December 2017

President's Message

Biosimilars for Patients with Inflammatory Arthritis

Marc Hochberg, MD, MPH, MACP, President, USBJI

The topic of the use of biosimilars for the management of patients with inflammatory rheumatic diseases including rheumatoid arthritis was the topic of a debate at the annual meeting of the American College of Rheumatology in November. Given the increasing interest in and timeliness of this topic, I am devoting my commentary for this month's issue to Biosimilars.

Many patients with inflammatory arthritis such as rheumatoid arthritis, axial spondyloarthritis (formerly known as ankylosing spondylitis) and psoriatic arthritis, are being treated with biologic agents, including but not limited to monoclonal antibodies to tumor necrosis factor (TNF inhibitors). The U.S. Food and Drug Administration (FDA) has approved a number of biologic products that are being used instead of the original or reference products; these new products are referred to as biosimilars. A biosimilar can be defined as a biological product that is highly similar to and has no clinically meaningful differences from the biopharmaceutical reference product already approved by the FDA. The biosimilar must have undergone rigorous testing and been shown to be “non-inferior” to the reference product in a randomized clinical trial in patients with at least one of the conditions for which the reference molecule is approved. The rationale behind the development of biosimilars is to offer more affordable treatment options to patients and, thus, for a comparable overall investment by the healthcare system, treat more patients with a given disease.

Biosimilars are different from generic drugs as the latter are small molecules that are structurally identical to the original compound. Biosimilars are complex proteins that have the same amino acid structure and have no clinically meaningful differences in biologic activity, including both pharmacokinetic (exposure) and pharmacodynamics (response), as well as efficacy and safety. Indeed, biosimilars are officially approved versions of original reference products, and can be manufactured when the original product’s patent expires. The FDA maintains a page on its website providing information on biosimilars for patients (http://bit.ly/2gBjPzY).

The current list of approved biosimilar products for use in patients with inflammatory arthritis, including rheumatoid arthritis, axial spondyloarthritis (formerly known as ankylosing spondylitis) and psoriasis/psoriatic arthritis, along with the original compound is shown in the Table.

infliximab-dyyb (Inflectra)	Infliximab (Remicade)
etanercept-szzs (Erelzi)	Etanercept (Enbrel)
adalimumab-atto (Amjevita)	Adalimumab (Humira)
infliximab-abda (Renflexis)	Infliximab (Remicade)
adalimumab-adbm (Cyltezo)	Adalimumab (Humira)

The American College of Rheumatology (ACR) issued a position paper on biosimilars in 2016 (https://www.rheumatology.org/Portals/0/Files/Biosimilars-Position-Statement.pdf). Briefly, “The" ACR agrees with the need for more cost effective biologic therapeutics and believes that biosimilars offer hope of cost reduction if physicians and patients can be sufficiently reassured of their efficacy and safety through rigorous scientific study of these products.” A recent consensus statement by the Task Force on the Use of Biosimilars to Treat Rheumatological Diseases (Kay J, et al. Ann Rheum Dis 2017;0:1–10. doi:10.1136/annrheumdis-2017-211937) endorsed eight recommendations including that “[n]o switch to or among biosimilars should be initiated without the prior awareness of the patient and the treating healthcare provider” and “[t]he availability of biosimilars must significantly lower the cost of treating an individual patient and increase access to optimal therapy for all patients with rheumatic diseases.” It is in the spirit of the latter statement, that the U.S. Bone and Joint Initiative wishes to inform the readers of this newsletter about the availability of biosimilars for treatment of inflammatory rheumatic diseases.

USBJI's Featured Member Organizations

American Academy of Orthopaedics Surgeons (AAOS)

OrthoInfo.org—the authoritative, trusted consumer website on bone and joint health—has a new design that is easier to navigate, access and view, the American Academy of Orthopaedic Surgeons (AAOS) announced November 15, 2017. OrthoInfo, which receives approximately 42 million page visits each year, provides more than 525 consumer articles, videos and interactive learning modules on symptoms, causes and treatment options for a broad range of musculoskeletal conditions. The website offers new illustrations and multi-media resources, is more optimally organized—by body part and popular topics—and the responsive mobile design makes viewing on a phone or table more convenient than ever.

"The new OrthoInfo empowers patients by helping them to better understand their conditions, find answers to questions and prepare for surgical procedures-anytime, anywhere," said AAOS President William J. Maloney, MD. "In addition, OrthoInfo is an important in-office resource and tool for our orthopaedic surgeon members, reflecting the Academy's commitment to providing optimal patient care.

“Our goal is to provide clear and accurate orthopaedic information in a way that patients, families and caregivers can easily understand,” said OrthoInfo Editor-in-Chief Stuart J. Fischer, MD. “We have added new illustrations, animations and videos to supplement the articles. The new responsive design will allow viewers to access orthopaedic information on many platforms—desktop, mobile, table and smart TV.”

At OrthoInfo.org, visitors can:

Enlarge X-rays, images, illustrations and photographs.
Share content and resources via email or social media.
Easily search for and access related articles, patient stories and other multimedia resources, providing visitors with a complete picture of their musculoskeletal condition, treatment and/or recovery.

For orthopaedic surgeons, physician assistants, nurses and other health care staff. OrthoInfo is a valuable took in aiding and enhancing patient care. The site offers images, articles and learning modules on a variety of topics-from arthritis and sports injuries, to preparing for surgery, pain management, and recovery-that can be viewed on a laptop, phone or tablet during the office visit. Staff also can email specific OrthoInfo links, or direct patients and caregivers to the website, for more information.

All OrthoInfo articles and resources are rigorously reviewed by orthopaedic surgeon experts, ensuring that content is accurate and reflective of the latest orthopaedic research, and treatment and care standards. Many of the articles and resources are available in Spanish and Portuguese.

American Board of Orthopaedic Surgery (ABOS)

ABOS Survey Results

By David F. Martin, MD, ABOS Executive Medical Director
Almost 11,000 American Board of Orthopaedic Surgery (ABOS) Diplomates participated in a recent Maintenance of Certification (MOC) survey that the ABOS conducted with RTI International. The ABOS appreciates each response and RTI was amazed that we had over a 60% response rate to the survey. This article will give you a snapshot of the results and discuss the next steps being considered by the ABOS.

While the survey had many questions, the one of most interest to many orthopaedic surgeons was, “Of the four MOC Part III Knowledge Assessment options, which one would you prefer to complete when your next Knowledge Assessment is due?” Two current options (Computer and Oral Examinations) and two possible future options (Longitudinal Assessment and Virtual Practice Assessment) were provided. Here are the results for Knowledge Assessment preferences of ABOS Diplomates:

Computer-Based Examination 41.2%
Longitudinal Assessment 39.8%
Virtual Practice Assessment 14.2%
Oral Recertification Examination 3.9%

As you can see, the top two preferences of ABOS Diplomates responding to the survey were Computer-Based Examination and Longitudinal Assessment at approximately 40% preference for each option. This distribution remained consistent among subgroups of respondents. There was a slightly higher level of support for a Longitudinal Assessment program for those who had earned their initial Certification in the last decade as compared to those who have participated in several recertification cycles. However, both groups showed significant interest in both a newly developed Longitudinal Assessment program and the current Computer-Based Practice-Profiled Examinations.

A similar question was asked about Diplomates’ comfort level with each of the Knowledge Assessment options. Most Diplomates indicated that they were at least moderately comfortable with each of the assessment options. Here is how comfortable (cumulative of responses of “moderately”, “very”, or “extremely”) Diplomates felt with each option:

Computer-Based Examination        91.4%
Longitudinal Assessment                83.6%
Virtual Practice Assessment           71.2%
Oral Recertification Examination 64.8%

Based on the results of the survey, the ABOS Board of Directors voted unanimously to have the ABOS MOC Committee formulate a plan to add a Longitudinal Assessment program as an alternative Knowledge Assessment option in the ABOS MOC Program. The MOC Committee will work with RTI to solicit input from Diplomates on the design of the ABOS Longitudinal Assessment process.

The Board has also tasked the ABOS MOC Committee to continue to investigate the Virtual Practice Assessment program. This is a program that involves a virtual practice evaluation, performed without the examinee present at the time of the assessment. The ABOS piloted the Virtual Practice Assessment during the 2017 Oral Examination Sessions held in July of 2017. The feedback from Oral Examiners was positive and based on the comments that we received, the ABOS is looking to refine and implement this program with another round of testing being carried out next July. If this program is found to be valid and feasible then it could potentially be launched in the next two to three years.

More than 5,800 ABOS Diplomates left comments on the survey. The ABOS is reviewing these comments and will provide a full report on the survey to our Diplomates in the coming months.

The ABOS will continue to partner with RTI to help us conduct surveys and consider forming focus groups of Diplomates to gain further input. The ABOS values the feedback we receive from our Diplomates and we look forward to continuing to work with them. With their help and input, we look forward to continuing to improve ABOS programs and processes to minimize burden and add value to ABOS Board Certification.

American Chiropractic Association (ACA)

American Chiropractic Association Releases Choosing Wisely® List of Tests, Procedures to Question

The American Chiropractic Association (ACA) released a list of five tests and procedures commonly ordered but not always necessary in chiropractic care. The list is part of the Choosing Wisely® campaign, an initiative of the ABIM Foundation and Consumer Reports®, which encourages conversations between patients and their clinicians about what care is really necessary and appropriate.

To date, nearly 100 health care groups have participated in the Choosing Wisely® campaign to create lists identifying specific tests and procedures that evidence indicates may not always be necessary. ACA is the first chiropractic group to join the campaign.

“The ACA and its members support evidence-informed care as well as shared decision-making between patients and their doctors. For this reason, we are proud to partner with Choosing Wisely® in this effort to encourage important conversations between patients and chiropractors that may reduce unneeded or overused services, yielding the best possible patient care," said ACA President David Herd, DC.
ACA’s list features the following five recommendations:

In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain.
Do not perform repeat spinal imaging to monitor patients’ progress.
Avoid prolonged or ongoing use of passive or palliative physical therapeutic modalities for low back pain disorders unless they support the goal(s) of an active treatment plan.
Do not provide long-term pain management without psychosocial screening or assessment for possible related psychological disorders, most notably depression and anxiety.
Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.

ACA’s Choosing Wisely® recommendations were developed by the association's Committee on Quality Assurance and Accountability, and approved by the ACA Board of Governors, after an extensive search of the most current scientific evidence on management and treatment options and months of careful review and consideration.

“Conversations about what care patients truly need is a shared responsibility among all members of the health care team,” said Richard J. Baron, MD, president and CEO of the ABIM Foundation. “The American Chiropractic Association’s Choosing Wisely® list will help chiropractors across the country engage their patients in a dialogue about what care is best for them, and what we can do to reduce waste and overuse in our health care system.”

Using a non-drug approach, chiropractors focus on disorders of the musculoskeletal system, most often treating complaints such as back pain, neck pain, pain in the joints of the arms or legs and headaches. Widely known for their expertise in spinal manipulation, chiropractors are also trained to recommend therapeutic and rehabilitative exercises, as well as to provide nutritional, dietary and lifestyle counseling. According to a recent Gallup survey, about 35 million Americans visit a chiropractor each year.

To view details about ACA’s list of recommendations, visit www.acatoday.org/ChoosingWisely. To learn more about the Choosing Wisely campaign and to view all lists, visit www.ChoosingWisely.org.

National Association of Orthopaedic Nurses (NAON)

Throughout 2017, the National Association of Orthopaedic Nurses (NAON) worked to analyze and improve numerous aspects of orthopaedics. Since the last association update in July, we released new products, hosted a successful inaugural event, and provided tremendous networking opportunities for Nurse Navigators.

Releasing New Products
The brand new Orthopaedic Pain Management Review Course was launched in September. This course tests your management knowledge and provides the most up-to-date information on managing pain in orthopaedic patients. The 2017 revision is streamlined into three sections: In-depth Overview of Pain Management in Relation to Orthopaedics; Pharmacology Review; and Medication Administration and Patient Safety Considerations for Orthopaedic Patients. Participants who successfully complete this course are awarded 3.6 Category A Contact Hours as well as Pharmacology Hours.

A Successful Inaugural Event
In October, NAON hosted its first ever Orthopaedic Symposium in Rosemont, IL. Over 250 orthopaedic professionals attended this two-day event filled with educational sessions, informative panels, and hands-on labs. With additional support of numerous exhibitors and sponsors, the event was a tremendous success. We would like to thank everyone who attended for contributing towards a fruitful inaugural event.

Networking with Nurse Navigators
Every month, NAON’s Director of Education, Tandy Gabbert, MSN, RN, ONC, leads an informational networking call for a network of nurse navigators in multiple settings. During this call, various topics ranging from developing a mentor program to implementing best practices for outpatient joint replacement patients are discussed. Since its inception earlier this year, the group has grown to include over 100 individuals who are interested in learning more about the navigator role and how it functions in various settings.

NAON has had a very busy – and very successful – year thus far. We look forward to continuously supporting orthopaedic nurses in their diverse roles as we end 2017 and head in to 2018.

Orthopaedic Research & Education Foundation (OREF)

Study in JBJS Examines Impact of OREF Grants on NIH Funding

A study published in the August 16^th issue of The Journal of Bone and Joint Surgery (JBJS) concluded that investigators who received an OREF grant were more likely to be successful in applying for funding from the National Institutes of Health (NIH) than were other investigators. The study, “The Relationship Between OREF Grants and Future NIH Funding Success,” analyzed data for OREF grants awarded between 1994 and 2014.

The authors calculated an overall NIH funding rate of 22.3% for OREF grant recipients versus an average national rate of 18% for other NIH applicants. OREF Career Development Grant recipients achieved a conversion rate of 46.3%, far surpassing the national rate.
Researchers from certain subspecialties, including arthroplasty, sports medicine, oncology, trauma and pediatrics, were more likely to achieve both OREF and NIH funding.

The authors concluded that, “Grants awarded by the OREF are not only important for supporting orthopaedic surgeons during the years they are funded, but also achieve their purpose of identifying and supporting young researchers with the Career Development Award, leading to an NIH funding rate that is nearly triple the 18% national average of successful NIH funding applications.”

To read more about the study and its findings, please see the following resources.
Abstract
Selected study highlights
Commentary by John J. Callaghan, MD

Orthopaedic Research & Education Foundation (OREF)

OREF awards $800,000 grant honoring James R. Urbaniak, MD to Christopher L. Mendias, PhD, of Hospital for Special Surgery (HSS)

Dr. Mendias received the OREF Clinical Research Grant in Cellular Therapy in Honor of James Urbaniak, MD, which provides funding for clinical research to advance breakthroughs in adult stem cell therapies. Dr. Mendias is an associate scientist at HSS in New York.
The study, SVFC Therapy to Improve Rotator Cuff Tears: A Phase II Clinical Trial, will examine the ability of stromal vascular fraction stem cells to enhance the regeneration of musculoskeletal tissues, and seeks to determine if autologous stem cell therapy can improve outcomes for patients with chronic rotator cuff tears who undergo surgical repair.

Funding for the grant, which is the largest in OREF’s history, was provided by generous support from individual donors, including many of the residents and fellows who trained under Dr. Urbaniak and who have contributed to the OREF James R. Urbaniak, MD Mentor campaign, and by the National Stem Cell Foundation (NSCF).

OREF President David G. Lewallen, MD, expressed his gratitude to the many donors who contributed to the OREF James R. Urbaniak, MD Mentor Campaign, which has raised over $1 million, including gifts of approximately $700,000 from more than 80 orthopaedic surgeons. “OREF’s origins are firmly rooted in the philosophy that the orthopaedic community must come together to advance our knowledge of musculoskeletal diseases and injuries. We are pleased that through the generosity of these donors, OREF is able to provide funding for research which may provide improved quality of life for millions of patients suffering from chronic rotator cuff tears.”

Visit www.oref.org/grants for more information about OREF’s grant programs.

Regenerative Biomaterials for Joints: From Bench-to-Bedside-to-Bench

Dr. Blanka Sharma is an Assistant Professor of Biomedical Engineering at the University of Florida, and an Alumna of the USBJI Young Investigator Initiative. Dr. Sharma’s research focuses on the development of orthopedic biomaterials and targeted drug delivery systems. The research in her laboratory is supported by the Florida Department of Health, the National Institutes of Health, and the National Academies Kecks Futures Initiative.

Blanka Sharma, PhD

A long and windy road across disciplines and sectors.

My career path is somewhat unusual, having worked in multiple fields in both academia and industry. My undergraduate training was in Chemical Engineering and I spent some time working in the petroleum industry before deciding to pursue my PhD in biomedical engineering. Intrigued by the tissue engineering field, my doctoral work focused on cartilage tissue engineering and stem cells. I developed hydrogels to guide stem cell chondrogenesis and to mitigate fibrous tissue growth in cartilage lesions. This technology was transferred to a start-up company, where I served as Director of Research for several years and continued to develop the technology up to first-in-man clinical studies. This bench-to-beside experience reinforced to me how fundamental and applied research leads to therapies that impact the lives of patients, and shaped many of the research questions I ask today. Though I enjoyed the start-up environment, I missed the freedom to explore more fundamental scientific questions, and felt an academic career would be more rewarding long-term. To transition back to academia and explore a new field, I pursued a postdoctoral fellowship in cancer nanomedicine at the Cleveland Clinic. There, I worked on a new approach for targeting drug and gene delivery systems to tumors to improve the efficacy and minimize systemic toxicity of cancer therapeutics.

I am now redirecting what I learned about tumor targeting into designing drug delivery systems that target specific cells and disease pathways within the osteoarthritic joint. As there is no monotherapy for cancer – similarly, a complex disease like OA is unlikely to be effectively treated by blocking a single regulator of the disease. Our long-term goal is to develop a whole-joint OA treatment strategy focused on targeting of multiple disease mechanisms in multiple locations throughout the joint. Our current research aims to develop nanoparticles that can localize chondroprotective cues to cartilage and immunomodulatory cues to synovial macrophages, to simultaneously protect the cartilage and prevent chronic inflammation in the OA-susceptible joint. Interestingly, our studies so far have found that the synovial fluid properties and the disease state of the joint have a profound affect on how nanoparticles interact with different cells and tissues within the joint, ultimately affecting their biodistribution. This work has revealed underappreciated challenges of targeted intra-articular drug delivery, which has led us to new strategies in drug carrier design.

USBJI Young Investigator Initiative

The USBJI YII has been invaluable in many ways. An important piece of advice that I seized from the first workshop was that the key to successful grant writing was time management – something I struggled with in the initial years of my faculty position given all the new and various demands on my time. I appreciated the detailed feedback I received from my mentors and the mock study panelists, who exposed missed opportunities in my research proposal. Specifically, there were unique disease mechanisms and joint structure-function relationships that could be obtained through our work that I had not realized. With their critiques, I was able to write a more compelling R01 proposal. Importantly, their advice enabled me to approach our work in a new way that could have an even greater impact on the OA field.

Global Alliance for Musculoskeletal Health (GMUSC) Annual Meeting 2017, Berlin, Germany - WHO Healthy Aging Framework / WHO Integrated Care for Older People (ICOPE)

The GMUSC Annual Meeting took place October 22-23, 2017 in Berlin, Germany, in conjunction with the World Health Organization (WHO). The meeting was sponsored by the German Ministry of Health. The theme of the meeting was MSK Care for Healthy Aging, and for part of it GMUSC and WHO delegates met to discuss the WHO Healthy Aging Framework and its program Integrated Care for Older People (ICOPE). Following the meeting GMUSC issued a Call to Action on the Importance of MSK Health for Healthy Aging.

The World Report on Ageing and Health proposes prioritizing interventions that optimize older people’s physical and mental capacities over their life course, their Intrinsic Capacity, instead of trying to manage an array of diseases and treat specific symptoms in a disjointed fashion. In assessing a person’s Intrinsic Capacity the aim is to improve their Functional Ability. This will require a change in the way health and social services are organized, and greater integration within the health system and between health and social-care services.

Intrinsic capacity is defined by WHO as the combination of the individual’s physical and mental (including psychosocial) capacities. Functional ability relates to the combination and interaction of an individual’s intrinsic capacity and the characteristics of the environment he or she inhabits.
As people age, their health issues tend to become more chronic and complex, and multi-morbidity becomes the norm rather than the exception. Physical, sensory and cognitive impairments become more prevalent and older people can develop complex health states, such as frailty, urinary incontinence and an increased risk of falling.

The GMUSC intends to continue to work with the WHO on this topic, and in support of that work has created six Task Forces, on Education, Fragility Fractures, Pediatrics, Research, Surveillance, and National and Regional Groups. USBJI Members are invited to email usbji@affinity-strategies.com if they are interested in naming representatives to these Task Forces. The USBJI is the US arm of GMUSC.

Dr. Edward Yelin elected to GMUSC International Coordinating Council

Edward Yelin, PhD, MCP, Professor of Medicine and Health Policy at the University of California – San Francisco, and Co-Chair of the USBJI Steering Committee for The Burden of Musculoskeletal Diseases in the United States (BMUS) has been elected to the International Coordinating Council of the Global Alliance for Musculoskeletal Health (GMUSC), represented in the US by the USBJI.

Help your community raise awareness about bone and joint health

The new year is an excellent time to educate patients and their family, friends and support networks on how to manage and take control of their bone and joint health. The USBJI works with communities to raise awareness and understanding of the advances that have and continue to be made to lessen pain, improve mobility, and restore function for those who live with bone and joint conditions and pain through the Experts in Arthritis and Fit to a T programs.

Experts in Arthritis is a free patient education program for people with arthritis and people who care about them. Arthritis and other rheumatic conditions are the second most common musculoskeletal disease among adults in America. The program offers people with arthritis the opportunity to be better informed about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis. Other forms of arthritis can be incorporated, based on need.

Fit to a T is a free patient education program to educate both men and women about fracture prevention, assessing their risk for fracture and osteoporosis, and how to prevent bone loss and a fragility fracture, particularly secondary fractures. This education program is called “Fit to a T” because the T-score is the measure of a person’s bone density and susceptibility to fracture.

Help patients take control of their bone and joint health when you present or host these free public education programs on arthritis and/or fracture prevention and osteoporosis. Each program features a PowerPoint presentation, handout materials and a question and answer period. All materials are supplied free of charge and USBJI will work with you to promote program sessions and provide planning support.

Visit www.ControlArthrits.org or www.Fit2T.org to learn more and to view entertaining whiteboard videos, available in English and Spanish, that encapsulate the messages for each program. Share these videos by adding the links to wellness pages and download to share in your community to encourage healthy lifestyle changes and to raise awareness about bone and joint health.

Call for Applications -January 15 Deadline - Young Investigator Initiative Grant Mentoring and Career Development Program

The next deadline for young investigators to apply for the Young Investigator Initiative Grant Mentoring and Career Development Program is January 15, 2018.

The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are dedicated to increasing research of musculoskeletal diseases. To keep pace with the high and increasing burden of these diseases, a higher level of research performed by young investigators in the musculoskeletal diseases is required, and future levels of research assured. This is particularly important given the current environment for research funding, and academic careers. In response, the Young Investigator Initiative is a grant mentoring and career development program providing early-career investigators an opportunity to work with experienced researchers in our field to assist them in securing funding and other survival skills required for pursuing an academic career.

To date 202 participants (55%) have successfully obtained $270 million in grants for 1,066 new musculoskeletal research studies. Participants consider this program instrumental to their success. They rate highly the one-on-one mentoring with experienced researchers, the opportunity for inter-disciplinary and peer-to-peer exchange, and collaborations established during workshops.

This grant mentoring and career development program is open to promising junior faculty, senior fellows or post-doctoral researchers nominated by their department or division chairs seeking to pursue a career in clinical or basic research. It is also open to senior fellows or residents that are doing research and have a faculty appointment in place or confirmed. Basic and clinical investigators, without or with training awards, are invited to apply. Investigators selected to take part in the program attend two workshops, 12-18 months apart, and work with faculty between workshops to develop their grant applications. The Spring 2018 workshop is scheduled to take place on April 6-8, 2018, in Rosemont (Chicago), Illinois. The unique aspect of this program is the opportunity for attendees to maintain a relationship with a mentor until their application is funded.

For more about the program and detailed application instructions, please refer to www.usbji.org/programs/yii.

Acknowledgements

We would like to thank the following for their support of USBJI programs during 2017.

You are here

December 2017

In This Issue

Calendar of Events

Biosimilars for Patients with Inflammatory Arthritis

American Academy of Orthopaedics Surgeons (AAOS)

American Board of Orthopaedic Surgery (ABOS)

American Chiropractic Association (ACA)

National Association of Orthopaedic Nurses (NAON)

Orthopaedic Research & Education Foundation (OREF)

Orthopaedic Research & Education Foundation (OREF)