Alexander Vaccaro explains the development of the AOSpine Classification Systems, shares some tips on OR productivity, and why he decided to get an MBA.

 

What is the background of the development of the AOSpine Classification Systems and how did you get involved in the project?

For many years AO had the most popular classification system in the world for thoracolumbar fractures: the Magerl system, while the Americans favored their own, descriptive classification, called the Denis classification. I always used the Denis system but I became interested in the AO classification because it is very logical in the way it uses the alphabet to place fractures in silos: A compression, B distraction C translation injuries.

 

In the early 2000s, a group of famous surgeons from around the world synthesized the world's literature and came up with the TLICS system.

Although both Magerl and TLICS are well-known schemes to describe thoracolumbar fractures, no injury classification system has really achieved universal adoption.

 

The AO then decided to look at it again and to develop a more widely accepted, comprehensive yet simple classification system.

 

I was invited to the group by my former mentor, Dr. Cumhur Öner (current Chairperson of the AOSpine Knowledge Forum Trauma Steering Committee). We all put our minds together and came up with the present-day AOSpine Classification System.

 

We started with the thoracolumbar classification in 2013, then we adapted the new system also to the cervical spine and took it even further into a sacral pelvic fracture classification. We are currently working on the classification for the upper cervical spine.

 

What is the difference between the AOSpine Classification System and the Magerl/TLICS method?

The system takes the principles of the AO ABC system and allows for simple grouping into various morphologic categories for ease of description. We can "The AOSpine Thoracolumbar Classification System combines the best of the Magerl ABC method and the TLICS method, which is phenomenal. This is now potentially the most user-friendly and reliable classification system around the world."now utilize this for registry creation. The classification system for the thoracolumbar spine has reduced the subdivisions of the Magerl system from 53 down to only 5 As, 3 Bs and 1 C.  The new classification also has a special focus on the patient's neurology along with modifiers.

 

 

What was the most difficult classification system to come up with so far, and which one was the easiest?

The upper cervical spine classification is proving the most challenging because every part is so different and it's hard to find a logical use of A, B, and C. The Atlas or C1 is so different than the C2 body or the interbody spaces and the ligaments are so different compared to other parts of the spine.

 

The easiest system to develop was the thoracolumbar classification, followed by the sacral classification and then cervical classification.

 

How does an international AOSpine Knowledge Forum collaboration of this scale work in practice? Is it easy to find consensus?

If you want to get a task like this done, you have to spend a few hours on it every week, then you have to get away from it and give it to someone else to kick around and get their feedback. Currently, we have someone on our team assigned to the classification full time. We discuss everything with the Knowledge Forum Committee, we argue, agree, disagree, argue some more… It's a bit like trying to get something past Congress.

 

There are people of different nationalities and cultural backgrounds working in the Knowledge Forum group. How does this reflect in the work of the Knowledge Forum and what were your biggest learnings?

"My biggest lesson learned is that you have to check your ego at the door. You're not right, you're not wrong, it doesn't matter how many papers you've published, you have to get people to see your vision and then get consensus and buy in by everyone."It's great to have different perspectives, but it's also challenging. Evidence-based medicine is predicated on the values and cultures of the population, so what's desired for someone in one country may not be acceptable somewhere else. For example, certain cultures are more aggressive in the sense that they feel surgery in certain fractures is optimum, while another culture may be more wary of the risk of surgical complications and favor a nonoperative approach. It can be hard to get everyone on the same page and it takes a lot of discussion and debate to get to the final solution.

 

What achievement in your career are you most proud of?

I recently received the position of Cavalier or the order of the Italian star from the Italian Government, which is given to someone who has worked to promote international co-operation between Italy and their country.

 

I'm proud of that achievement but what I'm most excited about is the opportunity to develop classifications in spine with some of the brightest medical minds. It's great to see external research papers which show that our work is validated and applicable.

 

You once said in an interview that the most difficult achievement in your career so far was your MBA, why is that?

As the president of the Rothman Institute, I have to ensure that our business model makes sense from a financial perspective. We're quite big now with a geographic territory ranging from New York, North and South Jersey to "Looking back, when you're a student taking organic chemistry, advanced physics, and calculus and staying up all night studying you mistakenly believe the humanities and business students have it easy. I thought this until I got my MBA."Southeastern Pennsylvania. In August, the U.S. News and World report ranked us 4th in the nation for Orthopaedic care. I enrolled in the MBA because I wanted to understand the business of medicine, and how business people think, so the Rothman Institute could help deliver valued care to a greater population of patients.

 

 

You have a very distinguished career as a surgeon, and you've served as the president of the Rothman Institute and the Chairman of Orthopaedics at Thomas Jefferson University since 2014. How does your typical work day look?

"Before I became President, I wasn't finished in operating theatre until between 4-6pm, but through a team based approach studying productivity and efficiency in the OR, we discovered that if you cut skin at 6 am instead of 8 am the surgery is often quicker and more efficient with the same degree of safety."I usually get up at 4.30am and after exercising have my first conference call at 5.30am. I do 4-5 hours office work a day, and I operate three days a week, usually 5-6 spine cases per day. I start my ORs at 6 am, and do a staggered room, so when I finish one surgery the next is ready go, without a break.

 

That's because everyone is focused and there are no interruptions. I usually finish my meetings around 8:30 pm at night after coming home for dinner with the family from 6-7pm. I take the weekends off, except for writing papers, but I can do that early in the morning before my kids wake up. I then have the weekend to dedicate to my family.