help fund
a collaborative research project between the Division of Pediatric
Rheumatology and the Gale and Ira Drukier Institute for Children’s
Health at Weill Cornell Medicine. The research project is entitled
“Development of Novel Urinary Biomarkers for Lupus Nephritis.”

OPPOSITE PAGE, Karen B. Onel, MD
FROM LEFT TO RIGHT:
Erin Treemarcki, MD
Nadine Saad, MD
Sarah Taber, MD
Alexa B. Adams, MD Jacob Spitznagle, MD
Keila Vega, MD Theresa T. Lu, MD, PhD
Nancy Pan, MD Natalie Rosenwasser, MD
Nayimisha Balmuri, MD
PATIENT CARE
• Division physicians are now seeing patients at the HSS Stamford
Outpatient Center in Stamford, CT, and HSS Westchester in
White Plains, NY.
• New patient volume increased by 27 percent over the last
academic year.
• We performed a pilot study to determine whether pulse oximetry
could be used to screen patients at risk for lung disease. We found
that our initiative to increase oxygen saturation recordings in the
clinic setting was effective and easy to achieve, and we identified
one patient who required further testing. More research is needed to
determine the efficacy of longitudinal oxygen saturation recordings
as a screening tool for lung disease in patients.
• Erin Treemarcki, MD, Clinical Fellow, created disease-specific
follow-up note templates inclusive of the HEEADSSS (home
environment, education/employment, eating, activities, drugs,
sexuality, suicide/depression and safety) assessment. The
templates were introduced to the Pediatric Rheumatology Fellows
Clinic. Charts of patients with Juvenile Idiopathic Arthritis (JIA)
and Systemic Lupus Erythematosus (SLE) were reviewed before
and after the templates were introduced, and Dr. Treemarcki and
colleagues found that there were improved rates of screening for
smoking and a trend toward improved screening rates for sexual
activity. Future studies will assess whether the improvement is
sustained and whether the template can be used for other pediatric
patient populations. Other Division members involved in the study
were Drs. Onel and Taber; Alexa B. Adams, MD, Associate Attending
Physician; and Nancy Pan, MD, Assistant Attending Physician.
RESEARCH INITIATIVES
• Dr. Rosenwasser was awarded a pilot research grant from the Barbara
Volcker Center for Women and Rheumatic Diseases to develop a
• Shipman WD, Chyou S, Ramanathan A, Izmirly PM, Sharma S,
cohort of pediatric lupus patients and investigate their gene expression
in relation to clinical manifestations of disease.
• We are developing a consensus treatment plan for Chronic Recurrent
Multifocal Osteomyelitis (CRMO), a rare inflammatory bone disease
that is often mistaken for bone tumors and infection. We are also
collaborating with Radiology and Imaging and Pediatric Orthopaedic
Surgeons to establish imaging protocols based on clinical presentation.
• We are continuing to enroll patients in the CARRA Registry of more
than 5,000 children and young adults with pediatric-onset rheumatic
conditions such as JIA. The Registry provides disease and treatment
data on children with rheumatic diseases.
91
• We investigated whether Patient Reported Outcome Measurement
Information System (PROMIS) Computer Adaptive Tests (CATs)
correlate with disease activity in JIA patients. In the study, which
was presented at the American College of Rheumatology meeting
in 2017, we found that anxiety, depressive symptoms and pain were
significantly correlated with disease activity, even though the mean
disease activity was relatively low. Parent proxy CATs, on the other
hand, showed poor correlations with disease activity, suggesting that
parents are inaccurate in assessing important aspects of their child’s
health. More research is needed to evaluate the sensitivity of PROMIS
CATs to changes in disease activity over time.
EDUCATION
• Dr. Onel spoke about wellness at the Arthritis Foundation Family
Fun Day in New York City in March 2018.
• Dr. Onel spoke at the Puerto Rico Association of Rheumatologists
Annual Convention in May 2018.
• Dr. Taber gave a Grand Rounds lecture at Lenox Hill Hospital entitled
“JIA for the General Practitioner.”
NOTABLE REFERENCES
• Brunner HI, Rider LG, Kingsbury DJ, Co D, Schneider R, Goldmuntz E,
Onel KB, Giannini EH, Lovell DJ; PRCSG Advisory Council. Pediatric
Rheumatology Collaborative Study Group — over four decades
of pivotal clinical drug research in pediatric rheumatology. Pediatr
Rheumatol Online J. 2018 Jul 11;16(1):45.
• Horton DB, Onel KB, Beukelman T, Ringold S. Attitudes and
Approaches for Withdrawing Drugs for Children with Clinically
Inactive Nonsystemic JIA: A Survey of the Childhood Arthritis and
Rheumatology Research Alliance. J Rheumatol. 2017 Mar;44(3):
352-360.
• Zhao Y, Wu EY, Oliver MS, Cooper AM, Basiaga ML, Vora SS,
Lee TC, Fox E, Amarilyo G, Stern SM, Dvergsten JA, Haines KA,
Rouster-Stevens KA, Onel KB, Cherian J, Hausmann JS, Miettunen P,
Cellucci T, Nuruzzaman F, Taneja A, Barron KS, Hollander MC, Lapidus
SK, Li SC, Ozen S, Girschick H, Laxer RM, Dedeoglu F, Hedrich
CM, Ferguson PJ; Chronic Nonbacterial Osteomyelitis/Chronic
Recurrent Multifocal Osteomyelitis Study Group and the Childhood
Arthritis and Rheumatology Research Alliance Scleroderma,
Vasculitis, Autoinflammatory and Rare Diseases Subcommittee.
Consensus Treatment Plans for Chronic Nonbacterial Osteomyelitis
Refractory to Nonsteroidal Antiinflammatory Drugs and/or With
Active Spinal Lesions. Arthritis Care Res (Hoboken). 2017 Nov 7. doi:
10.1002/acr.23462
Pannellini T, Dasoveanu DC, Qing X, Magro CM, Granstein RD,
Lowes MA, Pamer EG, Kaplan DH, Salmon JE, Mehrara BJ, Young
JW, Clancy RM, Blobel CP, Lu TT. A prospective Langerhans cell-
keratinocyte axis that is dysfunctional in photosensitivity. Sci Transl
Med. 2018 Aug 15;10(454).
Scleroderma, Vasculitis &
Myositis Center of Excellence
The Scleroderma, Vasculitis & Myositis
Center of Excellence initiates and conducts
clinical trials of promising new treatments
for rare diseases and provides support and
education for patients.
Director: Robert F. Spiera, MD
92
ACHIEVEMENTS
• Robert F. Spiera, MD, Director of the Scleroderma, Vasculitis &
Myositis Center of Excellence and Attending Physician, was a
member of a group of investigators that designed and executed a
clinical trial for a new therapy for giant-cell arteritis. Tocilizumab,
an interleukin (IL)-6 blocking agent, was the first therapy approved
by the U.S. Food & Drug Administration and European Medicines
Agency for this indication.
• Franck Barrat, PhD, Senior Scientist; Dr. Spiera; Jessica K.
Gordon, MD, Assistant Attending Physician; David R. Fernandez,
MD, Assistant Attending Physician; and other HSS investigators
published a significant study in Science Translational Medicine in 2018
identifying the plasmacytoid dendritic cell and Toll-like receptor 8 as
important contributors to the pathogenesis of systemic sclerosis.
• Dr. Spiera and Dr. Gordon are members of the Medical and Scientific
Advisory Board of the Scleroderma Foundation, Tri-State Chapter.
• Dr. Spiera is Chair of the Medical and Scientific Advisory Board of the
Scleroderma Foundation, Tri-State Chapter.
• Dr. Spiera and Dr. Gordon are members of the National Medical and
Scientific Advisory Board of the Scleroderma Foundation.
• Dr. Spiera is a Consultant for the Vasculitis Foundation.

OPPOSITE PAGE, Jesse Ojeda
FROM LEFT TO RIGHT:
Beemnet Amdemicael
Albairis Rosa, LMSW
Elizabeth Soto-Cardona,
David Fernandez, MD MPH
Mosammed Tasnin Kabir Alexandra Jurenko, LCSW
Franck Barrat, PhD Juliette Kleinman, LMSW,
ACSW
Jessica Gordon, MD
Theresa T. Lu, MD, PhD
Robert F. Spiera, MD NOT PICTURED:
Lindsay S. Lally, MD Ebony Jackson
Susan Rodriguez, LMSW Dorcas Mcrae
Eileen McCullagh, RN
PATIENT CARE
• The Center’s research is integrated into the clinical care of our
patients. This allows us to offer, when appropriate, therapeutic options
that are not yet available outside of a research center. The level of care
we provide has led to regional, national and international referrals.
• Our Center Manager, Elizabeth Soto Cardona, MPH, and social
workers provide educational programs and materials that contribute
to a more successful navigation of these challenging disorders.
• We work with foundations, including the Scleroderma Foundation
and the Vasculitis Foundation, and patient groups to sponsor patient
education programs.
• Dr. Gordon led a study validating the use of joint counts and modified
Rodnan Skin Score in patients with early systemic sclerosis (SSc).
It was published in The Journal of Rheumatology in 2017.
RESEARCH INITIATIVES
• We have established a strong clinical trial program focused on
SSc and vasculitis. We launch novel, investigator-initiated studies
of promising new agents and actively participate in multi-center,
federal- and industry-sponsored clinical trials.
• Our disease-focused registries facilitate enrollment in clinical trials
and serve to identify patients for collaborative studies on disease
mechanisms, as well as clinical observational studies.
• The Center has established close working relationships with HSS
Research Institute laboratories to identify novel mechanisms,
particularly for SSc and inflammatory muscle diseases.
• Dr. Spiera led a Phase II, industry-sponsored, multi-center,
randomized, placebo-controlled clinical trial investigating the
potential of lenabasum — a cannabinoid type 2 receptor agonist —
as a therapy for SSc. So far, the data suggest clinical efficacy
and acceptable safety. Based on those findings, a multi-center,
international, Phase III trial has been initiated. Dr. Spiera is the
lead investigator, and patient enrollment began in December 2017.
The goal is to enroll 300 patients across four continents (North
America, Europe, Asia and Australia). If the compound’s efficacy
and safety are confirmed, regulatory approval could follow.
• In January 2018, we published the results of an HSS-sponsored,
investigator-initiated trial of an anti-B cell strategy for treating
SSc in Arthritis & Rheumatology. In this randomized, double-blind,
placebo-controlled trial, led by Dr. Spiera and Dr. Gordon, patients
93
with early diffuse cutaneous SSc who recently started taking
mycophenolate mofetil (MMF) were randomized to receive
either belimumab intravenously or placebo. The results favored
belimumab but were not statistically significant. Acceptable safety
was demonstrated. Gene expression analysis showed that those
who improved in the belimumab-treated group had decreases in the
expression of B-cell signaling and pro-fibrotic genes and pathways.
This was not observed in the placebo-treated patients or in those
who did not improve while taking belimumab. The study is now the
basis for a larger, randomized placebo-controlled trial, which will be
initiated in 2019. We are excited about the potential efficacy of this
anti-B cell strategy, for which there is a strong, pre-clinical rationale
but few controlled clinical trials.
• Dr. Fernandez has initiated a study of the role of T lymphocytes in
inclusion body myositis, a type of inflammatory muscle disease with
characteristics of both autoimmunity and degenerative disease.
• Theresa T. Lu, MD, PhD, Associate Scientist, is studying the role of
loss of skin adipose tissue in the development of skin fibrosis and the
protective role of stromal cell-derived, anti-fibrotic cytokines.
EDUCATION
• Dr. Gordon developed a curriculum for training in capillaroscopy.
It was published in Clinical and Experimental Rheumatology in 2017.
• Dr. Spiera was the Invited Speaker at the Pan-American Congress of
Rheumatology (PANLAR) in 2018. He gave two talks: “Treatment
of Systemic Sclerosis” and “Therapy of Giant Cell Arteritis.”
• Dr. Spiera was the Invited Speaker at the Congress of Clinical
Rheumatology in Destin, FL in 2017. He gave two talks: “Advances
in the Treatment of Giant Cell Arteritis” and “Therapy of Systemic
Sclerosis.”
NOTABLE REFERENCES
• Ah Kioon MD, Tripodo C, Fernandez D, Kirou KA, Spiera RF, Crow
MK, Gordon JK, Barrat FJ. Plasmacytoid dendritic cells promote
systemic sclerosis with a key role for TLR8. Sci Transl Med. 2018
Jan 10;10(423).
• Gordon JK, Martyanov V, Franks JM, Bernstein EJ, Szymonifka J,
Magro C, Wildman HF, Wood TA, Whitfield ML, Spiera RF. Belimumab
for the Treatment of Early Diffuse Systemic Sclerosis: Results of a
Randomized, Double-Blind, Placebo-Controlled, Pilot Trial. Arthritis
Rheumatol. 2018 Feb;70(2):308-316.
• Marangoni RG, Lu TT. The roles of dermal white adipose tissue
loss in scleroderma skin fibrosis. Curr Opin Rheumatol. 2017
Nov;29(6):585-590.
• Lafyatis R, Mantero JC, Gordon J, Kishore N, Carns M, Dittrich H,
Spiera R, Simms RW, Varga J. Inhibition of ß-Catenin Signaling in
the Skin Rescues Cutaneous Adipogenesis in Systemic Sclerosis:
A Randomized, Double-Blind, Placebo-Controlled Trial of C-82.
J Invest Dermatol. 2017 Dec;137(12):2473-2483.
• Stone J.H, Tuckwell K, Dimonaco S., Klearman M, Aringer M.,
Blockmans D., Brouwer E.,Cid M.C., Bhaskar D., RechJ., Salvarani C.,
Schett G., Schulze-Koops H., Spiera R., Unizony S.H., Collinson N.
Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med. 2017;
377(4):317-328
About HSS
Founded in 1863, Hospital for Special Surgery (HSS) is a world leader in orthopaedics,
rheumatology and rehabilitation. HSS is ranked #1 in the U.S. for Orthopaedics and
#3 for Rheumatology by U.S. News & World Report “Best Hospitals” (2018–2019
rankings). It is also ranked Best in New York City for Pediatric Orthopaedics and #21
nationally by U.S. News & World Report “Best Hospitals” (2018–2019 rankings). It is
the first hospital in New York State to receive the Magnet® designation for Excellence
in Nursing Service from the American Nurses Credentialing Center four consecutive
times. Located in New York City, HSS also serves patients in the regional area with
outpatient centers in Westchester County, New York; Connecticut; New Jersey; Long
Island and Queens. In 2019, there will be a new HSS location in West Palm Beach, FL.
Patients choose to come to HSS from across the U.S. and from around the world. HSS
has one of the lowest infection rates in the country. The Hospital’s Research Institute
is internationally recognized as a leader in the investigation of musculoskeletal and
autoimmune diseases.

To learn more, please visit hss.edu.

ATTRIBUTIONS

The State of the World of Musculoskeletal Health is published by the Communications

Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.
866-976-1196
Hospital for Special Surgery is an affiliate of Weill Cornell Medical College.
© 2018 Hospital for Special Surgery. All rights reserved.

94
Officers
CO-CHAIRS SURGEON-IN-CHIEF AND EXECUTIVE VICE PRESIDENT,
MEDICAL DIRECTOR CHIEF LEGAL OFFICER AND

Thomas Lister SECRETARY

Todd J. Albert, MD
Robert K. Steel Irene Koch, Esq.
EXECUTIVE VICE PRESIDENT AND
CHIEF OPERATING OFFICER CHAIRMEN EMERITI
VICE CHAIR

Michael Esposito Lisa A. Goldstein Winfield P. Jones

Richard L. Menschel
EXECUTIVE VICE PRESIDENT AND
PRESIDENT AND
CHIEF EXECUTIVE OFFICER
CHIEF FINANCIAL OFFICER Aldo Papone
Louis A. Shapiro Stacey L. Malakoff Kendrick R. Wilson III

Credits
EXECUTIVE EDITORIAL EXECUTIVE EDITOR WRITERS PHOTO EDITORS MAJOR
BOARD PHOTOGRAPHY
Rachel Sheehan, Stacey Colino Deborah Garcia
Todd Albert, MD MA, MBA Robert Essel
Beth Howard Shawn Morrissey
Mary K. Crow, MD John Abbott
Jacqueline Stenson
John Englehart EDITOR-IN-CHIEF
PRINTING

Lionel Ivashkiv, MD Deborah Pike Olsen

DESIGN Earth Color
Louis A. Shapiro Addison

Innovation Partnerships
HSS has many innovation partnerships. The four below are featured in this issue of “The State of the World of Musculoskeletal Health.”

WISHBONE MEDICAL, INC. BOSTON BIOMOTION

Mark P. Figgie, MD, Chief of the Surgical Arthritis Service and Attending
Orthopaedic Surgeon, is a designer of, and receives royalties for, certain
products manufactured and sold by WishBone Medical, Inc. Dr. Figgie also
holds equity interest in WishBone Medical, Inc. In 2018, WishBone Medical,
Inc. and HSS entered into a license agreement for the development of a
novel Pediatric Total Hip.
LIMACORPORATE S.p.A.
Timothy M. Wright, PhD, Director of the Department of Biomechanics;
Dr. Figgie; Robert N. Hotchkiss, MD, Medical Director of the Innovation Institute
and Associate Attending Orthopaedic Surgeon; and Joseph Lipman, MS,
Director of Device Development, are designers of, and receive royalties for,
certain products manufactured and sold by LimaCorporate S.p.A.
In 2015, HSS entered into a co-development relationship with Boston Biomotion,
a novel performance training and assessment technology. HSS is a shareholder
in Boston Biomotion.
AGELITY BIOMECHANICS
AGelity BioMechanics was formed as a part of HSS’s strategic growth and
diversification plan to develop and commercialize technology and patents based
on research performed at HSS by Russell F. Warren, MD, Attending Orthopaedic
Surgeon, and Suzanne Maher, PhD, Associate Director of the Department of
Biomechanics and Senior Scientist. Dr. Warren, Dr. Maher and HSS each hold
equity interests in AGelity.
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New York, NY 10021

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