COA Bulletin #116 Spring 2017 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Spring / Printemps 2017 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

The official publication of the Canadian Orthopaedic Association Publication officielle de l’Association Canadienne d’Orthopédie

BULLETIN

116

Clinical Feature:

Update on Idiopathic Scoliosis.... See page 28 Rubrique clinique :

Mise à jour sur la scoliose idiopathique........................ Page 28

Business Meeting Showcases COA Initiatives While Engaging Member Feedback � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11 T. he Role of Biologic or Synthetic Enhancement of Soft Tissue Healing in Orthopaedic Sport Medicine� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 19 Intimate Partner Violence: .What Canadian Orthopaedic Surgeons Need to Know! � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 40 Misons sur une vie sans douleur propulse la croissance des programmes de la Fondation� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 51

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Have you activated your online subscription? If youâ€™re an Associate or Active Member of the COA, you receive a complimentary online subscription to The Bone & Joint Journal (formerly JBJS Br) and Bone & Joint 360

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Follow us on twitter @BoneJointJ and @BoneJoint360 The British Editorial Society of Bone & Joint Surgery. Registered Charity No. 209299

Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 116 - Spring / Printemps 2017 COA / ACO Peter B. MacDonald President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

ADVERTISING SPACE AVAILABLE The COA Bulletin, the official journal of the Canadian Orthopaedic Association, has been declared by our membership as one of the most valuable membership services. By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists. Don’t miss out on this kind of opportunity! Become a part of our publication cycle by contacting Cynthia Vezina at the COA Office - Tel: (514) 874-9003 ext. 3 or e‑mail: cynthia@canorth.org and details will be forwarded to you.

ESPACE PUBLICITAIRE Le Bulletin, publication officielle de l’Association Canadienne d’Orthopédie (ACO), a été désigné par nos membres comme l’un des services les plus utiles que nous leur offrons. Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays. Ne manquez pas cette occasion! Pour faire partie de notre cycle de publication, communiquez avec Cynthia Vezina, au bureau de l’ACO, au 514-874-9003, poste 3, ou à cynthia@canorth.org.

Participation and Engagement Peter B. MacDonald, M.D., FRCSC President, Canadian Orthopaedic Association

he last two months have been a busy time for the COA. The MidWinter Meeting held in Toronto in early January brought together several of our committees as well as the Executive and Board of Directors for a full day of productive meetings. Participation and engagement from the various committee chairs and members was excellent. We are very grateful for the time, effort and contributions that our volunteer committee members dedicate to the Association throughout the year. The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, automne, hiver par l’Association Canadienne d’Orthopédie, 4060, rue Ste-Catherine Ouest, Suite 620, Westmount, Québec H3Z 2Z3. Le Bulletin est distribué aux membres de l’ACO, aux gouvernements, aux hôpitaux, aux professionnels de la santé et à l’industrie orthopédique. Veuillez faire parvenir tout changement d’adresse à : cynthia@canorth.org

Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the author’s personal observations and do not imply endorsement by, nor official policy of the Canadian Orthopaedic Association. Legal deposition: National Library of Canada ISSN 0832-0128

À moins que le contraire ne soit spécifié, les opinions exprimées dans cette revue sont celles de leur auteur et ne reflètent aucunement un endossement ni une position de l’Association Canadienne d’Orthopédie. Dépot légal : Bibliothèque nationale du Canada ISSN 0832-0128

COA Bulletin ACO - Spring / Printemps 2017

Your COA / Votre association

(continued from page 5)

Meeting discussions surrounded areas including government advocacy, the employment situation and the economics of medicine in Canada as it currently stands. On the advocacy front, a meeting was arranged on January 12th, 2017 with senior policy advisers to the federal Minister of Health. We have engaged a government relations consultant to contribute to the efforts and projects being led by Trinity Wittman, the COA’s Manager of Advocacy and Development, as well as our CEO, Doug Thomson.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 16 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 40

During the meeting with the federal policy advisors, we referred to the COA’s Position Statement on Access to Orthopaedic Care and the importance of offering patients access to timely, appropriate orthopaedic care, thereby avoiding MSK disability and discomfort.

Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

The COA recognizes that there are many successful models of care across Canada that have demonstrated efficient, costeffective methods for government monies to increase access to care on many fronts. Some of the innovations that were cited in the meeting include better training and more information for primary care physicians resulting in more appropriate referrals to orthopaedic specialists, better utilization of allied health providers, digital innovation and technology, use of registries to track performance, and central intake models. Patient satisfaction is also an important outcome, with reduction in wait times and access to quality care often resulting in a more positive experience for orthopaedic patients.

role. As Chair, Dr. Grant brings along two years of experience as a member of this committee and will be reaching out to the membership for input on reinforcing the COA’s benefits and value programs.

The advisors were receptive to the idea of cost-neutral innovations, but noted that the federal government is hesitant to commit more financial resources to MSK care, although there have been precedents in the past to target transfer of payments for certain programs. They are now opting to approach individual provincial governments with similar models and arguments to help advance this cause. A summary of the discussions with the federal policy advisors can be found on page 44 of the Bulletin.

We would like to encourage all of you to make plans to attend the Annual Meeting in Ottawa this June 15-18. Hotel space is filling up quickly so you are encouraged to make reservations and travel plans as soon as possible. Lastly, if you have not yet renewed your COA membership, please proceed to do so and take advantage of the reduced registration fees by registering for the Annual Meeting by June 9.

Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 52

At this point in time, with the proposed restrictions on entering the United States and the obviously ever changing political situation, we would like to reaffirm the fact that the COA recognizes that its membership is a culturally diverse group. We stand for basic Canadian values including inclusiveness and recognizing that many of our members come from various cultural backgrounds.

We look forward to seeing you in Ottawa.

On another note, I would like to officially welcome Dr. John Grant as our Membership Committee Chair. We also would like to thank Dr. Dominique Rouleau for her previous work in this

Annual Meeting Moments

Look out for these round red buttons throughout this edition of the COA Bulletin featuring information about the upcoming COA, CORS & CORA Annual Meeting being held June 15-18 in Ottawa.

COA Bulletin ACO - Spring / Printemps 2017

CLICK ON EACH BUTTON TO LEARN MORE!

Your COA / Votre association

Participation active Peter B. MacDonald, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

es deux derniers mois ont été très occupés à l’ACO. À la réunion d’hiver, organisée à Toronto début janvier, plusieurs comités, de même que le Comité de direction et le conseil d’administration, ont tenu des réunions fructueuses toute la journée. Les présidents et les membres des comités ont été très actifs. Nous sommes très reconnaissants aux membres bénévoles des comités pour le temps, les efforts et les idées qu’ils donnent à l’ACO l’année durant. Les discussions ont porté sur divers sujets, dont les relations gouvernementales, l’emploi chez les orthopédistes et l’économie de la médecine au Canada à l’heure actuelle. Sur le plan de la défense des droits et intérêts, nous avons tenu une rencontre le 12 janvier 2017 avec des conseillers en politiques publiques du bureau de la ministre fédérale de la Santé. Nous avons retenu les services d’une spécialiste en relations gouvernementales, qui vient appuyer les activités de Trinity Wittman, directrice du développement et des activités de défense des droits, et de Doug Thomson, notre directeur général. Pendant la réunion avec les conseillers en politiques publiques du fédéral, nous avons fait référence à l’énoncé de position de l’ACO sur l’accès aux soins orthopédiques au Canada et souligné l’importance d’offrir un accès à des soins orthopédiques appropriés en temps opportun afin d’éviter les incapacités et l’inconfort. L’ACO sait qu’il y a au pays de nombreux modèles qui utilisent de façon efficace et judicieuse les fonds publics pour accroître l’accès aux soins. Parmi les innovations citées à la réunion, mentionnons une meilleure formation et davantage d’information pour les médecins de première ligne, ce qui entraîne un aiguillage plus précis vers les orthopédistes, une meilleure utilisation des professionnels des soins de santé connexes, des innovations et des technologies numériques, le recours aux

Infobulles sur la Réunion annuelle

Les petites pastilles rouges dans ce numéro du Bulletin de l’ACO fournissent des renseignements sur la Réunion annuelle de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO), qui aura lieu du 15 au 18 juin, à Ottawa.

registres pour assurer le suivi du rendement et les systèmes centraux d’admission. La satisfaction des patients est aussi un résultat important, la réduction des temps d’attente et l’accès à des soins de santé de qualité se traduisant souvent par une expérience plus positive pour les patients en orthopédie. Les conseillers ont été réceptifs à l’idée des innovations sans conséquence sur les coûts, mais ont souligné que le gouvernement fédéral est réticent à allouer davantage de ressources aux soins de l’appareil locomoteur, bien qu’il y ait des précédents de transferts ciblés. Ils souhaitent maintenant proposer à chaque gouvernement provincial des modèles et arguments semblables pour promouvoir le dossier. Un résumé des discussions avec les conseillers en politiques publiques du fédéral est fourni à la page 44. Changement de sujet : j’en profite pour souhaiter la bienvenue au Dr John Grant à la présidence du Comité d’adhésion, et remercier la Dre Dominique Rouleau pour son travail à ce poste. Fort de ses deux années de service au sein du Comité, notre nouveau président communiquera avec les membres pour connaître leurs idées sur les façons de rehausser les avantages et la valeur des programmes offerts par l’ACO. Dans la foulée des restrictions proposées aux visiteurs étrangers et de la volatilité manifeste de la situation politique aux États-Unis, l’ACO souhaite réaffirmer la diversité culturelle de ses membres. Nous adhérons aux valeurs canadiennes fondamentales, dont l’inclusion, et reconnaissons que beaucoup de nos membres sont issus de milieux culturels divers. Nous vous invitons tous à être des nôtres à la Réunion annuelle d’Ottawa, du 15 au 18 juin. Les chambres partent vite; nous vous conseillons donc de réserver la vôtre et de prévoir vos déplacements dès que possible. Enfin, si vous n’avez pas encore payé votre cotisation à l’ACO, nous vous prions de le faire d’ici le 9 juin pour profiter de la réduction des droits d’inscription à la Réunion annuelle. Au plaisir de vous voir à Ottawa!

CLIQUEZ DESSUS POUR EN SAVOIR PLUS!

COA Bulletin ACO - Spring / Printemps 2017

Your COA / Votre association

Improving Member Services with New Addition at COA Headquarters Cynthia Vezina Executive Director, Strategic Initiatives

e are pleased to introduce Helen Chrenowski as the newest member of the COA Team. Helen joined our staff in mid-January this year as the Association’s Coordinator of Membership Services & Affiliate Programs. She will work closely with the Membership Committee and Exchange Fellowships Committee as she supports and develops the COA’s various membership services, travelling fellowships and affiliate programs. Helen brings over 22 years of project management experience to the Association office. Prior to joining the COA, she worked as an independent consultant on a number of different initiatives, most recently establishing a corporate social responsibility program for a large international company. Her keen eye for detail, strong communications and interpersonal skills make her an excellent addition to the Association’s membership department. “I am delighted to join the COA Team and have the opportunity to work closely with our members and provide the exceptional value and experience that they have come to know and expect from our association. I am pleased to work alongside such a dedicated and talented team, and I look forward to collaborating with each of our members on the COA’s many initiatives and programs. Preparations for our Annual Meeting in June are well underway and I hope to meet each of you in person in Ottawa. Please feel free to stop by our onsite office to say hello. In the meantime, do

not hesitate to contact me if you have any questions or comments that you would like to share.” - Helen Chrenowski, Membership Services & Affiliate Programs Why You Need to Reach Helen: Membership Inquiries - You require assistance paying your membership dues or need to confirm if your membership is in good standing. - You need to update your membership profile with a new address or career change (eg. now in practice, on a fellowship). - You would like get some of your colleagues signed up as COA members. Travelling Fellowships and Affiliate Programs - You are interested in any of the travelling fellowship programs (ABC, NATF, CFBS, ASG). - You are a member of one of the COA’s Committees and have questions about an upcoming meeting or need to circulate communications to your committee members. - You are an invited keynote speaker at the COA’s Annual Meeting and have a question about your presentation. - You have a general inquiry about the COA, our membership services and benefits. How to Reach Helen: Helen Chrenowski can be reached at helen@canorth.org or 514 874-9003 x 6.

De meilleurs services aux membres grâce à un nouveau visage aux bureaux de l’ACO Cynthia Vezina Directrice générale, Initiatives stratégiques

ous sommes heureux de vous présenter Helen Chrenowski, nouvelle membre de l’équipe de l’ACO. Helen s’est jointe à l’équipe à la mi-janvier à titre de coordonnatrice des services aux membres et programmes affiliés de l’ACO. Elle travaille en étroite collaboration avec le Comité d’adhésion et le Comité des bourses de voyage pour soutenir et développer les différents services aux membres, les bourses de voyage et les programmes affiliés. Helen compte plus de 22 ans d’expérience en gestion de projets. Avant de se joindre à l’ACO, elle a été conseillère indépendante pour diverses initiatives, dont le développement d’un programme de responsabilité sociale pour une grande société COA Bulletin ACO - Spring / Printemps 2017

internationale. Son grand souci du détail, ses indéniables compétences en communications et son entregent en font une excellente recrue pour les services aux membres. « Je suis ravie de me joindre à l’équipe de l’ACO et de pouvoir travailler en étroite collaboration avec les membres afin de leur offrir une valeur exceptionnelle pour leur adhésion et l’expérience qu’ils attendent de notre association. Je suis heureuse de travailler avec une équipe de talent et fort dévouée, et j’ai hâte de collaborer avec chacun de nos membres dans le cadre des nombreux programmes et initiatives de l’ACO. Les préparatifs de la Réunion annuelle d’Ottawa, en juin, vont bon train, et j’espère avoir l’occasion de vous y rencontrer. Passez nous saluer à notre bureau sur place. D’ici-là, n’hésitez surtout pas à communiquer avec moi si vous avez des questions ou des commentaires pour nous. » – Helen Chrenowski, coordonnatrice des services aux membres et programmes affiliés

Your COA / Votre association

(suite de la page 8)

Raisons de joindre Helen : - Questions liées à l’adhésion - Si vous avez besoin d’aide pour le paiement de votre cotisation, ou encore si vous souhaitez confirmer que votre statut de membre est en règle. - Si vous devez mettre à jour votre profil en raison d’un déménagement ou d’un changement professionnel (p. ex. en exercice ou en formation spécialisée). - Si vous souhaitez que certains de vos collègues adhèrent à l’ACO.

Bourses de voyage et programmes affiliés - Si vous vous intéressez à l’une des bourses de voyage offertes : Bourse de voyage américano-britanno-canadienne (ABC), Bourse de voyage nord-américaine (VNA), Bourse de voyage canado-franco-belge-suisse (CFBS) et Bourse de voyage autrichienne-suisse-allemande (ASA). - Si vous êtes membre d’un des comités de l’ACO et avez des questions sur une réunion à venir ou besoin de transmettre des renseignements aux membres du comité. - Si vous êtes invité à donner une conférence à la Réunion annuelle de l’ACO et avez des questions à propos de votre présentation. - Si vous avez des questions générales sur l’ACO, les services aux membres et les avantages de l’adhésion. Coordonnées d’Helen : On peut joindre Helen Chrenowski à helen@canorth.org ou au 514-874-9003, poste 6.

The COA’s 2017 NATF Fellow Dr. Beeshma Ravi

Kelly A. Lefaivre BScH, MD, MSc (Epid), FRCSC Chair, COA Exchange Fellowships Committee Vancouver, BC

r. Beeshma Ravi of Toronto, Ontario has been selected as the COA’s 2017 North American Travelling Fellow (NATF). Dr. Ravi obtained his M.D. and completed his orthopaedic surgery residency at the University of Toronto. During his residency training, he enrolled in the university’s Surgeon Scientist Training Program through which he completed a PhD in clinical epidemiology and health-care research at the Institute of Health Policy, Management and Evaluation (IHPME). He then pursued subspecialty training in adult reconstruction at the Mayo Clinic in Arizona. Dr. Ravi’s clinical practice at the Sunnybrook Health Sciences Centre is focused on elective total joint arthroplasty (hip and knee), including complex primary and revision surgery. He

is Assistant Professor at the University of Toronto and has a strong commitment to clinical outcomes research. He has been a member of the COA since 2013 and is also a member of the Canadian Arthroplasty Society (CAS). Dr. Ravi will tour various centres in Canada and the US in October of this year along with four American fellows selected by the American Orthopaedic Association. Please join us in congratulating Dr. Ravi on this achievement.

Article submissions to the COA Bulletin are always welcome!

Les contributions au Bulletin de l’ACO sont toujours les bienvenues!

Contact: Cynthia Vezina Tel: (514) 874-9003 ext. 3 E-mail: cynthia@canorth.org

Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org COA Bulletin ACO - Spring / Printemps 2017

Your COA / Votre association

Keynote Speakers Deliver Messages on Teamwork, Innovation, Career Reflections and Evidence-based Practice at the 2017 COA & CORS Annual Meeting

Les conférenciers invités à la Réunion annuelle 2017 de l’ACO et de la SROC abordent les questions du travail d’équipe, de l’innovation, du parcours professionnel et de l’exercice fondé sur des données probantes

Find guest speaker bios in the ‘Program’ tab in the top menu at www.coaannualmeeting.ca.

Vous trouverez leur notice biographique sous « Programme » dans le menu principal à www.coaannualmeeting.ca.

Opening Ceremonies Guest Speaker – Milt Stegall Thursday, June 15, 17:30 Plenary Hall, Governor General 2&3, 4th Floor, Westin Hotel The Off-field Work that Fueled his Body of Work

Macnab Lecturer – Hani Awad Friday, June 16, 14:45-15:30 Plenary Hall, Governor General 2&3, 4th Floor, Westin Hotel Applications of 3D printing in Bone Tissue Engineering

R.I. Harris Speaker – Richard J. Hawkins

Conférencier aux cérémonies d’ouverture – Milt Stegall Le jeudi 15 juin, à 17 h 30 Salle plénière, salles Gouverneur général 2 et 3, 4e étage, hôtel The Westin La clé de ma réussite sur le terrain

Conférencier Macnab - Hani Awad Le vendredi 16 juin, de 14 h 45 à 15 h 30 Salle plénière, salles Gouverneur général 2 et 3, 4e étage, hôtel The Westin Des allogreffes aux échafaudages : Applications de l’impression 3D en ingénierie tissulaire osseuse

Conférencier R.I. Harris – Dr Richard Hawkins

Friday, June 16, 15:30-16:00 Plenary Hall, Governor General 2&3, 4th Floor, Westin Hotel

Le vendredi 16 juin, de 15 h 30 à 16 h Salle plénière, salles Gouverneur général 2 et 3, 4e étage, hôtel The Westin

The Journey, Orthopedics and Life

La vie et l’orthopédie sont une aventure

Presidential Guest Speaker – James G. Wright Saturday, June 17, 15:30-16:00 Plenary Hall, Governor General 2&3, 4th Floor, Westin Hotel It’s no Longer Okay to Say I Practice Differently than Everyone Else COA Bulletin ACO - Spring / Printemps 2017

Conférencier invité par le président – Pr James G. Wright Le samedi 17 juin, de 15 h 30 à 16 h Salle plénière, salles Gouverneur général 2 et 3, 4e étage, hôtel The Westin Il n’est plus acceptable de dire qu’on exerce différemment de tout le monde

Your COA / Votre association

Business Meeting Showcases COA Initiatives While Engaging Member Feedback Kishore Mulpuri, M.D. Secretary, Canadian Orthopaedic Association

his year’s Annual Business Meeting will take place on Friday, June 16 at 11:45 in Governor General 2/3 room on the fourth floor of the Westin Ottawa Hotel during the upcoming COA Annual Meeting being held in Ottawa. The Business Meeting is your opportunity to learn about the initiatives, projects and collaborations being developed by the COA leadership.

- Which policy resources are available? Learn more about the position statements and toolkits being developed by both the Standards Committee and Practice Management Committee. - What educational opportunities are being offered by the COA? Updates and improvements to the educational offerings available through the Annual Meeting and affiliate programs will be provided by the Continuing Professional Development (CPD) Committee. The program and planning chairs of the 2018 Annual Meeting from Victoria, BC will also be introduced. - What are my membership benefits? Find out how the Membership Committee is delivering the best value for your commitment. - Who will be the next COA President? The Nominating Committee will ask for your vote on who will be named the 74th President of the COA.

Add the Business Meeting to your calendars Friday, June 16 @ 11:45

- Which direction is the COA heading? The COA President will outline the main topics discussed by the Board of Directors and Executive Committee during their recent meetings. - What is the financial health of the Association? The audited financial statements for 2016 will be delivered by the Treasurer providing members with a transparent look at the COA’s current and projected financial position. - Wait, is that a new COA web site? The COA will be launching a completely redesigned web site this summer – the Surgeon and Internal Communications Committee will highlight some of its new features and structure.

The Business Meeting is not only an opportunity for the COA to share its story with our membership, it also serves as a platform for members to bring forward their suggestions and questions directly to the COA leadership. All COA members are encouraged to attend and participate.

La séance de travail de l’ACO lui permet de présenter ses initiatives et d’écouter ses membres Kishore Mulpuri, MD Secrétaire de l’Association Canadienne d’Orthopédie

a séance de travail de l’ACO aura lieu le vendredi 16 juin, à 11 h 45, dans les salles Gouverneur général 2 et 3, au quatrième étage de l’hôtel Westin Ottawa, dans le cadre de la Réunion annuelle. Il s’agit d’une excellente occasion de prendre connaissance des initiatives, projets et collaborations menés par la direction de l’ACO. - Où s’en va l’ACO? Le président de l’ACO brossera le portrait des principaux dossiers abordés par le conseil d’administration et le Comité de direction à leurs dernières réunions.

- Quelle est la santé financière de l’ACO? Les états financiers vérifiés de 2016 seront déposés par le trésorier afin de permettre aux membres de prendre connaissance des finances de l’ACO en toute transparence. - Changements en vue sur le site Web de l’ACO. L’ACO lancera un tout nouveau site Web cet été; le Comité des communications internes et avec les orthopédistes en présentera certaines des nouvelles caractéristiques et fonctions. - Quelles sont les ressources disponibles? Apprenez-en davantage sur les énoncés de position et les trousses que préparent le Comité sur les normes et le Comité sur la gestion de l’exercice.

Mettez la séance de travail à votre calendrier : Le vendredi 16 juin, à 11 h 45

COA Bulletin ACO - Spring / Printemps 2017

Your COA / Votre association

(suite de la page 11)

- Quelles sont les possibilités de perfectionnement offertes par l’ACO? Le Comité de perfectionnement professionnel présentera les mises à jour et autres améliorations aux possibilités de perfectionnement offertes à la Réunion annuelle et par l’intermédiaire de ses programmes affiliés. Les présidents des comités organisateur et responsable du programme de la Réunion annuelle 2018, à Victoria, en Colombie-Britannique, seront également présentés. - Quels sont les avantages de mon adhésion? Découvrez la façon dont s’y prend le Comité d’adhésion pour que vous puissiez tirer le maximum de votre cotisation.

- Qui sera le prochain président de l’ACO? Le Comité des candidatures vous invite à voter pour élire le 74e président de l’ACO. La séance de travail de l’ACO n’est pas seulement l’occasion de présenter ses résultats aux membres; c’est aussi un forum qui leur permet de formuler des suggestions et de poser des questions directement à la direction. On invite tous les membres de l’ACO à y assister et à se faire entendre.

Residents! Take a Sneak Peek at the CORA Meeting Lisa Lovse, M.D. Bogdan Matache, M.D. CORA Co-chairs, University of Ottawa

he Canadian Orthopaedic Residents’ Association (CORA) Annual Meeting will be held on Thursday, June 15, at the Westin Ottawa. We encourage all Canadian orthopaedic residents to register for this exciting event, and to stay on for the COA Annual Meeting immediately following CORA. Click here for a recap of the highly-attended 2016 CORA Annual Meeting in Quebec City. What’s on this year’s program? Resident research projects will be presented at the podium during the morning’s paper session moderated by Drs. Alberto Carli and Sasha Carsen, as well as in poster format. Prizes will be awarded to the top three podium presentations as well as the top poster presentation. You do not want to miss the afternoon symposium, featuring advice throughout the career stages from Drs. Geoffrey Wilkin (University of Ottawa), Kevin Smit (University of Ottawa), Darren Drosdowech (Western University), and Don Johnson (University of Ottawa). The meeting caps off with a social night at Blue Cactus Bar and Grill, where residents can network with colleagues from across the country. CORA Annual Meeting Program (tentative times) 08:00-09:00 – Registration & Breakfast 09:00-12:00 – Residents’ Paper Session Moderators: Hesham Abdelbary and Alberto Carli 12:00-12:50 – Lunch (and poster viewing) 13:00-15:00 – Symposium and Discussion: Navigating a Career in Orthopaedics: Different Perspectives on a Common Journey Speakers: Geoffrey Wilkin, Kevin Smit, Darren Drosdowech, Don Johnson 20:00 – CORA Social Event at Blue Cactus Bar and Grill Tickets cost $10/person, which includes one drink and hors d’oeuvres (cash bar available).

COA Bulletin ACO - Spring / Printemps 2017

How to Register for the CORA Meeting 1. You can register for the CORA meeting through the online COA meeting registration system by visiting www.coaannualmeeting.ca. 2. When registering for your sessions, select the CORA Annual Meeting on the ‘Registration Program Sessions’ Page 3. Select the CORA Social Event from the ‘Registration Extras’ page. If you are a Canadian resident and would like to become a COA Associate member, please click here to download and submit a membership application form. For more information about the CORA meeting, visit www.coraweb.org, and do not hesitate to contact coraweb@canorth.org with questions. We look forward to hosting our resident colleagues in June.

Celebrating the Nation’s 150th Ottawa will be commemorating Canada’s 150 years of confederation with various events and celebrations held throughout the summer. The COA is thrilled to be hosting our Annual Meeting in Ottawa this June during such an exciting time!

Célébrons les 150 ans de la Confédération Ottawa souligne cette année les 150 ans de la Confédération canadienne par diverses activités et festivités estivales. L’ACO est ravie de tenir sa réunion annuelle à Ottawa en juin, pendant cette période d’effervescence!

Your COA / Votre association

Hope

A Resident’s Experience Providing Rural Health Care in Tanzania Supriya Singh, M.D. PGY 3 Orthopaedic Resident, Western University London, ON

elivering a baby can be the most heart-warming or the most frightening moment of one’s life.

When I travelled to rural Tanzania in 2011 as a young medical student, I was eager to apply my new knowledge and help anyone in need. However, I soon encountered local medical problems beyond my expertise - malaria, typhoid fever, leprosy, HIV/AIDS, and numerous other tropical diseases to which I had never been exposed. Faced with unfamiliarity, my differential diagnoses were scarce and the limited resources inhibited the usual investigation and treatment options. I found myself to be more useful changing bed sheets and folding gauze than running a clinic. I learned to follow the lead of the nursing staff at Nkoaranga Hospital. They were as accustomed to dealing with encephalopathy and psychosis from end-stage HIV as we are to dealing with the common cold.

APGAR…?” My colleague and I looked at each other nervously - the baby was not showing any signs of life. No crying, no coughing, no moving. We did the only thing we could think of, administering CPR and oxygen. Though only seconds were passing, they felt like hours. We did not have any equipment or access to medications. We felt so helpless. Nevertheless, we were determined to save this baby. We owed it to the mother, so we would do our best and we continued our efforts. With passing time, we were terrified thinking of the effects of lack of oxygen to the baby’s brain. Finally, after a few harrowing minutes, the baby began to cry. We cried with him, tears of relief and some of fear. Handing the newborn to his mother is a moment that I will never forget. We checked on “Big Baby” daily and although it was too soon to know what kind of longterm outcomes he might face, we felt hopeful for the family, and enjoyed wishing them health and happiness.

Morning rounds visiting Mom and Baby.

Scrubbed in for surgery at Nkoaranga Hospital with Dr. Julius.

I was fortunate to participate in a number of childbirth deliveries in Nkoaranga including both C-sections and natural births. It was not unusual for pregnant women to walk for days or even weeks to arrive at the rural hospital in time for delivery. Labouring without the amenity of analgesia, they were often sent on their way immediately following the birth, turning around to trek back home the very same day with their newborn in tow. One night, I scrubbed in with two of my Canadian colleagues and the local surgeon for a C-section for fetal macrosomia, or as they indicated in their chart, “reason for C-section: big baby”. Once we delivered the baby boy, my colleague and I brought the newborn to the back table while the surgeon continued operating on the mother. He asked “APGAR…? APGAR…?

This particular travel opportunity was established by MedOutreach, a student-run organization doing charitable work to improve access to primary health care in Tanzania. Although MedOutreach no longer exists, the benefits of volunteering overseas continue to inspire my work to this day. The street children that we screened for disease slowly developed a trust in the Westerners, and by listening to their needs, we initiated a program offering housing, food and education, which eventually helped many of them to support themselves autonomously. As students, we may feel limited in our medical ability to serve patients, but there is always a way to assist the local people. This early exposure motivated me to continue philanthropic work as I progressed through my orthopaedic residency. My experiences in Tanzania changed my perspective on health care and on life. In Canada, “Big Baby” would have been transported immediately to the Neonatal Intensive Care Unit for resuscitation, with minimal time spent in hypoxia. As much as any other child, he deserved the best care that is available, COA Bulletin ACO - Spring / Printemps 2017

Your COA / Votre association

(continued from page 13)

and it was humbling that despite our best intentions, we were unable to provide it. I was overwhelmed by inequality, but I was reminded that we can never give up hope. Hope is what the Tanzanian women held on to as they trekked for miles to deliver their babies in the hospital. Hope is the fuel to keep us going. Hope for a better future, hope that we can try to make the world a better place and hope that one day, all people will be treated with the best possible medical care.

How to Avoid Complications in Upper and Lower Extremity Trauma A two-part update session addressing complications seen in both upper and lower extremity trauma cases (and how to avoid them!) will take place on Saturday, June 17. The upper extremity portion will be held from 7:50-9:20 with the lower extremity segment immediately following from 9:30-11:00.

Éviter les complications associées aux traumatismes aux membres inférieurs et supérieurs Une séance de rafraîchissement en deux parties sur les complications associées aux traumatismes aux membres inférieurs et supérieurs (et la façon de les éviter!) aura lieu le samedi 17 juin. La partie sur les membres supérieurs aura lieu de 7 h 50 à 9 h 20, et sera immédiatement suivie de celle sur les membres inférieurs, de 9 h 30 à 11 h.

Hope in the life of “Big Baby”

I would strongly encourage all medical training centres to expose students to international medical electives. If you would like to contact members of the COAGS Committee for recommendations, please email trinity@canorth.org. “Hope is being able to see that there is light despite all the darkness.” ~ Desmond Tutu

The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, or if you are a resident and you would like to share an essay about your global surgery experience, please contact trinity@canorth.org for details.

COA Bulletin ACO - Spring / Printemps 2017

Who are Your Ottawa Annual Meeting Hosts? Dr. J Pollock is looking forward to welcoming members to Ottawa as the event’s Local Arrangements Committee Chair. He has put together an exciting social and guest program showcasing the best of our Capital’s culture and heritage. Look for him at the Opening Ceremonies!

Dr. Peter Lapner, along with his Program Committee, has assembled an enriched educational program that caters to every interest and subspecialty. Look for him at the various sessions throughout the meeting.

Vos hôtes à la Réunion annuelle d’Ottawa Le Dr J Pollock, président du Comité organisateur, a hâte de vous accueillir à Ottawa. Il vous propose un excellent programme d’activités sociales et pour les invités qui met en valeur ce que la capitale nationale a de mieux à offrir sur les plans culturel et patrimonial. Allez le saluer aux cérémonies d’ouverture!

Le Dr Peter Lapner, en collaboration avec le Comité responsable du programme, a concocté un riche programme de formation, pertinent pour toutes les sous-spécialités et tous les intérêts. Vous pourrez le croiser aux diverses séances.

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

Cementless. Redefined. Single radius and delta keel Triathlon design elements provide initial stability for biologic fixation.1,2 Defined porous and solid zones Tritanium 3D printing enables complex designs to improve tibial fixation3 and patella strength.4 SOMA-designed Size-specific peg design secures into denser regions of bone.5

FONT: Helvetica with bell curve

1. Bhimji S, Alipit V. The effect of fixation design on micromotion of cementless tibial baseplates. Orthopaedic Research Society Annual Meeting. 2012; Poster #1977. 2. Harwin S, et al. Excellent fixation achieved with cementless posteriorly stabilized total knee arthroplasty. J Arthroplasty. 2013;28(1):7–13. 3. Alipit V, Bhimji S, Meneghini M. A flexible baseplate with a partially porous keel can withstand clinically relevant loading. Orthopaedic Research Society Annual Meeting. 2013; Poster #0939. 4. Stryker Test Report RD-12-044. 5. Stryker Test Protocol 92911; D02521-1 v1. © 2014 Stryker Corporation. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: SOMA, Stryker, Triathlon, Tritanium. All other trademarks are trademarks of their respective owners or holders. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. TRITAN-AD-1

Clinical Features, Debates & Research / Débats, recherche et articles cliniques +

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COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Early Revision Risk Curves for Hip and Knee Replacements Based on Data from the Canadian Joint Replacement Registry Carolyn Sandoval, MSc Katy Molodianovitsh, MA Junior Chuang, MSc Nicole de Guia, MHSc Michael Dunbar, M.D., PhD, FRCSC Eric Bohm, M.D., MSc, FRCSC

In March 2017, the Canadian Institute for Health Information (CIHI) released the report, Hip and Knee Replacements in Canada, 2014–2015: Canadian Joint Replacement Registry (CJRR) Annual Report.1 For the first time, this report includes cumulative revision risk estimates using data from the CJRR and CIHI’s Discharge Abstract Database (DAD). This brief article presents a summary of the main revision risk findings.

of death may also play a role in the converging risk for this population. A closer look was taken for hip replacement surgeries with acute hip fracture as the most responsible diagnosis. Among the 10,250 primary hip replacements performed to treat acute hip fractures, 283 (2.8%) required at least one revision surgery. For this group, the cumulative revision rate was significantly higher for those surgeries employing cementless femoral fixation (3.8%) compared to those with a cemented fixation (2.3%) (Figure 2). Cementless femoral fixation was far more common than cemented (72.1% versus 27.9%). For other results pertaining to hip replacement revision (i.e., by sex, by type of procedure), refer to the full report.

Context n 2014–2015, there were 51,272 hip replacement surgeries and 61,421 knee replacement surgeries performed in Canada. Among those, 8.5% of hip replacements were revision surgeries and 6.8% of knee replacements were revision surgeries. While revisions may represent a relatively small proportion of all joint replacement surgeries, reducing the need for early revisions offers substantial patient and cost-related benefits and is a primary objective of the CJRR, as well as other orthopaedic registries around the world, including those from Australia, the United Kingdom, New Zealand and Sweden.

Methods The analysis included more than 163,000 primary surgeries performed from 2012–2013 to 2014–2015 in provinces that are mandated to report to the CJRR (Ontario, Manitoba and British Columbia). Early revision risk (i.e., up to three years postprimary surgery) was examined by several factors such as age, sex and type of surgery. Important patient sub-groups such as those with degenerative arthritis or acute hip fracture were also examined separately. Only data from CJRR-mandated provinces was included to ensure a high coverage rate for this analysis. Time to first revision was determined based on revisions identified in the Discharge Abstract Database, CIHI’s primary hospitalization database. This was done to ensure capture of the revision, which may have occurred in any province or territory. Selected Key Findings Hip replacements Included in this analysis are 68,954 primary hip replacements completed between 2012–2013 and 2014–2015. Almost threequarters of surgeries had a diagnosis of degenerative arthritis (72.4%); 826 (1.7%) of these had a subsequent revision. Among this group, the risk of having an early revision was significantly higher for older patients compared with younger patients (Figure 1). It should be noted that the risk curves appear to converge after two years, suggesting that older patients may be at a higher risk for early complications. The competing risk

Figure 1 Cumulative revision rate for primary total hip replacement by age group (primary diagnosis of degenerative arthritis), 2012 to 2014

Age

Years after primary replacement <55 1 2 55–64 1 2 65–74 1 2 75+ 1 2

Cumulative revision rate (%) 1.36 1.75 1.41 1.83 1.42 1.85 1.95 2.22

95% confidence interval 1.06–1.66 1.38–2.12 1.20–1.63 1.56–2.10 1.23–1.61 1.60–2.09 1.71–2.20 1.96–2.49

Number at risk 4,015 1,867 8,221 3,816 10,316 4,717 8,571 4,007

Sources Canadian Joint Replacement Registry (Ontario, Manitoba and British Columbia only) and Discharge Abstract Database, 2012–2013 to 2014–2015, Canadian Institute for Health Information.

COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 17)

Figure 2 Cumulative revision rate for primary partial hip replacement by femoral fixation (primary diagnosis of acute hip fracture), 2012 to 2014

Femoral fixation

Years after primary replacement Cemented 1 2 Cementless 1 2

Cumulative revision rate (%) 1.93 2.27 2.90 3.78

95% confidence interval 1.30–2.56 1.53–3.02 2.43–3.37 3.18–4.38

Number at risk 1,173 569 3,160 1,377

Sources Canadian Joint Replacement Registry (Ontario, Manitoba and British Columbia only) and Discharge Abstract Database, 2012–2013 to 2014–2015, Canadian Institute for Health Information; Global Arthroplasty Product Library, July 29, 2015 version, International Consortium of Orthopaedic Registries–International Society of Arthroplasty Registries (ICORISAR).

Knee replacements Included in this analysis are 94,771 primary knee replacements completed between 2012–2013 and 2014–2015. The early revision risk for all types of partial knee replacements (medial, lateral and patellofemoral) was significantly higher than total knee replacements. Total knee replacements had the lowest rate with 1.6% at the two-year mark (Figure 3). Of the three types of partial knee procedures, the partial medial knee replacement had the lowest revision rate (3.6%) two years post-surgery, compared with partial lateral (6.5%) and patellofemoral (6.9%). For revision risk results by sex and by age group refer to the full report. Implications for the Canadian Health System Our revision risk curve analyses provide a high-level view of the revision risk over the first three years for selected factors using Canada’s national joint replacement registry. Most of our findings are consistent with those from other national joint replacement registries2,3. Over time, with longer follow-up periods available, we will able to better assess the revision risk for hip and knee replacement patients and further compare national outcomes with other countries. Future analyses will look at developing curves at more granular levels, e.g. by component, implant type, manufacturer.

COA Bulletin ACO - Spring / Printemps 2017

Figure 3 Cumulative revision rate for primary total and partial knee replacement by type of procedure (all diagnoses), 2012 to 2014

Type of knee arthroplasty Total Partial, medial Partial, lateral Patellofemoral

Years after primary replacement 1 2 1 2 1 2 1 2

Cumulative revision rate (%) 0.94 1.58 2.04 3.63 3.94 6.52 1.80 6.89

95% confidence interval 0.87–1.01 1.47–1.68 1.58–2.50 2.95–4.31 1.65–6.24 3.16–9.88 0.00–3.84 1.98–11.80

Number at risk 57,342 27,090 2,894 1,530 208 120 144 66

Sources Canadian Joint Replacement Registry (Ontario, Manitoba and British Columbia only), Discharge Abstract Database and National Ambulatory Care Reporting System, 2012–2013 to 2014–2015, Canadian Institute for Health Information.

Additional findings and more details regarding the methodology can be found in the full report available on www.cihi.ca/cjrr. The CJRR, which collects demographic, clinical and prosthesis information on hip and knee replacements, is managed by CIHI. It was launched in 2001 in collaboration with the Canadian Orthopaedic Association. CIHI would like to thank the CJRR Advisory Committee for their support and the Scientific Working Group for their invaluable advice on the revision risk analysis. CIHI also thanks the co-chairs, Drs. Eric Bohm and Michael Dunbar, for their leadership and support. For additional information about the CJRR, contact cjrr@cihi.ca. References 1. Canadian Institute for Health Information. Hip and Knee Replacements in Canada, 2014–2015: Canadian Joint Replacement Registry (CJRR) Annual Report. 2017. URL: www.cihi.ca/cjrr. 2. Australian Orthopaedic Association, National Joint Replacement Registry. Hip and Knee Arthroplasty: Annual Report 2015. 2015. 3. Swedish Knee Arthroplasty Register. Annual Report 2014. 2014.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

The Role of Biologic or Synthetic Enhancement of Soft Tissue Healing in Orthopaedic Sport Medicine The latest bandwagon appears to be Bone Marrow Aspirate Concentrate (BMAC), which is a slightly more invasive technique than PRP for harvesting growth factors and pluripotent cells from the iliac crest. The indications for BMAC are growing at an exponential rate including repair and reconstruction of cartilage lesions, treatment of delayed or malunion, enhancement of anterior cruciate graft or rotahe race between the mechanitor cuff healing. Once again science cal properties of healing soft tisis lagging far behind the marketing sues and the loads imposed by campaigns from the multiple suppliers The practice of orthopaedic surgery continues to evolve. accelerated rehabilitation and return of BMAC kits. We are faced with an explosion of information stemming from published cutting-edge research (bench and clinical). to functional activities continues to Likewise, an increasingly informed public has rapid challenge surgeons. Now that so many Finding the right mix and concentraaccess to information about novel therapies and surgical procedures and reconstructions can be tion of growth factors is an enormous techniques. Oftentimes the best way to integrate evidenceperformed through arthroscopic assisobstacle. Growth factors used in isolabased practice and innovative treatments is unknown or tance, the misconception is that the tion appear to accelerate tissue healing challenging. To add some perspective on how to approach deeper tissue layers will also recovbut when mixed with other factors or in emerging and/or controversial topics, we have developed this Horizons feature in the COA Bulletin. er at a more rapid pace. Our patients higher or lower concentrations, this may are increasingly impatient to return no longer be true. This leads to an infinite In the Horizons articles, thought leaders from various to life and sport pushing the demand number of growth factor concoctions subspecialties will provide insights based on their extensive for stronger repairs. In most areas of and concentrations to sort in clinical triclinical experience and ongoing research. The goal of this the body, soft tissue healing, whether als. The financial barrier to entry for startfeature is to «shed some light» on the best way forward. it be tendon, ligament or cartilage, is up companies looking to create the next Femi Ayeni, M.D., FRCSC limited by a myriad of host factors “biologic” solution to soft tissue healScientific Editor, COA Bulletin including age, body mass index, aligning is massive, especially to get through ment and general health factors. In expensive regulatory clinical trials. One of addition, surgical factors such as initial fixation and the type the few survivors also has a Canadian connection: BST-CarGel is a and quality of tissues utilized (local tissue, allograft, autograft, biopolymer scaffolding that sets up at body temperature and can zenograft) come into play. In the past couple of decades, be used mixed with the patient’s blood to fill chondral defects in dramatic improvements have taken place within the device joints. The pivotal trial included several Canadian centres lead by industry that allows for significantly improved fixation at time the efforts of Dr. Bill Stanish at Dalhousie University. This product is zero. Tissue integration into bone or surrounding soft tissue is one of the few new products that have been able to navigate the now the rate-limiting step allowing our patients to return to way from bench top to the surgical field. unrestricted activity. Innovations such as high strength sutures and tapes, knotless and double row cuff fixation, improved In another multi-centered Canadian-based study, we have suspensory and screw fixation for ligament grafts are examples looked at biologic enhancement of the suture materials. The of these important innovations. concept is promising and we await full clinical and imaging results. Animal studies have shown increased angiogenesis in The concept of biologic enhancement of healing is not new the region around the sutures. If positive, the indications would and is extremely broad with respect to potential options. In be endless. In addition to the staggering costs to get products the simplest form, enhancement of the interface between through regulatory hurdles, most health-care systems lack the soft tissues and bone has included the use of endogenous or capacity to absorb the costs of these new technologies. exogenous growth factors. The use of platelet rich plasma (PRP) exploded into a multi-billion dollar industry and was hailed as The daunting pathway to market for biologics has led to the the “holy grail” to augment healing. The advantages appear resurgence of synthetic products to reinforce tendons and obvious: use the patients own serum and through simple use ligaments or to reconstruct menisci. There are many predicate of a centrifuge, enrich the concentration of platelet derived synthetic devices so that manufactures can go straight to margrowth factors and hopefully accelerate healing. Despite the ket with new indications. In the elite and professional athlete continued enthusiasm, multiple randomized clinical trials lookworld, there is an explosion of interest in use of synthetic splinting at a broad range of indications have failed to show clinical ing of repaired tissue. The concept is to allow natural healing to efficacy. When we looked at using platelet derived growth take place with protection of the load to the injured ligament factor to enhance healing rates of surgically repaired rotator or tendon therefore preventing tissue creep and potentially cuffs, the challenge was keeping an adequate concentration at shortening recovery. This technique is now being promoted for the tendon-bone interface. Unfortunately, this was not feasible use in “Tommy John” ulnar collateral ligament reconstruction, with an arthroscopic approach and so far, this has not yielded Gamekeeper’s thumb and to stabilize ankle sprains. Of signifiimproved clinical outcomes. cant concern is the lack of level 1 or 2 clinical trials to justify these procedures, but that never seems to dampen the enthusiasm! Bob Litchfield, M.D., FRCSC Professor of Surgery Medical Director, Fowler Kennedy Sport Medicine Clinic Western University London, ON

Horizons

COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Young Adults with FAI - What’s the Appropriate Imaging Work-up?

emoroacetabular impingement has increasingly been recognized as a cause of hip pain in the young adult. However, once clinical history and physical examination suggest further information is needed, a plethora of radiological options exist. In this edition’s debate, experts from Dalhousie University, University of Alberta and

Queen’s University, debate the “next steps” with regards to imaging modalities to obtain in the patient with presumed FAI. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

The X-ray is All You Need George Konstantinidis M.D., PhD, Dalhousie University Halifax, NS Ivan Wong, M.D., FRCSC Associate Professor, Dalhousie University Halifax, Nova Scotia

emoroacetabular impingement (FAI) is considered to be one of the predisposing factors of hip osteoarthritis (OA) especially in young active patients1-4. FAI is defined as impingement of the femur (cam) and/or the acetabulum (pincer). Both of these can be diagnosed using X-ray investigations. The pincer type of deformity is typically found in 30-40-yearold women. The local or global overcoverage of the acetabulum causes repeated linear impaction between the acetabular rim and the head-neck junction5,6. The labrum fails first and presents intrasubstance degeneration. In the long-term, posteroinferior “contrecoup lesion” or central OA presents1,7,8. By contrast, the cam lesion mainly presents in 20-30-year-old athletic men5. The repeated impaction of the non-spherical deformity of the antero-superior head-neck junction causes cartilage delamination, detachment of the labrum and antero-superior hip OA5,6. Early identification of FAI and close follow-up with imaging investigations are necessary for young active patients to obtain maximum benefit from an early surgical intervention. A complete plain radiographic series should include a weightbearing anteroposterior (AP) pelvic view; at least one lateral view such as a cross-table, a 90° of flexion Dunn/Rippstein, a frogleg view or a false-profile of Lequesne and de Sèze view; and finally, a 45° Dunn/Rippstein view6,9,10. Specific impingement parameters of pincer need to be measured on the functional position of the pelvis, which is best depicted on the AP pelvic standing X-ray view and not in supine. It remains controversial how accurate static radiographs in supine position reflect functional acetabular coverage. Pelvic tilt and rotation are a natural component of the patient’s posture and can vary significantly among patients11,12 as well as over time13. Pelvic orientation differs in supine and standing position and there is a backward rotation of the pelvis around the transverse axis when changing from the lying to the standing position14,15. The CT and MRI studies may mislead the COA Bulletin ACO - Spring / Printemps 2017

Figure 1. (A) The lateral centre edge angle is depicted on the right hip and the Tönnis angle on the left hip. (B) Coxa profunda of left hip. Acetabular fossa (F) is touching the ilioischial line (IIL). Presence of the crossover sign (blue and red line).

surgeon due to the functional difference in the pelvic flexion angle in the supine position. The AP pelvic standing view16 is performed with the legs in 15° of internal rotation to compensate the femoral anteversion and to maximize the length of the femoral neck. The X-ray beam should be perpendicular to the cassette with a focus-film distance of 120cm. In a pincer deformity (Figure 1a, b), the findings on this view are: - Coxa profunda or protrusion acetabuli. The floor of the fossa acetabuli or the medial aspect of the femoral head is medial to the ilioischial line respectively10. The position of the hip centre is not lateralized and is located in less than 10mm of the ilioischial line17. - Tönnis angle, known also as acetabular index or acetabular roof angle, is smaller than 0° with pincer impingement. This angle is formed by a horizontal line passing through the most inferior part of the sclerotic acetabular sourcil (and being parallel to the line that connects the tips of the two acetabular teardrops) and a line connecting the most inferior and lateral point of the sclerotic acetabular sourcil10,17. - Lateral centre edge angle is greater than 39° and is formed by a perpendicular line starting from the centre of the femoral head and being transverse to the pelvic axis and a line starting from the same point and passing from the most superolateral point of the acetabulum18,19. Similarly, the anterior centre edge angle measured on the false profile view may reveal anterior pincer morphology.

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(continued from page 20)

- Retroverted acetabulum can be present with positive the crossover sign, i.e. the shadow of the anterior aspect of the rim crossovers with the shadow of the posterior aspect of the rim before reaching the lateral edge of the sourcil6,10,17. The retroverted hip may cause anterior impingement due to anterior head overcoverage or posterior instability due to posterior acetabular wall deficiency. In the latter case, the centre of the femoral head is located lateral to the posterior rim.

- The false-profile view of Lequesne and de Sèze10,17,24 performed with the patient in a standing position, the affected hip against the cassette, the ipsilateral foot parallel to the latter and pelvic rotation of 65° in relation to the wall stand. The X-ray beam aims at the centre of the femoral head with focus-film distance 102cm. The cam findings (Figure 3a-d) on the above mentioned views are10,16,25: - The alpha angle is greater than 50° and is formed from the femoral neck axis and a line connecting the femoral head centre with the beginning point of asphericity of headneck junction contour. - The head-neck offset is less than 10mm and is the distance between the widest diameter of the femoral head and the most prominent part of the femoral neck. - The offset ratio is smaller than 0.17 and is the ratio between the anterior offset and the diameter of the head.

C D

Figure 2 (A), (B): 45° of flexion Dunn/Rippstein view (C) Frogleg lateral view (D), (E) False-profile view of Lequesne and de Sèze.

The cam deformity can be assessed by measuring the alpha angle on different X-ray views. Preoperative osteoplasty can be planned measuring the millimetre of extra bone formation that needs to be removed on the lateral, anterolateral and anterior level based on the AP pelvic, 45° Dunn and frogleg view (or any other lateral view such as a cross-table, 90° of flexion Dunn/Rippstein, false-profile of Lequesne and de Sèze view) respectively. No further advanced imaging is required. The views needed to assess cam deformity (Figure 2a-e) in detail are: - The 45° and 90° of flexion Dunn/Rippstein view21,22 performed with the patient in supine position, the symptomatic hip in 45° or 90° of flexion, 20° of abduction and neutral rotation. The X-ray beam is perpendicular to the table and the focus-film distance should be 102cm. The crosshairs aim at the centre of the femoral head. - The cross-table view1,20 performed with the patient in supine position, the contra-lateral hip and knee flexed more than 80° and the symptomatic leg internally rotated 15°. The X-ray beam should be parallel to the table with 45° of cranial angulation to the symptomatic hip aiming at the centre of the femoral head. - The frogleg lateral view17,23 performed with the patient in supine position, the symptomatic hip in flexion and abduction of 45° and the ipsilateral knee in flexion 30°-40°. The heel of the affected leg should rest at the medial aspect of the contra-lateral knee. The X-ray beam is perpendicular to the table, aiming at the centre of the femoral head with focus-film distance 102cm.

Figure 3 (A), (B), (C) Cam deformity on AP weight bearing, 45° Dunn and frogleg view of a left hip. Head-neck offset 3.8mm (normal values: greater than 10mm) and offset ratio 3.8/59.3=0.06 (normal values: greater than 0.17) at the same patient. (D) Alpha angle and head-neck offset in a right hip frogleg view of another patient with significant cam deformity.

In conclusion, the diagnosis of FAI bone morphology with pincer or cam can be concluded from the above mentioned series of plain radiographs which provide discrete information of a patient’s hip structural anatomy. Imaging should accompany a detailed history and physical examination. In cases where the diagnosis is uncertain, a diagnostic intra-articular injection could confirm the source of hip pain. Finally, advanced imaging of CT and/or MRI(A) would only be necessary in cases where bony anatomy is normal and a painful labral tear or extra-articular pathology is suspected.

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References 1. Ganz R., Parvizi J., Beck M., Leunig M., Nötzli H., Siebenrock K.A. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; 417:1–9 2. Murphy S.B., Tannast M., Kim Y.J., Buly R., Millis M.B. Débridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clin Orthop Relat Res 2004; 429:178–181 3. Tanzer M., Noiseux N. Osseous abnormalities and early osteoarthritis. Clin Orthop Relat Res 2004; 429:170–177 4. Jäger M., Wild A., Westhoff B., Krauspe R. Femoroacetabular impingement caused by a femoral osseous head–neck bump deformity: clinical, radiological, and experimental results. J Orthop Sci 2004; 9:256–263 5. Ganz R., Leunig M., Leunig-Ganz K., Harris W.H. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008 Feb;466(2):264-72 6. Byrd J.W. Femoroacetabular impingement in athletes: current concepts. Am J Sports Med. 2014;42(3):737-751. 7. Beck M., Kalhor M., Leunig M., Ganz R. Hip morphology influences the pattern of damage to the Acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005; 87:1012–1018 8. Schmid M.R., Nötzli H.P., Zanetti M., Wyss T.F., Hodler J. Cartilage lesions in the hip: diagnostic effectiveness of MR arthrography. Radiology 2002; 226:382–386 9. Lequesne M., Bellaiche L. Anterior femoroacetabular impingement: an update. Joint Bone Spine. 2012;79(3):249255. 10. T annast M., Siebenrock K.A., Anderson S.E. Femoroacetabular impingement: radiographic diagnosis -what the radiologist should know. AJR Am J Roentgenol. 2007 Jun;188(6):1540-52. 11. DiGioia A.M., Hafez M.A., Jaramaz B., et al. 2006. Functional pelvic orientation measured from lateral standing and sitting radiographs. Clin Orthop Relat Res 453:272–276. 12. Tannast M., Murphy S.B., Langlotz F., et al. 2005. Estimation of pelvic tilt on anteroposterior X-rays—a comparison of six parameters. Skeletal Radiol 35:149–155. 13. Hammerberg E.M., Wood K.B. 2003. Sagittal profile of the elderly. J Spinal Disord Tech 16:44–50.

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14. Konishi N., Mieno T. 1993. Determination of acetabular coverage of the femoral head with use of a single anteroposterior radiograph. A new computerized technique. J Bone Joint Surg 75A:1318–1333. 15. Eddine T.A., Migaud H., Chantelot C., et al. 2001. Variations of pelvic anteversion in the lying and standing positions. Analysis of 24 control subjects and implications for CT measurement of position of a prosthetic cup. Surg Radiol Anat 23:105–110. 16. Tannast M., Murphy S.B., Langlotz F., Anderson S.E., Siebenrock K.A. Estimation of pelvic tilt on anteroposterior X-rays: a comparison of six parameters. Skeletal Radiol 2006; 35:149–155 17. Clohisy J.C., Carlisle J.C., Beaulé P.E., Kim Y.J., Trousdale R.T., Sierra RJ, Leunig M., Schoenecker P.L., Millis M.B. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008 Nov;90 Suppl 4:47-66. doi: 10.2106/JBJS.H.00756. 18. Murphy SB, Kijewski PK, Millis MB, Harless A. Acetabular dysplasia in the adolescent and young adult. Clin Orthop Relat Res 1990; 261:214–223 19. Tönnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am 1999; 81:1747–1770 20. Eijer H, Leunig M, Mahomed MN, Ganz R. Crosstable lateral radiograph for screening of anterior femoral head–neck offset in patients with femoro-acetabular impingement. Hip Int 2001; 11:37–41 21. Dunn D.M. Anteversion of the neck of the femur; a method of measurement. J Bone Joint Surg Br. 1952;34:181-6. 22. Meyer D.C., Beck M., Ellis T., Ganz R., Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res. 2006;445:181-5. 23. Clohisy J.C., Nunley R.M., Otto R.J., Schoenecker P.L. The frog-leg lateral radiograph accurately visualized hip cam impingement abnormalities. Clin Orthop Relat Res. 2007;462:115-21. 24. Lequesne M., de Seze. [False profile of the pelvis. A new radiographic incidence for the study of the hip. Its use in dysplasias and different coxopathies]. Rev Rhum Mal Osteoartic. 1961;28:643-52. French. 25. Nötzli H.P., Wyss T.F., Stoecklin C.H., Schmid M.R., Treiber K., Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84:556-60.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

The MRI is All You Need Kelly Johnston M.D., FRCSC Chief, Division of Hip and Knee Joint Reconstruction, Department of Surgery, Orthopaedic Section, Cumming School of Medicine, University of Calgary Calgary, AB J. Bevan Frizzell M.D., FRCPC Clinical Associate Professor, Cumming School of Medicine, University of Calgary Musculoskeletal Radiologist, EFW Radiology Calgary, AB

he value of a detailed history and observant physical exam cannot be overlooked when working up a patient for presumed hip impingement. Plain X-rays of the pelvis and hip are essential but not sufficient. Hip impingement is a three-dimensional problem and requires advanced imaging techniques to complement our three-dimensional understanding of this condition. Cam and pincer anatomic deformities, which predispose to FAI, can be missed with two-dimensional plain radiographs. The epicentre of the cam deformity is variable around the femoral neck and various lateral hip radiographs can miss this lesion if it is not tangent to the X-ray beam. Additionally, pincer deformities can be under- or overestimated if particular attention is not paid to positioning the patient or aligning the X-ray beam during image acquisition. Plain X-rays often identify the FAI diagnosis but the greatest use of X-rays is to screen out the significantly arthritic joint not amenable to FAI surgery. The outcome of hip joint preservation surgical techniques is directly determined by the quality of the articular cartilage present in the hip at the time of intervention, and MRI is vastly superior in this regard1. When cartilage is damaged on both sides of the hip, joint space narrowing is typically already visible on X-rays. MRI can determine if the cartilage on one side of the joint, typically the acetabular side, is compromised. So plain X-rays are essential but do not clinch the diagnosis of impingement every time, nor do they accurately assess the cartilage damage that may already be present in the impinging hip.

Figure 1 Coronal, sagittal and oblique sagittal PD images respectively. These are the high-resolution images particularly useful for assessing the labrum and hyaline cartilage. The gadolinium-containing solution accounts for the bright fluid in the joint. Note the anterior subcapital cam lesion and labral tear (arrows), with sclerotic acetabular rim. The hyaline cartilage (preserved in this patient) is the grey signal over the black cortex.

We prefer techniques that avoid ionizing radiation as these are typically young patients. A so-called “Impingement Protocol MRI” of the hip is performed routinely at our institution. Typical images from this protocol are shown in Figure 1. Our comprehensive MR arthrogram protocol evolved from the Bern, Switzerland technique2,3 and includes: • • • • •

Axial T1 Axial CUBE PD (or equivalent 3D sequence) Coronal, sagittal, and oblique sagittal PD Radial PD sequence reformatted from the CUBE Axial T1 distal femur (for femoral version assessment) Figure 2 The radial images are generated through the 3D CUBE sequence from the perspective that one is looking “down the barrel” of the femoral neck (second image). The final series of images allows a 360-degree view around the neck that is particularly useful in evaluating for subtle cam lesions (arrow). How these images are generated in part depends on the MRI vendor.

The powerful aspects of this protocol include the radial sequences that give a 360-degree view of the femoral head-neck junction (Figure 2) and also takes axial slices at the level of the knee to determine femoral neck version (Figure 3). Understanding femoral neck version is critical to the comprehensive workup of a patient with FAI4. We have seen many examples of patients with normal plain radiographs but very abnormal physical exams with limited internal, but often excessive external, rotation of the hip with profoundly positive anterior hip impingement sign. These patients can have femoral retroversion as the cause of FAI and it will be missed if detailed three-dimensional imaging is not performed. Impingement in these patients is solved with a rotational femoral osteotomy to correct the femoral version, not a cam or pincer debridement. Understanding femoral neck version also explains why a large cam lesion may not be causing a patient too much trouble or why a small cam lesion results in significant anterior hip pain. A small cam lesion on a background of femoral neck retroversion can be as significant as a large cam lesion on a normally anteverted femoral neck. We consider normal femoral neck anteversion to be 15o, recognizing that there is variation within any population5. We find it helpful to look at femoral neck version in both legs as it serves as a control and can be correlated with the history and physical exam findings. Often, it is bilaterally symmetric but we do see cases where the versions are significantly different from side to side, and more often than not, the more symptomatic side is the more retroverted side. COA Bulletin ACO - Spring / Printemps 2017

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References 1. Chan, W. P., Lang, P., Stevens, M. P., Sack, K., Majumdar, S., Stoller, D. W., et al. (1991). Osteoarthritis of the knee: comparison of radiography, CT, and MR imaging to assess extent and severity. American Journal of Roentgenology, 157(4), 799–806. 2. Leunig, M., Werlen, S., Ungersböck, A., Ito, K., & Ganz, R. (1997). Evaluation Of The Acetabular Labrum By MR Arthrography. The Journal of Bone & Joint Surgery, 79(2), 230–234. Figure 3 Axial PD CUBE and T1 sequences. While the axial CUBE is used to comprehensively assess the hip in the axial plane, the simple addition of the axial sequence through the distal femur allows for femoral version measurement. 15° anteversion is used as the normal reference.

The other advantage of MRI for FAI is to better understand acetabular orientation while compensating for pelvic rotation and tilt. Image interpretation can be separated from the acquisition process and so the acquired image can be maneuvered to eliminate unwanted rotation or to reduce excessive forward tilt of the pelvis due to excessive lumbar lordosis6. As a result, a better understanding of the acetabular socket volume and version can be achieved, thereby avoiding over-treatment with rim trimming or PAO for presumed acetabular retroversion. Of course, MR arthrography also allows the acetabular rim to be evaluated for labral tearing (Figure 1). A word of caution is necessary as hip labral tears are often over-called on MRI7. In our experience, true labral tears coincide with abnormal bone anatomy. Labral tears in structurally normal hips with preserved joint space may be sub-labral recesses or artifactual in the absence of major traumatic injury or hyper ligamentous laxity. Therefore, the reason for obtaining an MRI of the hip should be to look for abnormal bone morphology and cartilage damage as opposed to primarily determining the presence/ absence of labral tear. With 3T MRI becoming more widely available, this technique is readily modified from an MR arthrogram to a non-arthrographic exam, making the test noninvasive. We have started using this successfully locally as in other centres8. In summary, impingement protocol MRI of the hip that scans through to the knee to determine femoral version is really what one needs to make the correct treatment decisions to solve an impinging hip. Correlative X-rays are important but do not comprehensively analyze FAI in all cases. We are convinced that understanding the 3D osseous anatomy around the hip is critical and goes beyond the value of MRI in simply assessing for a labral tear. *The authors would like to acknowledge the work of Drs. Jim Powell and Gerry Kiefer for their contributions to understanding FAI in Calgary.

COA Bulletin ACO - Spring / Printemps 2017

3. Locher, S., Werlen, S., Leunig, M., & Ganz, R. (2002). ArthroMRI mit radiärer Schnittsequenz zur Darstellung der präradiologischen Hüftpathologie. Zeitschrift Für Orthopädie, 140(1), 52–57. 4. Kamath, A. F., Ganz, R., Zhang, H., Grappiolo, G., & Leunig, M. (2015). Subtrochanteric osteotomy for femoral mal-torsion through a surgical dislocation approach. Journal of Hip Preservation Surgery, 2(1), 65–79. 5. Sutter, R., Dietrich, T. J., Zingg, P. O., & Pfirrmann, C. W. A. (2012). Femoral Antetorsion: Comparing Asymptomatic Volunteers and Patients with Femoroacetabular Impingement. Radiology, 263(2), 475–483. 6. Albers, C. E., Wambeek, N., Hanke, M. S., Schmaranzer, F., Prosser, G. H., & Yates, P. J. (2016). Imaging of femoroacetabular impingement-current concepts. Journal of Hip Preservation Surgery, 3(4), 245–261. 7. Lee, A. J. J., Armour, P., Thind, D., Coates, M. H., & Kang, A. C. L. (2015). The prevalence of acetabular labral tears and associated pathology in a young asymptomatic population. The Bone & Joint Journal, 97-B(5), 623–627. 8. Magee, T. (2015). Comparison of 3.0-T MR vs3.0-T MR arthrography of the hip for detection of acetabular labral tears and chondral defects in the same patient population. The British Journal of Radiology, 88(1053), 20140817.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

The CT Scan is All You Need Gavin C.A. Wood, MB ChB, FRCS Edin, FRCSC Assistant Professor Queens University Kingston, ON

emoroacetabular impingement (FAI) is a condition in which subtle morphological abnormalities cause abutment between the proximal femur and the acetabulum with loss of range of motion, pain with progress towards joint damage and osteoarthritis1. There are three types commonly described: 1) pincer, a state of over coverage of the acetabulum, 2) cam, a growth or lack of concavity at the femoral head-neck junction, and 3) mixed, which consists of both cam and pincer together2. The linkage between abnormal morphology and eventual pathology was made several decades ago, with Murray’s observation of tilt deformity in 19653, Stulberg’s description of pistol-grip deformity in 19754, and more recently, Myers et al.5 coining the term FAI. Background FAI is fundamentally a morphologic issue characterized by subtle abnormalities; innovations in imaging and image interpretation have played an important role in developing reliable methods of diagnosis. Plain radiograph is the most common starting point and often forms the basis for diagnosis6. Several measurements have been adapted to the plain radiograph to measure femoral neck concavity, such as the commonly used alpha angle and anterior offset7,8. While useful, the plain radiograph is sensitive to variation in patient positioning, and the values obtained by radiographic analysis may vary depending on the type of radiograph taken6,9. X-ray is a good screening tool for marked bony deformities but less sensitive to the subtle morphologic relationships that have been shown to exist between femur and acetabulum. CT is more robust for the detailed characterization of proximal femoral and acetabular bony deformity in FAI for surgical planning10-12. Typically, CT is used to further define and more accurately quantify the deformities detected on plain radiographs such as alpha angles, femoral head neck offset ratios, beta angles head tilt or retroversion of femoral head. Similarly, on the acetabular side, more detailed evaluation of acetabular version, socket depth, volume head coverage and centre edge angles13. Both alpha angle and anterior offset were pioneered using MR images with post-image processing to obtain multi-planar reformation (MPR)14,15. This has the distinct advantage of allowing for precise analysis in a chosen anatomical plane. Recently, these techniques have been further revised to evaluate, not only the traditional planes in which measurements were conducted14,15, but also radial planes16, which achieve greater sensitivity to morphological abnormality17. However, currently MRI lacks some of the bone definition of CT scan; is a longer and more expensive process and fails to provide quality threedimensional imaging.

Figure 1 3D CT recon.

Figure 2 CT Scan multi planar format showing detailed measurements alpha angle at 1.30 position, beta angle and head neck offset.

CT scan has also shown to be more inter-observer and intraobserver reliability with regards to these parameters18,19. The main cause for recurrence of pain and revision hip arthroscopic surgery, as we know, is under correction that could be explained by a surgeon’s failure to properly locate the impingement lesion as ascertained on plain radiograph20,21. In this situation, CT is imperative to identifying the persistent impingement lesion and locating it for correction. Some postulate that if all patients had CT scans preoperatively, the revision hip arthroscopy rate would be lower21. CT scan formatting and 3D imaging can give the surgeon a greater perspective and understanding of the impingement lesion and its location. Pinpointing herniation pits as well as os acetabuli and recognizing their size, depth and location can lead to a better understanding of the impingement and guide surgeons to more accurate morphological correction22.

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Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 25)

The advancement of software program technology now permits these 3D-formatted images to be placed in virtual animations to mimic movements of the hip and reveal impingement areas as an adjunct to surgical correction but has limitations and can vary in accuracy23,24. The benefit of CT scan is positioning of the hip in flexion and internal rotation during scanning to permit a more natural reproduction of the impingement lesion than that conceived through a simulated animation, so termed 4D CT25,26. CT allows more detailed quantification of the lesion with regard to volume, size and location generating more accurate data for research purposes. Establishing the classification of impingement lesions preoperatively; the clinical outcomes of surgery will be better correlated with the degree of surgical correction. The major drawback of using CT and especially 4D CT is the substantial radiation exposure to this young patient population. Typically, radiation exposure from a CT scan of the hips or pelvis in this population is 5 to 7mSv. Advances in CT protocols may produce significant reductions in radiation exposure, to as low as 2.5mSv at some centres27,28. The Future The hip is a complex three-dimensional structure with combined movements of rotation, translation and leverage that we donâ€™t yet fully understand. It is not the ball and socket joint that revolves around a centre of rotation that Charnley led us to believe; that is for the arthroplasty surgeon. The advancement of CT scans, surface mapping and tracking with computerassist surgery, I believe, will soon provide us with the complex relationship we know to exist during hip movement. Always remember that FAI is a clinical diagnosis supported by appropriate imaging. References 1. Ganz R., Parvizi J., Beck M., Leunig M., Notzli H., Siebenrock K.A., et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop. 2003(417):112-20. 2. Ganz R., Leunig M., Leunig-Ganz K., Harris W.H., Ganz R., Leunig M., et al. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop. 2008;466(2):26472. 3. Murray R.O. The aetiology of primary osteoarthritis of the hip. British Journal of Radiology. 1965;38:810-24. 4. Stulberg S.D., editor Unrecognized childhood hip disease: a major cause of idiopathic osteoarthritis of the hip. The Hip: Proceedings of the Third Open Scientific Meeting of the Hip Society; 1975; St Louis, MO: CV Mosby. 5. Myers S.R., Eijer H., Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop. 1999(363):93-9. 6. Clohisy J.C., Carlisle J.C., Beaule P.E., Kim Y.J., Trousdale R.T., Sierra R.J., et al. A systematic approach to the plain radiographic evaluation of the young adult hip. Journal of Bone & Joint Surgery - American Volume. 2008;90 Suppl 4:47-66. COA Bulletin ACO - Spring / Printemps 2017

7. Clohisy J.C., Carlisle J.C., Trousdale R., Kim Y.J., Beaule P.E., Morgan P., et al. Radiographic evaluation of the hip has limited reliability. Clin Orthop. 2009;467(3):666-75. 8. Barton C., Salineros M.J., Rakhra K.S., Beaule P.E., Barton C., Salineros M.J., et al. Validity of the alpha angle measurement on plain radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthop. 2011;469(2):464-9. 9. Clohisy J.C., Nunley R.M., Otto R.J., Schoenecker P.L., Clohisy J.C., Nunley R.M., et al. The frog-leg lateral radiograph accurately visualized hip cam impingement abnormalities. Clin Orthop. 2007;462:115-21. 10. Beaule P.E., Zaragoza E., Motamedi K., Copelan N., Dorey F.J. Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2005;23(6):1286-92. 11. Tannast M., Kubiak-Langer M., Langlotz F., Puls M., Murphy S.B., Siebenrock K.A. Noninvasive three-dimensional assessment of femoroacetabular impingement. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2007;25(1):122-31. 12. Tannast M., Siebenrock K.A., Anderson S.E. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol. 2007;188(6):1540-52. 13. Dandachli W., Najefi A., Iranpour F., Lenihan J., Hart A., Cobb J. Quantifying the contribution of pincer deformity to femoroacetabular impingement using 3D computerised tomography. Skeletal Radiol. 2012;41(10):1295-300. 14. Notzli H.P., Wyss T.F., Stoecklin C.H., Schmid M.R., Treiber K., Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. Journal of Bone & Joint Surgery - British Volume. 2002;84(4):556-60. 15. Ito K., Minka M.A., 2nd, Leunig M., Werlen S., Ganz R. Femoroacetabular impingement and the cam-effect. A MRIbased quantitative anatomical study of the femoral headneck offset. Journal of Bone & Joint Surgery - British Volume. 2001;83(2):171-6. 16. Pfirrmann C.W., Mengiardi B., Dora C., Kalberer F., Zanetti M., Hodler J. Cam and pincer femoroacetabular impingement: characteristic MR arthrographic findings in 50 patients. Radiology. 2006;240(3):778-85. 17. Rakhra K.S., Sheikh A.M., Allen D., Beaule P.E., Rakhra K.S., Sheikh A.M., et al. Comparison of MRI alpha angle measurement planes in femoroacetabular impingement. Clin Orthop. 2009;467(3):660-5. 18. Wassilew G.I., Heller M.O., Diederichs G., Janz V., Wenzl M., Perka C. Standardized AP radiographs do not provide reliable diagnostic measures for the assessment of acetabular retroversion. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2012;30(9):1369-76.

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19. Heyworth B.E., Dolan M.M., Nguyen J.T., Chen N.C., Kelly B.T. Preoperative three-dimensional CT predicts intraoperative findings in hip arthroscopy. Clin Orthop Relat Res. 2012;470(7):1950-7. 20. Zhuo H., Wang X., Liu X., Song G.Y., Li Y., Feng H. Quantitative evaluation of residual bony impingement lesions after arthroscopic treatment for isolated pincer-type femoroacetabular impingement using three-dimensional CT. Arch Orthop Trauma Surg. 2015;135(8):1123-30. 21. Ross J.R., Larson C.M., Adeoye O., Kelly B.T., Bedi A. Residual deformity is the most common reason for revision hip arthroscopy: a threedimensional CT study. Clin Orthop Relat Res. 2015;473(4):1388-95.

CFL All-Star Kick Starts Annual Meeting

CFL All-Star, Milt Stegall, will deliver his guest lecture address during the Opening Ceremonies on Thursday, June 15 at 17:30. Meet him afterwards, while catching up with your colleagues from across the country, at the President’s Welcome Reception in the Exhibit Hall at 19:00.

22. Genovese E., Spiga S., Vinci V., Aliprandi A., Di Pietto F., Coppolino F., et al. Femoroacetabular impingement: role of imaging. Musculoskeletal surgery. 2013;97 Suppl 2:S117-26. 23. Brunner A., Horisberger M., Herzog R.F. Evaluation of a computed tomography-based navigation system prototype for hip arthroscopy in the treatment of femoroacetabular cam impingement. Arthroscopy. 2009;25(4):382-91.

Une vedette de la Ligue canadienne de football donne le coup d’envoi à la Réunion annuelle L’ancien joueur étoile Milt Stegall donnera une allocution aux cérémonies d’ouverture, qui auront lieu le jeudi 15 juin, à 17 h 30. Vous pourrez ensuite le rencontrer tout en renouant avec vos collègues de partout au pays à la Réception de bienvenue du président, dans la salle d’exposition, à 19 h.

24. Bedi A., Dolan M., Magennis E., Lipman J., Buly R., Kelly B.T. Computer-assisted modeling of osseous impingement and resection in femoroacetabular impingement. Arthroscopy. 2012;28(2):204-10. 25. Grabinski R., Ou D., Saunder K., Rotstein A., Singh P., Pritchard M., et al. Protocol for CT in the position of discomfort: preoperative assessment of femoroacetabular impingement - how we do it and what the surgeon wants to know. Journal of medical imaging and radiation oncology. 2014;58(6):649-56. 26. Wassilew G.I., Janz V., Heller M.O., Tohtz S., Rogalla P., Hein P., et al. Real time visualization of femoroacetabular impingement and subluxation using 320-slice computed tomography. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2013;31(2):275-81.

Poster Pub Night

On Friday evening from 17:30-19:00, cash bars will be set up in the Exhibit Hall’s poster area for a ‘Poster Pub’ where you can enjoy a drink with colleagues while having designated time to view the poster presentations.

Pub des affiches Le vendredi soir, de 17 h 30 à 19 h, des bars payants seront aménagés dans la zone de présentation des affiches de la salle d’exposition. Le « Pub des affiches » vous permettra de prendre un verre avec vos collègues tout en jetant un coup d’œil aux affiches présentées.

27. Fabricant P.D., Berkes M.B, Dy C.J., Bogner E.A. Diagnostic medical imaging radiation exposure and risk of development of solid and hematologic malignancy. Orthopedics. 2012;35(5):415-20. 28. Saroki A.J., Wijdicks C., Philippon M.J., Bedi A. Orthopaedic surgeons’ use and knowledge of ionizing radiation during surgical treatment for femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3962-70.

COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Idiopathic Scoliosis - Introduction to this edition’s clinical feature Christopher Reilly, M.D., FRCSC Associate Professor and Head of the Division of Paediatric Orthopaedics University of British Columbia Guest Editor, COA Bulletin Vancouver, BC

diopathic scoliosis is a complex three-dimensional deformity of the growing spine that is not associated with any other underlying condition. The deformity associated with idiopathic scoliosis has been recognized for thousands of years. Hippocrates is credited with describing scoliosis and devising some dramatic forms of traction and brace treatment. Some principles of management have stood the test of time, while others have changed dramatically. Brace treatment of idiopathic scoliosis flourished in the last century, in part driven by a lack of effective surgical solutions. The last 15 years of the previous century was a time when the true three-dimensional nature of idiopathic scoliosis began to be addressed in surgical corrective strategies. Deformity correction was moderate due to a limitation in spine instrumentation anchor techniques. The first 15 years of this century have been highlighted by the wide use of pedicle screws in deformity correction surgery, which has provided surgeons with a much greater ability to correct the three-dimensional nature of

the deformity. In this featured COA Bulletin series on idiopathic scoliosis, Dr. Neil Saran from McGill University will explore the current state of the art in deformity correction surgery. There are a number of key challenges that remain. Early onset scoliosis remains a cause of severe morbidity and in some cases, creates significant changes in lifespan. Growing spinal technologies have been used for many years. Recently developed instrumentation systems have eliminated the need for operative procedures to achieve lengthening. Dr. Ron El-Hawary, from IWK Hospital in Halifax, will review our current management of early onset idiopathic scoliosis On the surgical horizon is the possibility of fusionless correction of the idiopathic scoliotic deformity. Fusion remains the mainstay of surgical management but it is irreversible and may have significant negative effects later in life. Dr Firoz Miyanji, from British Columbia’s Children’s Hospital, will review the current state of fusionless techniques in the management of idiopathic scoliosis. Interestingly, just when advances in surgical techniques seem to have really shifted the risk/benefit ratio away from nonoperative technique, a major study was completed that demonstrated a very positive effect of bracing. I will begin the series by reviewing the current state of non-operative management techniques.

Non-operative Management of Idiopathic Scoliosis Christopher Reilly, M.D., FRCSC Associate Professor and Head of the Division of Paediatric Orthopaedics University of British Columbia Vancouver, BC

diopathic scoliosis remains a relatively common musculoskeletal condition worldwide. Although it is difficult to accurately define the incidence, school screening studies performed in the United States have given us guidelines which further our understanding of the condition. Curves greater than 30 degrees have an incidence of approximately .2% in an at-risk student population1. The incidence of small curves is equal in males and females; however, idiopathic scoliosis appears to be more progressive in females, resulting in an almost 10:1 female:male gender ratio in patients undergoing surgical correction. While non-idiopathic scoliosis is common in patients with cerebral palsy or any disorder affecting neuromuscular control or strength, by definition, patients with idiopathic scoliosis have no definite underlying condition leading to the deformity. The search for a specific underlying cause of idiopathic scoliosis has COA Bulletin ACO - Spring / Printemps 2017

been challenging. To date, no single causative factor has been identified. There is also a lack of evidence in genetic studies for a single genetic site2. It appears that the scoliotic phenotype may be an expression of many different underlying factors. We have appreciated the role of excessive anterior growth in driving progression of the scoliotic deformity as well as causing the crankshaft phenomenon seen in isolated posterior fusions in growing patients. The common link between the many nonidiopathic causes of scoliosis and the genetic heterogeneity of idiopathic scoliosis may be an imbalance of anterior and posterior spinal growth, leading to the characteristic threedimensional deformity. The most critical factors in the assessment and management of scoliosis are residual growth and curve magnitude. Growth fuels curve progression, and bigger curves progress more rapidly. The period of rapid pubertal growth is a time of particular risk for progression. The risk of progression has been generally felt to warrant treatment in patients with curves of 25-30 degrees who have two years or more of growth remaining3,4. Many bracing techniques have been developed and used clinically. Unfortunately, because of the nature of scoliosis

Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 28)

being a disorder of spinal growth that occurs over many years, the development of a successful brace that is tolerated by growing patients is challenging. Children with scoliosis may need to wear a brace for many years. Also, a direct association has been drawn between daily hours of wear and effectiveness, with part-time strategies being less effective5,6,7. We also understand that in order for the brace to be effective, it must alter future spinal growth. That may require alteration of the patientâ€™s spinal position, which renders the device more challenging to construct and wear. In-brace correction does appear to be of major importance in successful management, with many physicians and orthotists having a goal of 50% deformity correction in-brace8,9. In-brace correction is not only dependent on brace design, but also highly dependent on the flexi- Figure 1 bility and location of the curve 40-degree right thoracic idiopathic (Figure 1). scoliosis with a curve apex at T8. As the success rate of surgical correction increased, clinicians who questioned the evidence for the effectiveness of bracing adopted a strategy of observing patients and correcting those that progressed to an unacceptable deformity with surgery. Recent developments in surgical techniques have created excellent cosmetic results for patients and allowed most patients to participate in all activities. Surgeons also became more concerned about the psychosocial effects of bracing teens, who in some cases had to tolerate bracing 23 hours a day over many years. Males, in particular, may have greater difficulty as they are usually older at the time of brace treatment and would have to wear the brace in high school10. In addition, males prolonged adolescent growth requires a longer duration of brace wear, which contributes to lower success rates and a higher progression rate after brace cessation10. These concerns, along with the success of surgical correction and lack of evidence for the effectiveness of bracing, led some clinicians to significantly reduce the use of bracing in their management of idiopathic scoliosis. Interestingly, at the same time, the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) was completed and published, demonstrating a clear benefit of bracing in idiopathic scoliosis11. This study, funded by the National Institute of Health, compared the use of various types of rigid thoracolumbarsacral orthoses with observation alone, with the purpose of evaluating the efficacy of bracing as a treatment option. It enrolled 242 patients, involving patients from a number of Canadian centres. Enrollment was halted by the

data safety monitoring board when interim analyses reached an a priori level of efficacy. The primary finding was that 72% of the patients treated with bracing until maturity had a curve below the surgical threshold of 50 degrees, while only 48% of the observation group were below the threshold. The study also reinforced the association between the effectiveness of bracing and hours of use. Based on temperature monitors embedded in the brace, patients who wore the brace for more than 12.9 hours a day had success rates of greater than 90%. In addition, the bracing group was found to have quality of life scores equivalent to the observation group. Other studies have similarly demonstrated that bracing does not appear to change the patientâ€™s quality of life in the short- or long-term12. Many different scoliosis bracing systems have been designed. Most commonly, the original brace designs were the result of collaborations between surgeons and orthotists at scoliosis centres. Common examples include the Milwaukee brace, the Boston brace, the Providence brace, the Charleston brace and the Wilmington brace. Local orthotists may also modify designs in consultation with treating surgeons. Recently, CADCAM systems have grown in popularity. These braces are all manufactured to achieve some degree of physical correction of the deformity. Flexible brace systems have been proposed as a method of controlling the scoliotic deformity while improving compliance and quality of life13. However, followup studies with flexible brace systems have demonstrated higher rates of curve progression than that seen with rigid orthoses14,15. As a result, interest in flexible bracing has decreased. Many other nonsurgical techniques have been used to try to resolve or prevent progression of scoliotic deformities. The most widely known program is the Schroth method16. Katharina Schroth, born 1894 in Dresden, Germany, developed scoliosis in her teenage years and was treated with a rigid metal brace. She experimented with breathing and postural exercises, often using a mirror, to manage her deformity. Later in life, she further developed the method and, with the assistance of her daughter, opened a large clinic in Germany where the method is still in use. Although there are many proponents of exercise management, most studies have low levels of evidence, being retrospective and lacking appropriate controls. Consequently, a 2013 systematic review concluded that there was a lack of

Figure 2 In brace correction to 26 degrees. Thoracic curves with higher apex locations, above T9, may be more challenging to manage with bracing. COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 29)

high-quality evidence to recommend the use of scoliosis-specific exercises in the management of scoliosis17.

10. Karol L.A. Effectiveness of bracing in male patients with idiopathic scoliosis. Spine. 2001;26:2001-2005.

It does appear that a custom-made thoracolumbarsacral orthosis is the best non-operative option for the prevention of progression in idiopathic scoliosis, having the potential to prevent the need for surgical correction. However, bracing does not appear to have the ability to resolve the radiographic or clinical deformity. The decision to proceed with brace use is a complex one that requires detailed discussion with the patient and family. Successful brace management requires a good working relationship between the surgeon, orthotist, patient and family. Other options have not demonstrated a positive effect on the natural history of the scoliotic deformity, but may provide important general health advantages.

11. Weinstein S.L., Dolan L.A, Wright J.G., Dobbs M.B. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013;369:1512-1521.

References 1. Rogala E.J., Drummond D.S., Gurr J. Scoliosis: Incidence and natural history. A prospective epidemiological study. J Bone Joint Surg Am. 1978;60:173-176. 2. Grauers A., Einarsdottir E., Gerdhem P. Genetics and pathogenesis of idiopathic scoliosis. Scoliosis Spinal Disord. 2016;11. 3. Nachemson A., Peterson L. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg. 1995;77:815-822. 4. Lonstein J., Winter R. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of one thousand and twenty patients. J Bone Joint Surg. 1994;76:1207-1221. 5. Rowe D.E., Bernstein S.M., Riddick M.F., Adler F., Emans J.B., Gardner-Bonneau D. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg. 1997;79:664-74. 6. Katz D.E., Richards B.S., Browne R.H., Herring J.A. A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis. Spine. 1997;22:1302-1312. 7. Katz D.E., Herring J.A., Browne R.H., Kelly D.M., Birch J.G. Brace wear control of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg. 2010;92:1343-1352. 8. Clin J., Aubin C., Sangole A., Labelle H., Parent S. Correlation between immediate in-brace correction and biomechanical effectiveness of brace treatment in adolescent idiopathic scoliosis. Spine. 2010;35:1706-1713. 9. Emans J.B., Kaelin A., Bancel P, Hall J.E,. Miller M.E. The Boston bracing system for idiopathic scoliosis. Follow-up results in 295 patients. Spine. 1986;11:792-801.

COA Bulletin ACO - Spring / Printemps 2017

12. Negrini S., Minozzi S., Bettany-Saltikov J., Chockalingam N., Grivas T.B., Kotwicki T., Maruyama T., Romano M., Zaina F. Braces for idiopathic scoliosis in adolescents. Spine. 2016;41:1813-1825. 13. Coillard C., Circo A.B., Rivard C.H. A prospective randomized controlled trial of the natural history of idiopathic scoliosis versus treatment with the SpineCor brace. Sosort Award 2011 winner. Eur J Phys Rehab Med. 2014;50:479. 14. Gutman G., Benoit M., Joncas J., et al. The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis. Comparison with the Boston brace. Spine J. 2016;16:626-631. 15. Guo J., Lam T.P., Wong M.S., Ng B.K.W., Lee K.M., Liu K.L., Hung L.H., Lau A.H.Y., Sin SW, Kwok W.K., Yu F.W.P., Qiu Y., Chen J.C.Y. A prospective randomized controlled study on the treatment outcome of SpineCor brace versus rigid brace for adolescent idiopathic scoliosis with follow-up according to the SRS standardized criteria. Eur Spine J. 2014;23:2650-2657. 16. Weiss H. The method of Katharina Schroth - History, principles and current development. Scoliosis. 2011;6:17-17. 17. Romano M., Minozzi S., Bettany-Saltikov J., Zaina F., Chockalingam N., Kotwicki T., Maier-Hennes A., Negrini S. Exercises for adolescent idiopathic scoliosis. Cochrane Database Syst Rev. 2012:CD007837.

Changing of the Guard Dr. Kevin Orrell will become the COA’s 72nd President during the Transfer of Office Ceremony. Hear his address as President Elect and meet your new President on Saturday, June 17 at 11:30.

Changement de garde Le Dr Kevin Orrell deviendra le 72e président de l’ACO à la cérémonie de transfert des charges. Ne ratez pas son allocution à titre de président élu, et venez rencontrer votre nouveau président le samedi 17 juin, à 11 h 30.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Operative Care of Idiopathic Scoliosis – The Success of Posterior Pedicle Screw Constructs Neil Saran, M.D., MHSc (Clin. Epi.), FRCSC Montreal Children’s Hospital Shriners Hospital for Children McGill University Montreal, QC

he modern era of scoliosis surgery started in the 1980’s when Cotrel and Dubousset introduced their CD system to the world. The system involved using multiple anchor points consisting of either hooks alone or thoracic hooks and lumbar pedicle screws and two rods used to realign the spine using a rod rotation maneuver (Figure 1a). A rod that was contoured to the coronal deformity into multiple anchors was rotated 90 degrees such that the apex would be brought back towards the midline and into neutral rotation. The idea was to derotate the spine to eliminate the coronal plane scoliotic deformity and restore normal kyphosis which is typically lost in patients with idiopathic scoliosis. It was the first attempt to correct the three dimensional nature of the scoliotic deformity.

Figure 1 The rod rotation maneuver (A) is performed by contouring a rod to the coronal plane scoliosis, anchoring it to the spine, and then rotating the rod 90 degrees such that the coronal deformity is brought back to midline and the sagittal plane hypokyphosis is restored to a more normal alignment. The cantilever maneuver (B) involves contouring the rod for optimal sagittal alignment, anchoring the rod proximally, and segmentally anchoring the rod to the spine while cantilevering the spine such that the rod engages the implants. The apex of the deformity returns towards the midline and the sagittal plane alignment is improved. Whether or not these two methods result in a different final spinal alignment is debated.

Pedicle screws have an advantage over hooks and sublaminar wires by providing a three-column fixed anchor in the vertebrae that allows for full control of the vertebral segment. Pedicle screws allow for compression, distraction, translation, and axial derotation. As such, they provide the surgeon with maximal corrective power of spinal deformity. Another significant advantage is the ease of rod insertion with segmental fixation. Unlike hooks, which have a propensity to dislodge during corrective maneuvers, screws stay in place as they are rigidly fixed to the vertebrae. The 1990’s saw the use of pedicle screws slowly spread from the lumbar spine into the thoracic spine and many different screw, hook, and rod implant systems have come onto the market since. A new correction method of translating the spine using the cantilever technique (Figure 1b) was developed in order to further control sagittal plane alignment and is widely used today as is the rod rotation technique. Uniaxial and polyaxial pedicle screws emerged in the 2000’s which greatly facilitated rod insertion. By the mid to late 2000’s, the ease of rod insertion with uniaxial screws enabled high density implant constructs consisting of bilateral pedicle screws at every level to maximize deformity correction (Figure 2). Despite their steep learning curve, all pedicle screw constructs have become standard treatment for scoliosis care.

Figure 2 Preoperative AP (A), lateral (B) and bending (C) X-rays showing a 100 degree scoliosis that only bends down to 79 degrees in an 11-year-old premenarchal female. She was treated with a T2-L4 high density pedicle screw construct with good overall coronal and sagittal alignment as seen on sixmonth postoperative AP (D) and lateral (E) X-rays. COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 31)

Pedicle screws provide a stronger corrective ability in realigning the scoliotic spine than hooks and wires. Radiographically, various parameters of spinal alignment are significantly improved in all pedicle screw constructs compared to all hook constructs1. Also, all pedicle screw and hybrid constructs using pedicle screws distally save fusion levels compared to all hook constructs2-3. More impressively, pedicle screw constructs have greatly decreased the need for anterior release surgeries. In the past, severe or rigid scoliosis was a classic indication for anterior release of the spine prior to posterior instrumentation in order to allow for improved deformity correction. Over the last two decades, the use of the anterior release to treat such curves has decreased due to the power of pedicle screw constructs4-7. Another advantage of pedicle screws is in avoiding or limiting crankshaft. When a posterior fusion of the spine is performed at an early age, the anterior part of the spine can continue to grow resulting in torsional growth of the spine referred to as the crankshaft phenomenon. In order to prevent crankshaft from occurring, an anterior fusion is required. Patients around the age of ten years that require scoliosis surgery are at risk for developing crankshaft; however, by placing bilateral segmental pedicle screws which provides rigid three-column fixation of the spine, it is felt that crankshaft can be significantly decreased thus avoiding the need for anterior fusion in this population7-8. The main disadvantage of pedicle screw fixation is the steep learning curve associated with safe insertion (Figure 3). It has been shown that screw insertion precision continues to improve even at five years of practice experience9. A systematic review from 2010 showed that approximately 16% of pedicle screws have a breach and 11% of patients have a malpositioned screw10. Despite the high rate of pedicle breach, only 0.6% (12/1666) of patients underwent revision surgery for malpositioned screws. Another study looking at 2132 screws in 101 patients found 13% misplaced screws with 2% of screws (25% of patients) being labelled as at risk due to proximity with great vessels or viscera11. A meta-analysis of navigated pedicle screws showed a significant improvement in pedicle breach with an odds ratio of 0.30 (0.19-0.46) when intraoperative CT was used12 - meaning approximately two thirds of pedicle breaches are eliminated with intraoperative CT navigation. Fortunately, most malpositioned screws remain asymptomatic. Other disadvantages include increased implant costs related to high density screw constructs, the need for a wider dissection, and longer surgical times due to increased dissection and time to insert screws. Furthermore, it is still largely unknown, whether or not pedicle screws improve clinical outcomes compared to multiple hook or hybrid implant constructs. In the last ten years, the cost effectiveness of high density screw constructs has come into question. In 2013, the Minimize Implants Maximize Outcomes Study Group published a systematic study that showed lack of evidence to suggest that high density improved clinical outcomes13. In 2014, the same group reported on 952 patients in a retrospective review comparing high to low density constructs. They showed improved radiographic Cobb correction (69% vs 66%) with the high density constructs and showed minimally better results in the Spinal Appearance Questionnaire for Lenke 1 curves (14.1 vs 15, p=0.03) 14. Whether or not this is a clinically important difference remains unanswered. COA Bulletin ACO - Spring / Printemps 2017

Figure 3 A left T10 pedicle screw (A) that was misplaced is seen indenting the aorta (white arrow). An apical concave pedicle screw tract (B) is seen that resulted in loss of motor evoked potentials. The spinal cord (white arrow) which is hugging the concave pedicle is indented by the expansion of the pedicle.

Pedicle screws constructs are extremely powerful and have become the mainstay in scoliotic deformity treatment. They allow for rigid three-column segmental fixation of the spine and improved deformity correction parameters. Interestingly, patient-related outcomes have not been shown to be better that those in patients with hybrid or all hook constructs. Their greatest utility is in correcting severe and rigid deformities and in younger patients at risk for developing crankshaft. Whether they are used exclusively as in all pedicle screw constructs, or in hybrid constructs where hooks are used proximally in conjunction with distal screws, they decrease the extent of fusion distally. There is a steep learning curve in placement of pedicle screws and pedicle breach is common. Fortunately, very few misplaced screws are symptomatic or require removal. These rates will likely decrease as intraoperative navigation become more commonplace and refined. The next decade will hopefully better define the indications for low density constructs in order to improve the cost effectiveness of pedicle screw constructs when treating idiopathic scoliosis. References 1. Liljenqvist U., Lepsien U., Hackenberg L., Niemeyer T., Halm H. Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis. Eur Spine J. 2002 Aug;11(4):336-43. 2. Kim Y.J., Lenke L.G., Cho S.K., Bridwell K.H., Sides B., Blanke K. Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2004 Sep 15;29(18):2040-8. 3. Kim Y.J., Lenke L.G., Kim J., Bridwell K.H., Cho S.K., Cheh G., Sides B. Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006 Feb 1;31(3):291-8. 4. Suk S.I., Kim J.H., Cho K.J., Kim S.S., Lee J.J., Han Y.T. Is anterior release necessary in severe scoliosis treated by posterior segmental pedicle screw fixation? Eur Spine J. 2007 Sep;16(9):1359-65.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 32)

5. Dobbs M.B., Lenke L.G., Kim Y.J., Luhmann S.J., Bridwell K.H. Anterior/posterior spinal instrumentation versus posterior instrumentation alone for the treatment of adolescent idiopathic scoliotic curves more than 90 degrees. Spine (Phila Pa 1976). 2006 Sep 15;31(20):2386-91. 6. Burton D.C., Sama A.A., Asher M.A., Burke S.W., BoachieAdjei O., Huang R.C., Green D.W., Rawlins B.A. The treatment of large (>70 degrees) thoracic idiopathic scoliosis curves with posterior instrumentation and arthrodesis: when is anterior release indicated? Spine (Phila Pa 1976). 2005 Sep 1;30(17):1979-84. 7. Arlet V., Jiang L., Ouellet J. Is there a need for anterior release for 70-90 degree thoracic curves in adolescent scoliosis? Eur Spine J. 2004 Dec;13(8):740-5. 8. Burton D.C., Asher M.A., Lai S.M. Scoliosis correction maintenance in skeletally immature patients with idiopathic scoliosis. Is anterior fusion really necessary? Spine (Phila Pa 1976). 2000 Jan;25(1):61-8.

10. Hicks J.M., Singla A., Shen F.H., Arlet V. Complications of pedicle screw fixation in scoliosis surgery: a systematic review. Spine (Phila Pa 1976). 2010 May 15;35(11):E465-70. 11. Sarwahi V., Suggs W., Wollowick A.L., Kulkarni P.M., Lo Y., Amaral T.D., Thornhill B. Pedicle screws adjacent to the great vessels or viscera: a study of 2132 pedicle Screws in pediatric spine deformity. J Spinal Disord Tech. 2014 Apr;27(2):64-9. 12. Tian W., Zeng C., An Y., Wang C., Liu Y., Li J. Accuracy and postoperative Assessment of pedicle screw placement during scoliosis surgery with Computer-assisted navigation: a metaanalysis. Int J Med Robot. 2016 Mar 8. [Epub ahead of print] 13. Larson A.N., Aubin C.E., Polly D.W. Jr, Ledonio C.G., Lonner B.S., Shah S.A., Richards B.S. 3rd, Erickson M.A., Emans J.B., Weinstein S.L.; Minimize Implants Maximize Outcomes Study Group.. Are More Screws Better? A Systematic Review of Anchor Density and.Curve Correction in Adolescent Idiopathic Scoliosis. Spine Deform. 2013. Jul;1(4):237-247.

14. Larson A.N., Polly D.W. Jr, Diamond B., Ledonio C., Richards 9. Samdani A.F., Ranade A., Sciubba D.M., Cahill P.J., Antonacci B.S. 3rd, Emans J.B., Sucato D.J., Johnston C.E.; Minimize M.D., Clements D.H., Betz R.R. Accuracy of Implants Maximize Outcomes Study Group.. Does free-hand placement of thoracic pedicle Higher anchor density result in increased screws in adolescent idiopathic scocurve correction and improved clinical liosis: how much of a difference Outcomes in adolescent idiopathic Publishing, does surgeon experience scoliosis? Spine (Phila Pa 1976). Navigating the make? Eur Spine J. 2010 2014 Apr 1;39(7):571-8. Jan;19(1):91-5. Literature and Applying for

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COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Early Onset Idiopathic Scoliosis - Management Techniques Ron El-Hawary, M.D., MSc, FRCSC Associate Professor of Surgery, Orthopaedics Associate Professor of Surgery, Neurosurgery Associate Professor School of Biomedical Engineering Dalhousie University Chief of Paediatric Orthopaedics IWK Health Centre Halifax, NS

arly onset scoliosis has recently been defined as ‘‘scoliosis with onset less than the age of ten years, regardless of etiology’’1,2. These etiologies include congenital, neuromuscular, syndromic, and idiopathic scoliosis, with idiopathic being a diagnosis of exclusion3. Early onset idiopathic scoliosis is further sub-classified based upon age of onset: infantile, which is present before age three years, and juvenile, which is present between ages four and nine years4. These time periods are related to periods of rapid and quiescent spine growth, respectively. This distinction is important as scoliosis progression is related to spine growth, with infantile idiopathic scoliosis having a higher risk of progression during this period of rapid spine growth and juvenile idiopathic scoliosis having a lower risk of progression during this period of slow spine growth5,6. Curve progression in infantile idiopathic scoliosis is also related to the amount of axial plane rotation that is present at the apex of deformity7. If there is significant rotation at the apex of deformity, such that the rib heads overlap the vertebral bodies on a coronal radiograph, there is a significant chance of curve progression (phase 2 rib-vertebrae relationship). Alternatively, if there is no overlap of the rib heads at the apex of deformity (phase 1 rib-vertebrae relationship), the amount of rotation should be measured using the rib vertebral angle difference (RVAD). The RVAD is measured at the apical vertebra by measuring the angle between a line along the concave rib (from the midpoint of the neck of the rib through the midpoint of the rib head) and a line drawn perpendicular to the vertebral end plate. A similar angle is measured on the convex side and the RVAD is the difference between the concave and the convex angles. For resolving infantile idiopathic scoliosis, 80% of the time the RVAD will be less than 20 degrees (indicating minimal apical rotation); while for progressive scoliosis, 80% of the time the RVAD will be greater than 20 degrees (indicating significant apical rotation)7. This is important as curves that are unlikely to progress can simply be observed, while curves that are likely to progress should be aggressively treated in order to avoid the poor natural history of untreated infantile idiopathic scoliosis. Pehrsson studied the natural history of this condition and observed that the mortality rate was double that of the normal population by the age of 40 years as these patients often succumb to cor pulmonale8. Since the spine, chest wall, and pulmonary system have significant remaining growth and development during the early onset scoliosis age group, treatment is designed to not only prevent progression of scoliosis, but also to maintain this growth and development. Rather than performing surgical COA Bulletin ACO - Spring / Printemps 2017

fusion in this age group, “growth friendly” strategies should be employed9. The Growing Spine Committee of the Scoliosis Research Society has recently summarized the treatment goals for this population: Minimize spinal deformity over the life of the patient, maximize thoracic volume and function over the life of the patient, minimize the extent of any final spinal fusion, maximize motion of the chest and spine, minimize complications, procedures, hospitalizations and burden for the family, and consider overall development of the child2. Over the past two decades, growth friendly treatments have largely consisted of posterior distraction spine-based and ribbased systems. These treatments generally involve an insertion procedure which includes placing an upper foundation and a lower foundation of implants (screws or hooks). Submuscular tunneling of growing rods that span the apex of deformity are placed and are connected to the upper and lower foundations in order to avoid purposeful fusion at the apex. By periodically surgically lengthening these rods, deformity correction and spine growth are maintained. Typically these procedures are performed twice per year until skeletal maturity at which time a “graduation” procedure can be performed in order to convert the growth friendly system into a definitive fusion (Figure 1)10. A

Figure 1 (A) Preoperative 3D CT scan of a two-year-old girl with progressive infantile idiopathic scoliosis. Her early onset scoliosis has caused severely diminished lung volumes. (B) Preoperative PA radiograph of this patient demonstrating 60 degree left main thoracic scoliosis. (C) PA radiograph after insertion of rib-based growth friendly rods (VEPTR - vertical expandable titanium rib; Depuy Synthes Spine, Raynham, MA). (D) PA radiograph three years later after five serial lengthening procedures. Note that the medial implant is now at full excursion and requires elective exchange to a larger size.

While many of our overall treatment principles are achieved with these techniques, it is often at the expense of a high complication rate secondary to repetitive surgeries11. Casting has re-emerged as a viable option in this population and can be used as a “delay tactic” to avoid surgery at a young age or as a cure in certain idiopathic patients12. It has been found that casting is more successful in curing idiopathic scoliosis if the patient is young and the scoliosis is small. Recommendations for casting are variable; however, a well accepted criteria are for curves over 25 degrees that have greater than ten degrees of documented progression5.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 34)

Also, in an effort to minimize repetitive surgical procedures, growth guidance systems have been developed and include Shilla (Medtronic, Memphis, TN), TROLLEY (Depuy Synthes Spine, Raynham, MA), and MAGEC (Nuvasive, San Diego, CA)1315 . It is important to note that these products are not currently approved for general use by Health Canada, but have been used in individual patients under the Special Access program. These growth friendly techniques rely on either the patient’s own growth or on an external force to “drive” the growth of the spine (Figure 2). As a result, the strategy these novel devices share is that they should minimize the number of procedures and complications that these young patients experience. A

4. James, J.I.P.: Idiopathic scoliosis: the prognosis. diagnosis and operative indications related to curve patterns and the age at onset. J Bone Joint Surg Br 1954;36-B(1):36e49. 5. Yang, S., Andras, L.M., Redding, G.J., Skaggs, D.L.: Early-Onset Scoliosis: A Review of History, Current Treatment, and Future Directions. Pediatrics 2016;137(1):e20150709. 6. Gillingham, B.L., Fan, R.A., Akbarnia, B.A.: Early Onset Idiopathic Scoliosis. J Am Acad Orthop Surg 2006;14(2):101-112. 7. Mehta, M.H.: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br 1972;54:230-243. 8. Pehrsson, K., Larsson, S., Oden, A., Nachemson,A.: Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms. Spine1992;17(9):1091–1096. 9. Skaggs, D.L., Akbarnia, B.A., Flynn, J.M., Myung, K.S., Sponseller, P.D., Vitale, M.G., Chest Wall and Spine Deformity Study Group, Growing Spine Study Group, Pediatric Orthopaedic Society of North America, Scoliosis Research Society Growing Spine Study Committee: A Classification of Growth Friendly Spine Implants. J Pediatr Orthop 2014;34(3):260e74.

Figure 2 (A) Clinical photograph of a two-year-old girl with progressive infantile idiopathic scoliosis. (B) Preoperative PA radiograph . (C) PA radiograph after insertion of spine-based magnetic controlled growth rods (MAGEC).

Early onset idiopathic scoliosis remains a challenging entity to treat; it is still a condition that can threaten the life expectancy of our patients. Over the last decade, increasing communication internationally has led to greater collaboration and much larger patient numbers in clinical trials and registries. The Scoliosis Research Society and study groups, such as the Children’s Spine Study Group and the Growing Spine Study Group, have facilitated major advances in our understanding of early onset scoliosis. Although further research and development is necessary to fully optimize care for these young patients, it appears that modern growth friendly strategies offer great potential benefit with reduced need for multiple operative interventions and potentially much lower complication rates. References 1. El-Hawary, R., Akbarnia, B.A.: Early onset scoliosis: Time for consensus. Spine Deform 2015;3:105. 2. Skaggs, D.L., Guillaume, T., El-Hawary, R., Emans, J., Mendelow, M., Smitth, J.: Early onset scoliosis consensus statement, SRS Growing Spine Committee 2015. Spine Deform 2015;3(2):107. 3. Williams, B.A., Matsumoto, H., McCalla, D.J., Akbarnia, B.A., Blakemore, L.C., Betz, R.R., Flynn, J.M., Johnston, C.E., McCarthy, R.E., Roye, D.P., Skaggs, D.L., Smith, J.T., Snyder, B.D., Sponseller, P.D., Strum, P .F., Thompson, G.H., Yazici, M., Vitale, M.G.: Development and initial validation of the Classification of Early-Onset Scoliosis (CEOS).J Bone Joint Surg Am 2014;96(16):1359e67.

10. Flynn, J.M., Tomlinson, L.A., Pawelek, J., Thompson, G.H., McCarthy, R., Akbarnia, B.A.: Growing Spine Study Group. Growing-rod graduates: lessons learned from ninety-nine patients who completed lengthening. J Bone Joint Surg Am 2013;95(19):1745–1750. 11. Bess, S., Akbarnia, B.A., Thompson, G.H.,Spinseller, P.D., Shah, S.A., El Sebaie, H., Boachie-Adjei, O., Karlin, L.I., Canale, S., Poe-Kochert, C., Skaggs, D.L.: Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients. J Bone Joint Surg Am2010;92(15):2533–2543. 12. Fletcher, N.D., McClung, A., Rathjen, K.E., Denning, J.R., Browne, R., Johnston, C.E.3rd:Serial casting as a delay tactic in the treatment of moderate-to-severe early-onset scoliosis. J Pediatr Orthop 2012;32(7):664. 13. McCarthy, R.E., McCullogh, F.L.: Growth guidance for earlyonset scoliosis: Results after a minimum of five years of followup. J Bone Joint Surg Am 2015;97:1578-84. 14. Ouellet, J.: Surgical Technique - Modern Luque Trolley, a Self-growing Rod Technique. Clin Orthop Relat Res 2011;469(5):1356–1367. 15. Hosseini, P., Pawelek, J., Mundis, G.M., Yaszay, B., Ferguson, J., Helenius, I., Cheung, K., Demirkiran, G., Alanay, A., Senkoylu, A., Elsebaie, H., Akbarnia, B.A.: Magnetically controlled Growing Rods for Early-onset Scoliosis: A Multicenter Study of 23 Cases With Minimum 2 years Follow-up. Spine 2016;41(18): 1456-1462.

COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

Fusionless Surgery for the Treatment of Idiopathic Scoliosis Firoz Miyanji, M.D., FRCSC Associate Professor, Department of Orthopaedics University of British Columbia Vancouver, BC

pinal arthrodesis remains the gold standard in the management of progressive adolescent idiopathic scoliosis (AIS); however concerns about the long-term effect of spinal fusion and decreased spinal mobility1 have led to the development of growth-modulation techniques that may allow correction of the deformity without fusion. Specific concerns with arthrodesis include halting vertebral growth over the fused segments and the potential for disc degeneration of adjacent segments. Vertebral body stapling (VBS) and anterior vertebral body tethering (AVBT) are currently being investigated as potential fusionless treatment methods to manage progressive curves in the skeletally immature. The goal of these treatments is to control the patient’s remaining spinal growth to prevent further progression and achieve curve correction by exploiting the HeuterVolkman principle. The convex growth plates are compressed under tension, inhibiting their growth, while the concave growth plates continue to grow, hence straightening the spine. Historically growth-modulation of skeletally immature long bones for angular deformity of the lower extremities has been quite successful in deformity correction. Epiphysiodesis using staples and more recently, eight-plates, has been very effective in this setting. Nachlas and Borden2 in 1951 introduced the concept of epiphysiodesis using staples to modulate spinal growth in the setting of deformity. Their canine model showed promise in being able to create and correct lumbar scoliosis using a staple that spanned several vertebral levels. Unfortunately early clinical application of this concept yielded poor results in three children and hence was abandoned. Smith et al.3 in 1954 also reported disappointing results in a cohort of congenital scoliosis whose curves were stapled. The authors had a significant number of dislodgement of staples and curve progression. The Heuter-Volkman principle is thought to be intimately related to scoliosis progression. Compressive loads on the concavity decrease physeal growth leading to vertebral wedging, which induces more compressive inhibition of growth and curve progression. Distractive forces are felt to accelerate growth. This principle has been the impetus for a number of more recent animal studies showing the efficacy of anterior spinal growth modulation. Stokes4 is credited with a classic rat tail animal model, which demonstrated that the Heuter-Volkman principle could predict vertebral body growth through mechanical modulation. Using external fixators, compression reduced rat tail vertebral growth to 68% of normal, and distraction increased growth to 114%. The authors subsequently demonstrated that asymmetric loading of rat tail vertebrae resulted in differential growth on the compression and tension sides enabling both the production of deformity and its subsequent correction5,6. Others have also demonstrated spine deformity creation and COA Bulletin ACO - Spring / Printemps 2017

Figure 1 Eight-year-old female with progressive curve despite bracing.

subsequent control of its progression in experimental animal models using a variety of mechanical implants which have been either a shape memory allow staple, a staple/screw device, or a flexible tether7-12. More recently, studies investigated the ability of anterior spinal growth modulation to correct experimental deformity. Braun et al.14 noted tethering to be superior to staples in deformity correction in their caprine model. Chay et al.19 reported a more favourable three-dimensional correction of their scoliosis porcine model using an anterior-based tether compared to a control group. The authors of these experimental studies also reported on the health of the discs in the tethered segments and found no evidence of irreversible growth cartilage or disc injury13,15-18. Although qualitatively the disc health was maintained, quantitative changes were observed on the side opposite the tether15. The clinical implications and reversibility of these changes remains unknown. With advances in surgical techniques and implant technology, along with experimental studies showing the efficacy of anterior spinal growth modulation, there has been a renewed interest in fusionless techniques for the treatment of scoliosis. Betz et al.19 have popularized VBS reporting on their initial clinical experience. Although the authors conclude that vertebral body stapling can be considered for patients with progressive scoliosis, a number of authors have noted limited if any significant efficacy of VBS in controlling curves. Betz and colleagues20 found VBS to be 78% effective in thoracic curves <=35°, and 87% of thoracolumbar curves <=35°. Others have also noted VBS to have a potential role in minor curves of <=35°21,22. Most treating surgeons, however, would consider skeletally immature patients with curves <=35° bracing candidates and therefore enthusiasm for VBS has remained very limited.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 36)

eight patients: fourtether removals for overcorrection, one replaced broken tether, one contralateral lumber tether added, one conversion to posterior fusion with three more planned. The authors concluded that although the tether clearly affects spinal growth and avoided fusion in 13 of 17 patients, with current technology it resulted in a less than ideal outcome in 47% of their patients.

Figure 2 Anterior Thoracoscopic T5-T11 Vertebral Body Tethering Procedure.

Anterior vertebral body tethering, however, has shown promise in particular for larger curves in skeletally immature patients in whom bracing is ineffective at halting progression. Although clinical data remains limited, there have been published reports on proof of concept23 as well as emerging reports of patients with two-year follow-up. Samdani et al.24 reported their first series of 11 skeletally immature patients with two-year followup and found continued progressive correction of the tethered thoracic curve, non-structural lumbar curve, and the rib prominence. Patients had a mean age of 12.3+/-1.6 years and mean Risser grade of 0.6+/-1.1 with an average preoperative curve magnitude of 44.2° +/- 9.0° which corrected to 20.3°+/-11° on first erect X-ray, with continued improvement at two years to a mean 13.5°+/-11.6°. The authors noted a 70% correction of the curves with AVBT over two-year follow-up. Most recently, Samdani et al.25 presented on 25 patients treated with AVBT who have now reached skeletal maturity. The patients had a mean age of 12.5+/-1.4 years with a mean Risser of 0.5+/-1.0. The average preoperative Cobb was 40.9°+/-7.1°in this cohort which corrected to 20.1°+/-8.4° on first erect X-ray with progressive improvement to skeletal maturity to a mean 14.0°+/11.1°, noting a 66.1% correction over time. There were two patients who required subsequent surgery for over-correction of their curves that required loosening of the tether. The authors did not report on any patient requiring a conversion to fusion surgery. Newton and colleagues26 presented their review of 17 patients treated with AVBT and highlighted some of the concerns that should caution treating surgeons using this technology. Their group of Risser 0 patients with a mean age of 11 years had a mean thoracic preoperative curve of 52° (40°-67°). They defined clinical success as Cobb reduction to <30° at most recent follow-up. The Cobb at most recent follow-up was 23°+/23° (-18°-57°) with Cobb reduction due to growth modulation averaging 8°+/-17°. They found only nine patients with a clinical success and ten additional surgeries were undertaken in

Fusionless surgery for progressive AIS has shown efficacy in animal models and more recently in its clinical application. AVBT has shown to be more effective than VBS in this setting however ideal candidates and indications for AVBT continue to evolve. Currently, skeletally immature patients (Risser <=2) with either isolated thoracic curves, thoracolumbar curves, or a double major pattern (Lenke 3/6) with Cobb angles between 45°-65° may be considered. Caution should be exercised in extremely young, immature patients (open tri-radiate cartilage, age <10) for risk of over-correction24,27,28, and in very large curves (>=65°) for risk of tether failure28. The response of coronal correction may not equate to axial plane correction and patients with a significant rib hump deformity should also be warned. Finally, although thoracolumbar and lumbar curves can be considered, careful evaluation of the sagittal plane should be monitored, as anterior instrumentation is known to be kyphogenic. Although AVBT currently is gaining momentum for its clinical application in the surgical management for idiopathic scoliosis, data regarding its true effectiveness and long-term risk remain outstanding.

Figure 3 (A) Nine months postop. (B),(C) 23 months postop.

COA Bulletin ACO - Spring / Printemps 2017

Clinical Features, Debates & Research / Débats, recherche et articles cliniques

References 1. Marks M., Newton P.O., Petcharaporn M., et al. Postoperative segmental motion of the unfused spine distal to the fusion in 100 patients with adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012;37(10):826-832. doi:10.1097/ BRS.0b013e31823b4eab. 2. Nachlas I.W., Borden J.N. The cure of experimental scoliosis directed growth control. J Bone Joint Surg Am. 1951; 33(1):24-34. 3. Smith A.D., von Lackum H.L., Wylie R. An operation for stapling vertebral bodies in congenital scoliosis. J Bone Joint Surg Am. 1954; 36(2):342-348. 4. Stokes I.A.F, Spence H., Aronson D.D., Kilmer N. Mechanical modulation of vertebral body growth. Implications for scoliosis progression. Spine. 1996; 21(10):1162-1167. 5. Stokes I.A.F, Aronsson D.D., Spence H., Iatridis J.C. Mechanical modulation of intervertebral disc thickness in growing rat tails. Clinical Spine Surgery. 1998; 11(3):261-265. 6. Mente P.L., Aronsson D.D., Stokes I.A., Iatridis J.C. Mechanical modulation of growth for the correction of vertebral wedge deformities. J Orthop Res. 1999; 17(4):518-524. 7. Braun J.T., Ogilvie J.W., Akyuz E., et al. Fusionless scoliosis correction using a shape memory alloy staple in the anterior thoracic spine of the immature goat. Spine 2004; 29: 1980-89. 8. Braun J.T., Ogilvie J.W., Akyuz E., Brodke D.S., Bachus K.N., Stefko R.M. Experimental scoliosis in an immature goat model: a method that creates idiopathic-type deformity with minimal violation of the spinal elements along the curve. Spine. 2003; 28(19):2198-2203. 9. Wall E.J., Bylski-Austrow D.I., Kolata R.J., Crawford A.H. Endoscopic mechanical spinal hemiepiphysiodesis modifies spine growth. Spine. 2005; 30(10):1148-1153. 10. Newton P.O., Fricka K.B., Lee S.S., Farnsworth C.L., Cox T.G., Mahar A.T. Asymmetrical flexible tethering of spine growth in an immature bovine model. Spine. 2002; 27(7):689-93. 11. Newton P.O., Upasani V.V., Farnsworth C.L., et al. Spinal growth modulation with use of a tether in an immature porcine model. J Bone Joint Surg Am. 2008; 90(12):2695-2706. 12. Braun J.T., Ogilvie J.W., Akyuz E., Brodke D.S., Bachus K.N. Creation of an experimental idiopathic-type scoliosis in an immature goat model using a flexible posterior asymmetric tether. Spine. 2006; 31(13):1410-1414. 13. Hunt K.J., Braun J.T., Christensen B.A. The effect of two clinically relevant fusionless scoliosis implant strategies on the health of the intervertebral disc. Spine 2010; 35:371. 14. Braun J.T., Hoffman M., Akyuz E., et al. Mechanical modulation of vertebral growth in the fusionless treatment of progressive scoliosis in an experimental model. Spine 2006; 31:1314-20. COA Bulletin ACO - Spring / Printemps 2017

15. Upasani V.V., Farnsworth C.L., Chambers R.C., et al. Intervertebral disc health preservation after six months of spinal growth modulation. J Bone Joint Surg Am. 2011; 93(15):1408-1416. 16. Newton P.O., Farnsworth CL, Upasani V.V., Chambers R.C., Varley E., Tsutsui S. Effects of intraoperative tensioning of an anterolateral spinal tether on spinal growth modulation in a porcine model. Spine. 2011; 36(2):109-117. 17. Newton P.O., Farnsworth C.L., Faro F.D., et al. Spinal growth modulation with an anterolateral flexible tether in an immature bovine model: disc health and motion preservation. Spine. 2008; 33(7):724-733. 18. Chay E., Patel A., Ungar B., et al. Impact of unilateral corrective tethering on the histology of the growth plate in an established porcine model for thoracic scoliosis. Spine. 2012; 37(15):E883-889. 19. Betz R.R., Kim J., D’andrea L.P., Mulcahey M.J., Balsara R.K., Clements D.H. An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scoliosis: a feasibility, safety, and utility study. Spine. 2003; 28(20S):S255-265. 20. Betz R.R., Ranade A., Samdani A.F., et al. Vertebral body stapling: a fusionless treatment option for a growing child with moderate idiopathic scoliosis. Spine. 2010; 35(2):169-176. 21. Bumpass D.B., Fuhrhop S.K., Schootman M., Smith J.C., Luhmann S.J. Vertebral body stapling for moderate juvenile and early adolescent idiopathic scoliosis: cautions and patient selection criteria. Spine. 2015; 40(24):E1305-1314. 22. Cuddihy L., Danielsson A., Cahill P.J., et al. Vertebral body stapling vs. bracing for patients with high-risk moderate idiopathic scoliosis. Biomed Res Int. 2015. doi: http://dx.doi. org/10.1155/2015/438452 23. Crawford C.H., Lenke L.G. Growth modulation by means of anterior tethering resulting in progressive correction of juvenile idiopathic scoliosis. J Bone Joint Surg Am. 2010; 92(1):202-209. 24. Samdani A.F., Ames R.J., Kimball J.S., et al. Anterior vertebral body tethering for idiopathic scoliosis: two-year results. Spine. 2014; 39(20):1688-1693. 25. Samdani A.F., Ames R.J., Pahys J.M. et al: Anterior vertebral body tethering for immature idiopathic scoliosis: results of patients reaching skeletal maturity. Paper presented at: 50th SRS Annual Meeting; September - October 2015; Minneapolis, MN. https://www.srs.org/UserFiles/file/ meetings/am15/AM15_Abstracts_Web.pdf. 26. Newton P.O., Saito W., Yaszay B., Bartley C., Bastrom T. Successes and failures following spinal growth tethering for scoliosis – a retrospective look 2 to 4 years later. Paper presented at: 51st SRS Annual Meeting; September 2016; Prague, Czech Republic. https://www.srs.org/UserFiles/file/ am16FP-book-WEB-v9sm2.pdf.

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Intimate Partner Violence: What Canadian Orthopaedic Surgeons Need to Know!

he COA and the Centre for Evidence-Based Orthopaedics (CEO) at McMaster University have recently renewed our partnership with a shared goal of raising awareness and providing educational tools to orthopaedic surgeons on the topic of Intimate Partner Violence (IPV). This edition of the

Bulletin features one orthopaedic surgeon’s personal experience discussing IPV with a patient, as well as an update on two collaborative initiatives between the COA and the CEO. We look forward to providing the membership with additional valuable updates in upcoming editions.

The Day I Decided to Ask Carrie Kollias, M.D., FRCSC Lethbridge, AB

t was my last, packed, clinic before holidays. A lady with an unhealed, four month old upper extremity fracture was sitting in the cast room. “How did this happen?” I asked. “I fell…”, she said, looking at the floor. “Any chance this happened from domestic violence?” She shook her head “no”. Her voice was hoarse, citing laryngitis. I felt awkward; I was not particularly skilled at these discussions. In fact, up until the week prior I rarely would have asked; knowing would be an inconvenience in a busy clinic. But I paused. A recent event had changed my perspective. “The reason I ask is that a colleague of mine was recently allegedly abused and murdered by her husband, and it has heightened my awareness of domestic violence.” I was of course referring to Dr. Elana Fric, an accomplished physician and devoted mother, whose death sent shockwaves through the medical community in Canada. My patient then burst into tears and began to tell me that her spouse had broken her arm when he tried to kill her. We later discovered that he had also tried to strangle her. Clearly he had almost succeeded since she could still hardly speak three months later… This experience was practice-changing; how many victims had I missed in my first five years of practice? As orthopaedic surgeons, we are in a unique position to help these patients, and not just with titanium or plaster. We need to be aware of resources for Intimate Partner Violence and processes to help. Most of all though, we just need to start asking a few simple questions. The EDUCATE Program: Education on Domestic Violence: Understanding Clinicians’ And Traumatologists’ Experiences Sheila Sprague, PhD Taryn Scott, MSW Mohit Bhandari, M.D., PhD, FRCSC McMaster University. Hamilton, ON Dr. Kollias shares an important experience - one which many orthopaedic surgeons may recognize from their own practice. IPV is much more common than we think. Research confirms one in six women who present to fracture clinics have been COA Bulletin ACO - Spring / Printemps 2017

victimized by IPV in the past year and one in fifty women are presenting for the treatment of injuries directly sustained from IPV1. Let’s dig deeper. Most orthopaedic surgeons in Canada feel under-prepared to appropriately identify, and equally as important, assist patients who disclose IPV in their practices2. EDUCATE is a Canadian Institutes of Health Research funded program developing critical tools to help orthopaedic surgeons and health-care professionals in fracture clinics identify and assist these women. It focuses on IPV knowledge and skill development delivered via an online video, three interactive online modules, and an in-person presentation that includes case studies and discussion. To implement the program, each participating fracture clinic identifies one or more local champions who become experts on the program curriculum and content and deliver it at their fracture clinic. Currently, the EDUCATE program has been implemented at six fracture clinics and is being qualitatively and quantitatively evaluated as part of a research study. The ongoing research study assesses: 1) Champions’ experiences implementing the program; 2) Program participants’ comfort and knowledge about IPV; 3) Participants’ readiness to assist IPV victims; and 4) Participants’ knowledge utilization. The evaluation of EDUCATE program will be completed by June 2018 and the results of the research study will be released at the COA 2018 Annual Meeting. The findings of the study will be used to refine the EDUCATE program prior to widespread use. The finalized program will be disseminated to the orthopaedic community through a joint collaboration with the COA and McMaster University. Please visit us at the EDUCATE Program booth at the upcoming COA 2017 Annual Meeting to learn more about IPV and the EDUCATE program. How Can I Change my Practice Right Now? Basic IPV Interventions for Surgeons The COA recently updated its IPV Position Statement and Best Practice Recommendations, as well as IPV Resource Appendix, with the help of the Centre for Evidence-Based Orthopaedics (CEO) at McMaster University. We recognize that IPV is a significant social determinant of morbidity and mortality, and that orthopaedic surgeons are well positioned to identify patients living with IPV and provide assistance. We recommend that all

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members refresh their IPV knowledge by reviewing the latest recommendations. Click here to see the updated IPV Position Statement and Best Practice Recommendations. An excerpt follows: Asking the Question Surgeons and other health-care professionals interacting with women in emergency rooms, fracture clinics or office environments should conduct their assessment for IPV in a private setting, without the partner present. Asking direct questions about abuse tends to elicit direct answers, although surgeons should feel free to phrase the question to suit the immediate situation. Here is a suggested approach using a clinically validated screening tool: • Set the context with a lead-in question: “Because violence is so common in many women’s lives and because there is help available for women being abused, I now ask every patient about domestic violence.” • Follow up with the Partner Violence Screen, which consists of three quick questions designed to detect past physical violence and perceived personal safety: - “Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?” - “Do you feel safe in your current relationship?” - “Is there a partner from a previous relationship who is making you feel unsafe now?” First and foremost, surgeons must respect a woman’s choice not to disclose suspected IPV. Under such circumstances, doing no more than providing immediate care may be the only recourse. After Disclosure When a woman does disclose IPV during examination, surgeons and designated health-professionals should consider doing the following • Validate her feelings, by telling her that the abuse is not her fault. Be nonjudgmental, empathic and supportive throughout the interaction. This does not need to take a long time. The compassionate approach of the surgeon will go a long way in helping the patient to take the next steps in accessing other supports. • Assess her safety (and the safety of any children) in her home. “Do you feel safe returning home today?”

• If she feels unsafe, and with her permission, initiate a safety strategy immediately through referral to social services or shelter as required. • Provide care for her immediate injuries and orthopaedicrelated issues. • Take clear, legible, objective clinical notes, using her own words about abuse. Add diagrams or photographs, when appropriate. Should the patient be unwilling to talk about how she sustained her injuries or about the possibility of IPV, documentation and your impressions could be of benefit to the patient sometime in the future. • Offer her a referral and contact information for counseling, shelters and social and legal services. (See Appendix) Simple Measures Here are some suggested first steps that can facilitate helping victims of IPV: • Participate in education to increase knowledge and comfort with identifying IPV and initiating assistance. • Initiate discussion among clinic health-care professionals about strategies for asking about abuse and providing assistance to patients who are experiencing IPV. • Routinely ask all female patients about IPV. • Arrange for privacy in the fracture clinic, where a partner or others can’t overhear. • Compile a list of local IPV services to which health-care professionals can refer patients. • Contact hospital-based and community resources about anticipated referrals. • Place posters and pamphlets in the fracture clinic to signal disclosure is possible. References 1. PRAISE Investigators. Prevalence of abuse and intimate partner violence surgical evaluation (PRAISE) in orthopaedic fracture clinics: a multinational prevalence study. Lancet. 2013;7;382:866-76. 2. Bhandari M., Sprague S., Tornetta P. 3rd, D’Aurora V., Schemitsch E., Shearer H., Brink O., Mathews D., Dosanjh S. Violence Against Women Health Research Collaborative. (Mis) perceptions about intimate partner violence in women presenting for orthopaedic care: a survey of Canadian orthopaedic surgeons. J Bone Joint Surg Am. 2008 Jul;90(7):1590-7.

Violence conjugale : Ce que les orthopédistes canadiens doivent savoir…

’ACO et le Centre for Evidence-Based Orthopaedics (CEO) de l’Université McMaster ont récemment renouvelé leur partenariat dans le but de sensibiliser les orthopédistes à la violence conjugale et de leur fournir des outils sur le sujet. Ce numéro du Bulletin présente l’expérience d’une orthopé-

diste qui a été amenée à parler de violence conjugale avec une patiente, ainsi qu’une mise à jour sur deux initiatives communes de l’ACO et du CEO. Nous ne manquerons pas de transmettre aux membres d’autres mises à jour pertinentes dans les prochains numéros.

COA Bulletin ACO - Spring / Printemps 2017

Advocacy & Health Policy / Défense des intérêts et politiques en santé

Le jour où j’ai décidé de poser LA question Carrie Kollias, MD, FRCSC Lethbridge (Alberta)

’était ma dernière journée à la clinique avant les vacances. Une journée fort bien remplie. Une femme ayant une fracture au bras subie quatre mois plus tôt était assise dans la salle des plâtres. « Qu’est-ce qui vous est arrivé? », lui ai-je demandé. « Je suis tombée... », a-t-elle répondu, en regardant le sol. « Se pourrait-il que votre blessure soit le résultat d’un épisode de violence conjugale? » Elle a secoué la tête. Sa voix était enrouée. Elle m’avait dit avoir une laryngite. J’étais mal à l’aise. Je n’étais pas particulièrement douée pour ce genre de discussion. En fait, jusqu’à la semaine précédente, j’avais rarement posé la question. Savoir pouvait être un désagrément, dans une clinique aussi occupée que la nôtre. Mais j’ai marqué un temps d’arrêt. Un événement récent avait changé ma façon de voir les choses. « La raison pour laquelle je vous pose la question, c’est qu’une de mes collègues aurait récemment été battue et tuée par son mari, et que cette histoire m’a davantage sensibilisée à la violence conjugale. » Je faisais évidemment référence à la Dre Elana Fric, médecin accomplie et mère dévouée, dont la mort a causé une onde de choc au sein de la communauté médicale au Canada. Ma patiente a fondu en larmes et a commencé à me raconter que son conjoint lui avait cassé le bras en essayant de la tuer. Nous avons plus tard découvert qu’il avait aussi tenté de l’étrangler. De toute évidence, il était presque parvenu à ses fins, puisqu’elle arrivait encore à peine à parler trois mois plus tard… Cette expérience a changé ma façon d’exercer. Combien de victimes étaient passées dans mon bureau sans que je m’en rende compte au cours de mes cinq premières années d’exercice? En tant qu’orthopédistes, nous sommes dans une position unique pour aider ces patientes, et pas seulement avec du titane ou un plâtre. Nous devons connaître les ressources en matière de violence conjugale ainsi que les processus d’aide aux victimes. Mais, d’abord et avant tout, il faut commencer par poser quelques questions toutes simples. Le programme EDUCATE : Education on Domestic Violence: Understanding Clinicians’ And Traumatologists’ Experiences (sensibilisation à la violence familiale – Comprendre l’expérience des cliniciens et traumatologues) Sheila Sprague, Ph.D. Taryn Scott, M.Serv.Soc. Mohit Bhandari, MD, Ph.D., FRCSC Campus de Hamilton (Ontario) de l’Université McMaster

L’expérience dont nous fait part la Dre Kollias est importante. C’est le genre d’expérience que bon nombre d’orthopédistes ont vécu eux-mêmes dans le cadre de leur travail. La violence conjugale est bien plus répandue que nous le pensons. Les recherches montrent qu’une femme sur 6 qui se présente dans une clinique de traitement des fractures a été victime de violence conjugale au cours de la dernière année, et qu’une femme sur 50 s’y présente avec des blessures directement liées à la violence conjugale.1 Creusons la question. La majorité COA Bulletin ACO - Spring / Printemps 2017

des orthopédistes canadiens ne se sentent pas suffisamment préparés pour repérer les victimes et, fait tout aussi important, pour aider les patientes qui leur divulguent une situation de violence conjugale.2 Le programme EDUCATE est financé par les Instituts de recherche en santé du Canada; il a pour objectif de concevoir des outils essentiels pour aider les orthopédistes et autres professionnels de la santé travaillant dans les cliniques de traitement des fractures à repérer les victimes et à les aider. Le programme met l’accent sur le développement des connaissances et des compétences en matière de violence conjugale. Il comprend une vidéo en ligne, trois modules interactifs en ligne et une présentation traditionnelle qui inclut des études de cas et des discussions. Pour mettre en œuvre le programme, chaque clinique de traitement des fractures participante désigne au moins un champion local, qui devient le spécialiste du programme et l’offre dans sa clinique. À l’heure actuelle, le programme EDUCATE a été mis en œuvre dans six cliniques de traitement des fractures, en plus d’être évalué de manière qualitative et quantitative dans le cadre d’une étude. L’étude en cours vise à évaluer : 1) l’expérience vécue par les champions pendant la mise en œuvre du programme; 2) l’aisance et les connaissances des participants en matière de violence conjugale; 3) la volonté des participants d’aider les victimes de violence conjugale; et 4) l’application des connaissances par les participants. L’évaluation du programme EDUCATE sera terminée d’ici juin 2018, et les conclusions seront présentées à la Réunion annuelle 2018 de l’ACO. Les conclusions seront par la suite utilisées pour parfaire le programme EDUCATE avant son déploiement à grande échelle. La version finale du programme sera diffusée à la communauté orthopédique grâce à une collaboration de l’ACO et de l’Université McMaster. Venez nous rencontrer au stand du programme EDUCATE à la Réunion annuelle 2017 de l’ACO pour en apprendre davantage sur la violence conjugale et le programme. Comment puis-je changer ma façon d’exercer dès maintenant? Pistes d’intervention en cas de violence conjugale à l’intention des orthopédistes L’ACO, en collaboration avec le Centre for Evidence-Based Orthopaedics (CEO) de l’Université McMaster, a récemment mis à jour son Énoncé de position sur la violence conjugale et pratiques exemplaires recommandées ainsi que l’annexe dressant la liste des ressources disponibles en matière de violence conjugale. L’ACO est consciente que la violence conjugale est un important déterminant social de la morbidité et de la mortalité, et que les orthopédistes sont bien placés pour cerner les personnes qui en sont victimes et leur offrir de l’aide. Nous recommandons à tous les membres de rafraîchir leurs connaissances au sujet de la violence conjugale en lisant les dernières recommandations. Cliquez ici pour consulter la version à jour de l’Énoncé de position sur la violence conjugale et pratiques exemplaires recommandées. En voici un extrait :

Advocacy & Health Policy / Défense des intérêts et politiques en santé (suite de la page 42)

Poser la question Les orthopédistes et autres professionnels de la santé qui interagissent avec les patientes dans les urgences, les cliniques de traitement des fractures et les cabinets devraient effectuer leur évaluation des risques de violence conjugale dans un environnement confidentiel et en l’absence du conjoint. Poser des questions directes sur la violence appelle souvent des réponses directes, bien que les orthopédistes doivent tenir compte de la situation en formulant leurs questions. Voici une approche possible axée sur un outil de dépistage éprouvé en clinique : • Établir le contexte avec une amorce : « Comme la violence est un phénomène courant dans la vie de beaucoup de femmes et qu’il y a des services destinés à les aider, je pose maintenant des questions sur la violence conjugale à toutes mes patientes. » • Poursuivre avec une évaluation de dépistage de la violence conjugale, qui repose sur trois courtes questions conçues pour cerner toute violence physique passée et vérifier le sentiment de sécurité : - « Vous a-t-on déjà donné des coups de poing ou de pied ou encore blessée d’une autre façon au cours de la dernière année? Qui vous a fait ça? » - « Vous sentez-vous en sécurité dans votre relation? » - « Est-ce que vous êtes actuellement inquiète pour votre sécurité à cause d’un ex-conjoint? » Avant toute chose, les orthopédistes doivent respecter le choix de la femme de taire toute violence conjugale suspectée. Dans de telles circonstances, la prestation des soins immédiatement nécessaires peut être la seule avenue possible. Après la divulgation Quand une femme divulgue en cours d’examen qu’elle est victime de violence conjugale, l’orthopédiste et les professionnels de la santé désignés devraient tenir compte de ce qui suit : • Confirmer ses sentiments en lui disant qu’elle n’est pas responsable de cette violence. Garder l’esprit ouvert et manifester de l’empathie et du soutien tout le long de l’entretien. Cela n’a pas à prendre beaucoup de temps. La sollicitude de l’orthopédiste aide énormément la patiente à prendre des mesures pour obtenir de l’aide. • Évaluer sa sécurité (et celle de ses enfants, le cas échéant) à la maison. « Vous sentez-vous en sécurité à l’idée de retourner chez vous aujourd’hui? » • Si la personne ne se sent pas en sécurité et qu’elle donne sa permission, l’aiguiller immédiatement vers les services sociaux ou un refuge, le cas échéant, afin d’assurer sa sécurité. • Soigner les blessures et problèmes orthopédiques nécessitant des soins immédiats.

• Prendre des notes cliniques claires, lisibles et objectives en citant directement la patiente quand il est question de l’agression. Ajouter des illustrations ou photos, si c’est approprié. Même si la patiente ne veut pas aborder la façon dont elle a subi ses blessures ni la question de la violence conjugale, la documentation de son état et des impressions de l’orthopédiste peut lui être utile ultérieurement. • Lui proposer les coordonnées et l’aiguillage nécessaires pour recevoir du counseling, accéder à un refuge ou obtenir l’aide des services sociaux et juridiques (voir en annexe). Mesures simples Voici quelques suggestions quant aux premières mesures qui peuvent aider les victimes de violence conjugale : • Suivre de la formation afin d’être mieux renseigné et équipé pour cerner les cas de violence conjugale et offrir de l’aide. • Discuter avec les autres professionnels de la santé en clinique des stratégies d’approche du sujet de la violence et d’offre de soutien aux victimes de violence conjugale. • Aborder systématiquement la question de la violence conjugale avec toutes les patientes. • Prévoir un espace isolé en clinique de traitement des fractures où le conjoint ni personne d’autre ne peuvent entendre les conversations. • Dresser la liste des services locaux vers lesquels les professionnels de la santé peuvent aiguiller les victimes de violence conjugale. • Communiquer avec les ressources hospitalières et communautaires à propos des aiguillages possibles. • Installer des affiches et mettre des dépliants sur le sujet dans la clinique de traitement des fractures pour montrer qu’il est possible d’y divulguer les cas de violence conjugale. Références 1. CHERCHEURS PRAISE. « Prevalence of abuse and intimate partner violence surgical evaluation (PRAISE) in orthopaedic fracture clinics: a multinational prevalence study », Lancet, vol. 7, no 382 (2013), p. 866-876. 2. BHANDARI, M., S. SPRAGUE, P. TORNETTA III, V. D’AURORA, E. SCHEMITSCH, H. SHEARER, O. BRINK, D. MATHEWS et S. DOSANJH. « Violence Against Women Health Research Collaborative. (Mis)perceptions about intimate partner violence in women presenting for orthopaedic care: A survey of Canadian orthopaedic surgeons », The Journal of Bone & Joint Surgery (Am), vol. 90, no 7 (2008), p. 1590-1597.

COA Bulletin ACO - Spring / Printemps 2017

Advocacy & Health Policy / Défense des intérêts et politiques en santé

COA Continues to Advocate for Access to Orthopaedic Care Peter B. MacDonald, M.D., FRCSC President, Canadian Orthopaedic Association

hanging the political sphere can be challenging. Recently, the COA continued its efforts to bring our expertise to the government table. We recognize that we bring three key things to our government contacts: 1) We represent an important base of practical experience in improving access to care for our patients; 2) We speak with a collective voice, allowing government officials to deal with one group instead of many; 3) We represent, with our patients, a large group of voters to whom government will hopefully listen. It is in this spirit that the COA conducts an ongoing program of government relations and advocacy efforts.

(The Honourable) Jane Philpott’s office, as well as from the Health Canada Policy Unit. The primary objective was to offer the COA and its members as collaborative resources to the government in its quest to tackle improvements in access to care. Highlighting a number of innovations Through input received from COA which began as grassroots efforts by local health teams, messaging focused on memmembers, the Access to Care Steering bers’ commitment to improving efficiency, Committee developed an inventory quality of care and patient satisfaction, often of dozens of Canadian innovations while remaining cost-neutral. The discuswhich have improved access to MSK sions also touched on targeted funding and implementation of national standards. care. Commonalities incude: Advisors from both the political and departmore appropriate and timely ment units were invited to visit some of our referral through MSK centres of exemplar Canadian MSK clinics.

excellence, improved allied health or surgical screening of referrals, centralized intake, and use of digital innovations to improve communication and implement virtual clinics.

In 2016, The COA Access to Care Steering Committee enlisted member support in developing an inventory of dozens of Canadian innovations which have improved access to timely and appropriate MSK care. Notable commonalities include more appropriate and timely referral through MSK centres of excellence, improved allied health or surgical screening of referrals, centralized intake, and use of digital innovations to improve communication and implement virtual clinics.

Along with CEO, Doug Thomson, Manager of Development and Advocacy, Trinity Wittman and Government Relations Specialist, Dafna Strauss, I have recently met twice with federal government policy advisors, both from Health Minister

The advisors welcomed the collaboration, and urged the COA to continue to position itself with the provinces for practical healthcare delivery discussions, given that provinces are currently finalizing agreements with Health Canada and determining spending priorities. I have reached out to each of the provincial orthopaedic presidents, and we will continue to discuss cooperative approaches to advocacy. At the advisors’ suggestion, the COA will also pursue relationships with several other national bodies, including the Canadian Foundation for Healthcare Improvement, a non-profit organization funded by Health Canada, dedicated to accelerating healthcare improvement and spreading innovation. We are committed to pursuing an open dialogue with members, government and other stakeholders. Look out for updates in future editions of the COA Bulletin. If you would like to discuss an MSK advocacy initiative with the COA, please contact policy@canorth.org.

L’ACO continue de promouvoir l’accès aux soins orthopédiques Peter B. MacDonald, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

rovoquer des changements politiques n’est pas simple. Récemment, l’ACO a poursuivi ses efforts pour obtenir une place à la table des discussions gouvernementales. Nous offrons trois atouts majeurs aux représentants gouvernementaux : 1) nous représentons un bassin important d’expérience pratique dans l’amélioration de l’accès aux soins pour nos patients; 2) nous nous exprimons d’une même voix, COA Bulletin ACO - Spring / Printemps 2017

ce qui permet aux représentants gouvernementaux d’interagir avec un seul organisme; et 3) nous représentons, avec nos patients, un groupe important de constituants, qui auront, espérons-le, l’oreille du gouvernement. C’est dans cet esprit que l’ACO poursuit ses activités de relations gouvernementales et de défense des droits et intérêts. En 2016, le Comité directeur de l’ACO sur l’accès aux soins orthopédiques a demandé aux membres de l’aider à dresser l’inventaire de dizaines d’innovations canadiennes qui ont per-

Advocacy & Health Policy / Défense des intérêts et politiques en santé (suite de la page 44)

mis d’améliorer l’accès à des soins de l’appareil locomoteur appropriés et en temps opportun. Parmi les similitudes notables, mentionnons un aiguillage plus précis et rapide par l’intermédiaire de centres d’excellence en soins de l’appareil locomoteur, un meilleur triage chirurgical ou vers des soins de santé connexes, une admission centralisée et le recours à des innovations numériques pour améliorer les communications et créer des cliniques virtuelles.

Grâce à la rétroaction reçue des membres de l’ACO, le Comité directeur sur l’accès aux soins orthopédiques a dressé l’inventaire de dizaines d’innovations canadiennes qui ont permis d’améliorer l’accès aux soins de l’appareil locomoteur. Parmi leurs similitudes, mentionnons un aiguillage plus précis et rapide par l’intermédiaire de centres d’excellence en soins de l’appareil locomoteur, un meilleur triage chirurgical ou vers des soins de santé connexes, une admission centralisée et le recours à des innovations numériques pour améliorer les communications et créer des cliniques virtuelles.

Avec Doug Thomson, directeur général, Trinity Wittman, directrice du développement et des activités de défense des droits, et Dafna Strauss, spécialiste en relations gouvernementales, j’ai récemment rencontré à deux reprises des conseillers en politiques publiques du bureau de la ministre fédérale de la Santé, Jane Philpott, et du Groupe des politiques de Santé Canada. Notre principal objectif était de présenter l’ACO et ses membres comme des ressources prêtes à collaborer avec le gouvernement fédéral dans sa volonté d’améliorer l’accès aux soins. Nous avons mis de l’avant des innovations d’équipes locales et insisté sur l’engagement des membres à améliorer l’efficacité, la qualité des soins et la satisfaction des patients, souvent sans que les coûts s’en ressentent. Les discussions ont aussi porté sur le financement ciblé et la mise en œuvre de normes

nationales. Nous avons en outre invité les conseillers politiques et ministériels à visiter certaines de nos cliniques d’excellence en soins de l’appareil locomoteur. Les conseillers se sont dits heureux de cette collaboration et ont demandé à l’ACO de poursuivre ses discussions pratiques avec les gouvernements provinciaux sur la prestation des soins, puisque ces derniers sont en train de peaufiner leur entente avec Santé Canada et d’établir les dépenses prioritaires. J’ai joint mes homologues des associations provinciales, et nous continuons de discuter d’approches collaboratives dans ce dossier. À la suggestion des conseillers, l’ACO veillera aussi à tisser des liens avec plusieurs organes nationaux, dont la Fondation canadienne pour l’amélioration des services de santé, un organisme sans but lucratif financé par Santé Canada qui a pour mandat d’accélérer l’amélioration des services de santé et de promouvoir l’innovation.

Nous nous engageons à maintenir un dialogue ouvert avec nos membres, le gouvernement et les autres intervenants. Nous vous ferons part des progrès dans ce dossier dans les numéros à venir du Bulletin de l’ACO. Si vous souhaitez discuter d’une initiative de promotion des soins de l’appareil locomoteur avec l’ACO, écrivez à policy@canorth.org.

Innovation in Canadian Spine Care and its Relevance to the Orthopaedic Surgeon Hamilton Hall, M.D., FRCSC Markdale, ON Peter Jarzem, M.D., FRCSC Montreal, QC

an unsupervised non-surgeon can be even more problematic. Persuading the referring doctor that it is justified to have a patient re-assessed by a non-physician in order to reach the surgeon presents a further barrier.

Currently two spine triage pathways The COA will regularly be featuring address and attempt to resolve these he idea of using allied health care challenges. Although their formats vary, innovative orthopaedic care professionals to screen spine patients the underlying concepts are similar. The pathways from across the country. for an orthopaedic surgeon is not patient’s history and physical examination new in Canada. The original Canadian are used to identify mechanical patterns If you would like to submit your Back Institute clinic (the Women’s College of back pain and sciatica, to recognize facmodel of care for publication Back Education Unit) began that practice tors suggesting potential chronicity and to in the Bulletin, please contact in 1974. What has changed dramatically is detect significant psychosocial issues. The policy@canorth.org. the acceptance of this approach by both use of ancillary investigations, particularly surgeons and patients and its incorporation imaging, without clear clinical indications is into the government’s health-delivery system. discouraged. Aggressive education of the primary care providers is combined with the creation of designated clinics that will It has not been easy. The problems encountered four decades accept patients only from practitioners who have been trained ago persist today. Convincing a patient intent on seeing a in and agree to follow the referral guidelines. surgeon to settle for someone seemingly less qualified can be difficult. Convincing a surgeon to entrust clinical decisions to

COA Bulletin ACO - Spring / Printemps 2017

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 45)

Work began on the Saskatchewan Spine Pathway (SSP) in 2008, and culminated in 2010 with a pair of introductory conferences sponsored by the Ministry of Health. Invitations were sent to all family physicians and other primary care providers in the province, including chiropractors and physiotherapists. The goals of the meetings were to explain the essential elements of the system, and to educate and gain acceptance from all potential referral sources. The two live programs were followed by an online course based on the same training material. Two Spine Pathway Clinics, one in Regina and one in Saskatoon, opened in early 2011. Staffed by physiotherapists using the SSP approach, they accept referrals from clinicians who either attended one of the seminars or who, later in the first year when it became available, completed the online instruction. The SSP became the first province-wide standardized spine triage program. It allows all participating practitioners to refer back patients for additional assessment and, when indicated, expedited surgical referral. The Inter-professional Spine Assessment and Education Clinics (ISAEC) started a pilot program in 2012 as part of a spine care initiative by the Ontario Ministry of Health and Long-term Care. Reflecting the province’s larger population and more expansive geography, it was designed as a decentralized hub-and-spoke model. The three hubs – Toronto, Hamilton and Thunder Bay – each have a participating spine surgeon. These centres are linked to designated local clinics that, in addition to their regular practices, offer a finite number of government-funded assessments for back patients. Spine assessments are conducted by physiotherapists and chiropractors specifically trained in the ISAEC approach. Like the SSP, this system stresses a syndrome-based clinical assessment but also includes a standardized set of validated intake questionnaires. Selected primary care providers in the three areas attended training sessions in the fall of 2012 and were then able to refer their patients to any of the involved local clinics. Patients are evaluated and either sent back to the referring practitioner with explicit treatment recommendations or referred on to the spine surgeon. In Saskatchewan, the live and online courses have trained over two thirds of the family physicians, virtually all the nurse practitioners and chiropractors, and about a third of the physiotherapists. The web-based instruction gives the participant MainPro credits from the College of Family Physicians of Canada. Participation is also encouraged by billing incentives in the government fee schedule and by the prioritization of requests for spine MRIs and surgical consultations. Use of the Spine Pathway has reduced MRI utilization by over 50%. Referrals to a spine surgeon have decreased by 70% but the likelihood that the referred patient will be a suitable surgical candidate has doubled. Patient satisfaction with the care they received before seeing the surgeon was three times higher for Pathway patients than for those referred through other channels. While waiting to see the surgeon, every Pathway patient reported having been offered some type of spine care, whereas 12% of the non-Pathway patients stated that they had received no treatment at all.

COA Bulletin ACO - Spring / Printemps 2017

Since its inception, ISAEC has assessed just over 6000 patients with an average wait time for consultation of 12 days. Fewer than 400 (less than 7%) have been referred for imaging or surgery. For those needing a surgical opinion, the wait time to see the spine surgeon is typically less than six weeks, and within this group, the surgeons deemed more than 96% to be appropriate surgical referrals. Patients gave the ISAEC consultation process a 99% satisfaction rating. Over 95% of the primary care providers believe that using ISAEC has improved their patients’ spine care and that the system should be made available to all frontline practitioners. The Ontario Ministry is planning to extend the program to two additional regions. For orthopaedic surgeons interested in participating in spine triage, two elements are essential: education and delegation. Everyone, including patients, practitioners and regulatory bodies, must understand the benefits. To obtain consensus while maintaining the necessary clinical relevance, patient classification should be based on pertinent clinical features, not on putative pathology. A categorization such as the Patterns used in the CORE back tool allows referring physicians, treating clinicians and consulting surgeons to speak a common language. Agreed criteria warranting further assessment or surgical intervention improve the quality of initial referral and instill confidence in the triage process. Educating the referral sources is important, but trusting the education and competence of the delegated triage clinician is essential. For information about the Saskatchewan Spine Pathway, please contact Dr. Daryl Fourney: daryl.fourney@usask.ca For information concerning ISAEC, please contact Dr. Raj Rampersaud: raja.rampersaud@uhn.on.ca References 1. Hall H., Iceton J.A. Back School: Canadian Back Education Units: An overview with specific reference to the Canadian Back Education Units. Clinical Orthopaedics and Related Research: 1983: 179:10-17 2. Fourney D.R., Dettori J.R., Hall H., Hartl R., McGirt M.J., Daubs M.D. A Systematic Review of Clinical Pathways for Lower Back Pain and Introduction of the Saskatchewan Spine Pathway. Spine 2011: 36,(21S): S164–S171 3. Kindrachuk D.R., Fourney D.R. Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization. J Neurosurg Spine 2014: 20: 87–92 4. Wilgenbusch C.S., Wu A.S., Fourney, D.R. Triage of Spine Surgery Referrals Through a Multidisciplinary Care Pathway: A Value-Based Comparison with Conventional Referral Processes. Spine 2014: 39,(22S):S129 - S135 5. Kim J.S.M., Dong J.Z., Brener S., Coyte P.C., Rampersaud Y.R. Cost-effectiveness analysis of a reduction in diagnostic imaging in degenerative spinal disorders. Healthcare Policy. 2011 Nov;7(2):105-21

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 46)

6. Rampersaud Y. R., Bidos A., Schultz S., Fanti C., Young B., Drew B., Puskas D., Henry D. Ontario’s Inter-professional Spine Assessment and Education Clinics (ISAEC): Patient, provider and system impact of an integrated model of care for the management of LBP. Can J Surg, 2016: 59(3):S39.

7. Zarrabian M., Bidos A., Fanti C., Young B., Drew B., Puskas D., Rampersaud R. Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings. Can J Surg. 2016: 59 (3):S41. 8. https://thewellhealth.ca/low-back-pain/

The Waiting Games Brian Day, MRCP, FRCS, FRCSC Vancouver, BC

In the current marathon Medicare case, almost half the (8) months of expensive court time has been consumed on arguments about expert credentials, procedural wrangles and government motions to block evidence.” “In this challenge, the issue has become more about the strictures governing litigation and less about how long and at what cost people are waiting for needed medical services, the constitution and its requirements.” - Ian Mulgrew, columnist, Vancouver Sun, March, 2017

t the time of this writing, we are over seven months into the constitutional trial. The six patient plaintiffs (two of whom died during the nearly eight-year delay getting to trial) and the Cambie Surgery Centre are opposed by 22 lawyers and a large team of paralegals and consultants. Governments have a limitless budget – your and our tax dollars. I console our lawyer, usually sitting alone and isolated at the front of the courtroom, with a reminder of the David and Goliath story. Court observers have cringed at the discourteous dialogue between opposing lawyers and our witnesses. “Professionalism” appears absent from the code of conduct of the opposing legal team. Their manner of speech is often rude, aggressive, and ignorant. If physicians behaved similarly toward each other, or to patients, we would be disciplined for unprofessional conduct. Government backtracked on a pre-trial agreement to accept submitted expert reports, forcing the solicitation of additional reports leading to further expense and delays. They had previously violated the rules by not disclosing 300,000 documents until a week before the earlier 2016 trial date, causing another financially harmful delay. A national charity, the Canadian Constitution Foundation https://theccf.ca/ is assisting with fundraising and our lawyers are frugal and efficient, but the government strategy of pressuring us financially represents a serious threat. I believe they have deduced that forcing us to abandon the case represents their only path to victory. The court has heard protracted arguments and objections aimed at blocking the admission of factual evidence. Government appears to have no other strategy in place. They

even argued that their own, government authored, reports and publications should not be allowed into evidence. The British Columbia Health Minister was called as a witness after he publicly admitted that countries with hybrid systems in Europe, and Australia and New Zealand outperform us. Government opposed his appearance arguing, that like Manuel in the BBC’s Fawlty Towers, he knew nothing. Access to justice in Canada is as bad as access to care. We hear opponents calling for equal access to care, while enjoying inequality before the law. Compare our eight months to date with the few months that the landmark Chaoulli case lasted. The BC government web site lists 85,000 patients waiting for procedures from the time the hospital booking is processed. The evidence has already shown that surgical wait-time data is grossly underestimated. In targeted cases, such as knee replacements, less than half are receiving care within the benchmark of six months, and the time waiting for consultations and investigations is discounted. The COA has rejected government benchmarks as being over twice as long as they should be. Our Health Minister, a veterinarian, would likely lose his licence if he allowed a pet waiting for a hip arthroplasty to suffer in pain for even a week. The waits are worsening more so in the non-targeted procedures. Government lawyers have argued that patients neither deteriorate nor suffer while waiting. They repeatedly invoke procedural gerrymandering to prevent the judge from hearing evidence that proves harm to patients. In advance of the trial, both sides had agreed not to challenge the credentials of experts. However, once witnesses were on the stand, government lawyers reneged and demanded that major sections of the reports be censored and deleted. Even a lawyer for an opposing intervenor group described that process as nonsense. Such legal wrangling has forced multiple rearrangements and shuffling of witnesses. I was scheduled to appear in early April. The government asked for a two-month adjournment (remarkably, claiming it will help us better prepare our case). Because of the summer recess, that will effectively mean a four month delay. The real reason, I suspect, is that an election has been called, and the evidence of forthcoming witnesses would be embarrassing during an active campaign. My testimony will expose extreme pretentiousness on the part of the defending BC and federal governments, not to mention the intervenors. While I will not disclose Visa numbers, I will describe inconsistencies in their professed beliefs. Some of our COA Bulletin ACO - Spring / Printemps 2017

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 47)

doctor witnesses may have taken the “Hippocratic Oath”. I will describe how some key government players, and their supporters, appear instead to abide by a “Hypocritical Oath”.

patient-focused funding (instead of block funding), and a small component of non-government competition, as exists in every successful universal health system.

In 2005, the Supreme Court of Canada ruled that Quebec citizens have the right to purchase private insurance, and stated that Canadians are suffering and dying on wait lists. I presume government lawyers will argue that patients outside of Quebec should be allowed to suffer and die on wait lists.

Patrick Monaghan, a former Dean of Law at Osgoode Hall, has written:

Our case differs from the Quebec case in two important areas. First, it is argued only under the Canadian Charter of Rights and Freedoms and, as it rises through the hierarchy of courts, it will be precedent setting for all provinces. The Chaoulli ruling was under the Quebec charter. Secondly, we seek the legalization of “dual practice”, which will expand opportunities for many doctors, and their patients, constrained by limited access to hospitals. In orthopaedics, that will help solve the dilemma of the reported 178 young, highly qualified, surgeons who cannot get full time work. The court will ponder why Canada, in contrast to every other country on Earth (communist regimes of China, North Korea, Cuba, Laos, and Vietnam included), is alone in outlawing a citizen’s right to obtain private insurance for physician and hospital services. The court has heard arguments opposing governments’ tion that a monopoly serves consumers best. Our legal lenge is not about creating a free market in health We support a government-regulated internal market,

COA Bulletin ACO - Spring / Printemps 2017

posichalcare. with

“We conclude that where the publicly-funded system fails to deliver timely access, governments act unlawfully in prohibiting Canadians to use their own resources to access those services privately.” Our case is about forcing governments to obey the law. In upcoming editions of the COA Bulletin, Dr. Brian Day will be contributing trial updates from the Constitutional Challenge to B.C.’s ban on the purchase of private health insurance for medically necessary services that are already covered by the public system, led by the Cambie Surgery Centre. The outcome of this trial is important to orthopaedic surgeons across Canada as the decision in British Columbia will likely set a precedent for other provinces. Improving access will be beneficial to patients, to the economy of Canada, is compassionate, and will provide resources so that our orthopaedic graduates will have jobs in the future. Regardless of how you feel about the trial and its outcome, the debate on access and funding of care is critical to the future care of our patients – Ed.

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2016 / La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourse de recherche suivants pour 2016 : J. Edouard Samson Award / Prix J.-Édouard-Samson Dr. George S. Athwal (London, ON) – “The Biomechanical Assessment of Complex Shoulder Instability” Carroll A. Laurin Award / Prix Carroll-A.-Laurin Dr. Sasha Carsen (Ottawa, ON) – “Determining the role of physical activity in the development of hip impingement morphology in adolescents during the final stages of skeletal maturation” Robert B. Salter Award / Prix Robert-B.-Salter Dr. Aaron Nauth (Toronto, ON) – “The Use of Autologous Endothelial Progenitor Cells (EPCs) for the Healing of a Bone Defect in a Large Animal Model: A Comparison with Iliac Crest Bone Graft”

Canadian Orthopaedic Research Legacy (CORL) Awards

Bourses de L’Héritage de la Recherche Orthopédique au Canada (HROC)

Dr. Ryan Bicknell (Kingston, ON) – “A Study of the Trabecular Bone Density Distribution in the Scapula Relevant to Reverse Shoulder Arthroplasty” Dr. Anthony Cooper (Vancouver, BC) – “Development of a Patient Reported Quality of Life Questionnaire for Children with Lower Limb Deformities” Dr. Paul A. Martineau (Montreal QC) – “Bone repair in response to mast cell immunotherapy” Dr. Bill Ristevski (Hamilton, ON) – “DRIVSAFE - Distraction on the Road Injury eValuation in Surgery and FracturE clinics” Dr. Marlis Sabo (Calgary, AB) – “Intersection of Catastrophizing, Mood Disorders, and Gender in Rotator Cuff Surgical Patients: A Prospective Exploratory Study” Dr. Emil Schemitsch (London, ON) – “DECIPHER: Determinants of Clinically Important Outcomes following Proximal Humerus Fractures in the Elder Population: A National Cohort” The COF thanks Zimmer Biomet for its transformational gift, and DePuy Synthes for its generous donation, which enabled expansion of our research program. / La Fondation Canadienne d’Orthopédie remercie Zimmer Biomet pour son don transformateur et DePuy Synthes pour son don généreux, qui ont permis l’expansion de ses programmes de financement de la recherche. Benefactor / Bienfaiteur :

Champion / Champion :

DePuy Synthes Canada

Foundation / Fondation

Canadian Orthopaedic Foundation Registers Growth in Programs, Thanks to Powering Pain Free Movement

n 2016 the Canadian Orthopaedic Foundation (COF) launched a new major gifts program aimed at raising funds to grow its research program significantly, and to continue its investment in education and patient care. Led by Patron Dr. Marvin Tile, Professor Emeritus, University of Toronto, and orthopaedic surgeon at Sunnybrook HSC, the COF began reaching out to industry, surgeons and others to join the campaign. A year into the program, we look at what we have achieved to date, and are pleased to report some incredible successes.

in outstanding new research in the field of orthopaedics in Canada.”

Most notably, we have achieved tremendous success in growing the COF research program. Traditionally, we have presented two or three research awards each year. This year, thanks in large part to the success of Powering Pain Free Movement, we are able to do the following:

• The first contribution to the campaign came from The Wright Family Legacy. The family proudly boasts three generations of orthopaedic surgeons continuously carrying out orthopaedic care to Canadians for over 100 years, and the family has been committed to the COF’s success for decades. Dr. Stewart and Marilyn Wright, Dr. Paul Wright, and other Wright family members, collaborated in this important first donation to the campaign. • Bayer Healthcare is a partner of Powering Pain Free Movement, particularly committed to the Ortho Connect program which matches people scheduled for orthopaedic surgery with trained volunteers who have experienced the same surgery to lessen fear and isolation. • Sunnybrook Orthopaedic Associates pledged a multiyear commitment to the COF through Powering Pain Free Movement, noting that the orthopaedic surgeons at Sunnybrook Health Sciences Centre are fully aligned with the mandate of the COF. They challenge other surgical colleagues and groups to follow their lead with similar multi-year support of the COF.

• Award a total of six CORL research grants. The CORL program provides seed funding and helps to ensure Canada’s world-class status in orthopaedic research. • Present two special research awards for the first time since 2007. The Robert B. Salter award recognizes outstanding new basic research; and the Carroll A. Laurin award recognizes outstanding new clinical research. • Increase the value of the prestigious J. Édouard Samson Award, underscoring the significance of this award, presented to a seasoned investigator for a body of research over a five year period. Details of the award recipients appear on page 49 of this issue of the Bulletin. As well, we are able to introduce a new community and innovation awards program, with the first grants to be awarded in fall 2017. Powering Pain Free Movement donors enabled the growth of the COF research program, kicked off by a transformational donation by Zimmer Biomet as a Benefactor donor at the top level of the program. In announcing the company’s commitment, Zimmer Biomet Canada’s Vice President and General Manager, Dave O’Neil said, “We are pleased to be a partner in the Powering Pain Free Movement campaign. We fully support the concept of Canadians being leaders in global orthopaedic research, and are thrilled to work with the Canadian Orthopaedic Foundation to achieve that goal.” DePuy Synthes joined the campaign as a Champion partner. Jeff Deane, Medical Initiatives Director of DePuy Synthes, said, “Let me express our pleasure in being able to support such an important initiative through the COF, in recognition of leading individuals involved COA Bulletin ACO - Spring / Printemps 2017

In addition to growing the research program, Powering Pain Free Movement aims to ensure funding is available to support the COF’s much-needed programs in education and patient care, and to ensure the overall health and stability of the Foundation. This year, we welcomed three additional Powering Pain Free Movement partners:

COF Patron, Dr. Marvin Tile is pleased with the progress of the Powering Pain Free Movement campaign to date. He says, “In the first year, we have made remarkable progress towards achieving our goals. With the support of industry leaders and surgeons as campaign partners, we have been able to register significant growth in research funding. We know that Canadian surgeons have much to contribute in the global orthopaedic research arena, and our funding partners have Dr. Marvin Tile, enabled the COF to support those COF Patron Canadian researchers. At the same time, they are helping to ensure that we’re able to provide educational resources and care for thousands of orthopaedic patients. Most importantly, Powering Pain Free Movement partners are contributing to a vibrant, world-class Foundation.” The first year of the campaign has lived up to its promises. We look forward to continuing growth in the next year.

Dave O’Neil, Vice President and General Manager, Zimmer Biomet Canada

To learn more about the Powering Pain Free Movement program and its partners, visit http://whenithurtstomove.org/donors/

Foundation / Fondation

Misons sur une vie sans douleur propulse la croissance des programmes de la Fondation

n 2016, la Fondation Canadienne d’Orthopédie lançait une campagne de financement d’envergure afin d’accroître la portée de ses programmes de financement de la recherche, mais aussi de maintenir ses investissements dans la sensibilisation des patients et les soins. Avec le soutien de son champion, le Dr Marvin Tile, professeur en chirurgie (honoraire) à l’Université de Toronto et orthopédiste au Sunnybrook Health Sciences Centre, la Fondation a entrepris de solliciter l’industrie, les orthopédistes et d’autres intervenants. Après un an, nous sommes heureux d’annoncer de grandes réussites. L’expansion majeure des programmes de financement de la recherche de la Fondation, surtout, est un succès retentissant. Nous remettons habituellement deux ou trois bourses et prix de recherche par an. Cette année, en majeure partie grâce à la campagne Misons sur une vie sans douleur, nous sommes en mesure d’offrir les bourses et prix suivants : • Six bourses dans le cadre du programme de l’Héritage de la recherche orthopédique au Canada (HROC) : Le programme du HROC fournit du financement de démarrage et contribue à renforcer la réputation en recherche orthopédique du Canada à l’échelle mondiale. • Deux bourses de recherche spéciales, remises pour la première fois depuis 2007, soit la Bourse Robert-B.-Salter, qui reconnaît de nouveaux projets de recherche exceptionnels, et la Bourse Carroll-A.-Laurin, qui récompense de nouveaux projets de recherche clinique exceptionnels. • Augmentation de la valeur du prestigieux Prix J.-Édouard-Samson : Cette décision témoigne de l’importance du Prix, remis à un chercheur reconnu pour ses travaux sur une période de cinq ans. Pour les détails sur les lauréats, voir la page 49 du présent numéro du Bulletin. La Fondation est en outre heureuse de lancer les Prix d’innovation communautaire, qui seront remis pour la première fois à l’automne 2017. Les donateurs à la campagne Misons sur une vie sans douleur, en particulier Zimmer Biomet, ont permis l’expansion des programmes de financement de la recherche de la Fondation. Avec son don transformateur, l’entreprise figure parmi les « Bienfaiteurs » de la campagne, soit nos donateurs les plus importants. À l’annonce de la contribution, Dave O’Neil, vice-président et directeur général de Zimmer Biomet Canada, a déclaré : « Nous sommes heureux de nous associer à la campagne Misons sur une vie sans douleur. Nous appuyons entièrement l’idée de faire du Canada un chef de file mondial de la recherche en orthopédie et sommes très heureux de travailler avec la Fondation Canadienne d’Orthopédie à l’atteinte de cet objectif. » DePuy Synthes a contribué à la campagne à titre de parrain : « Nous sommes heureux de pouvoir soutenir, grâce à la Fondation Canadienne

Dave O’Neil, vice-président et directeur général de Zimmer Biomet Canada

d’Orthopédie, une initiative si importante, qui reconnaît des leaders qui mènent des recherches en orthopédie remarquables au Canada », a déclaré Jeff Deane, directeur des initiatives médicales chez DePuy Synthes. En plus de l’expansion des programmes de financement de la recherche, la campagne Misons sur une vie sans douleur vise à soutenir les programmes essentiels de la Fondation en sensibilisation des patients et en soins et à assurer sa santé et sa stabilité financières. Cette année, la campagne compte trois partenaires supplémentaires : • D’abord, la famille Wright. Fière de ses trois générations d’orthopédistes qui soignent la population canadienne depuis plus d’un siècle, la famille Wright soutient la Fondation dans ses activités depuis des décennies déjà. Le Dr Stewart Wright et son épouse, Marilyn, de même que le Dr Paul Wright et d’autres membres de la famille, ont contribué au premier don important de la campagne. • Bayer Healthcare est un partenaire de la campagne Misons sur une vie sans douleur, et plus particulièrement du programme Connexion Ortho, qui jumelle un patient en attente d’une chirurgie orthopédique à un bénévole formé qui a déjà subi une intervention semblable, une façon de réduire les craintes et l’isolement. • Le groupe Sunnybrook Orthopaedic Associates s’est engagé sur plusieurs années, soulignant que les orthopédistes du Sunnybrook Health Sciences Centre partagent pleinement le mandat de la Fondation. Ses membres invitent d’ailleurs leurs collègues à faire comme eux en offrant un soutien pluriannuel à la Fondation. Le Dr Marvin Tile, champion de la Fondation, est heureux des progrès de la campagne Misons sur une vie sans douleur jusqu’à maintenant. « La première année de notre campagne, nous avons fait des progrès remarquables vers l’atteinte de nos objectifs. Grâce au soutien de leaders de l’industrie et d’orthopédistes partenaires, nous avons constaté une croissance marquée du financement de la recherche. Nous savons que les orthopédistes canadiens ont beaucoup à offrir dans le secteur de la recherche, et ces parte- Le Dr Marvin Tile, naires permettent à la Fondation de les champion de la soutenir dans leurs travaux. De même, ils aident la Fondation à maintenir ses Fondation ressources d’information et ses programmes de soins pour des milliers de patients en orthopédie. Mais surtout, les partenaires de la campagne Misons sur une vie sans douleur font de la Fondation un organisme dynamique de qualité mondiale. » La première année de la campagne a répondu aux attentes, et nous avons hâte de poursuivre sur notre lancée! Pour en savoir plus sur la campagne Misons sur une vie sans douleur et ses partenaires, consultez http://whenithurtstomove.org/ fr/nos-genereux-donateurs/.

COA Bulletin ACO - Spring / Printemps 2017

Training & Practice Management / Formation et gestion d’une pratique

Calendar of Events / Calendrier des événements 40th CONA National Conference Fact, fiction or fantasy May 28-31 mai Toronto, ON Web Site/Site Int. : http://www.cona-nurse.org/ 12th Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip June 15-17 juin Westin Ottawa Held in conjunction with the COA Annual Meeting Web Site/Site Int. : http://www.coa-aco-services.org/websites/2017/index.php?p=80

British Orthopaedic Association (BOA) Annual Scientific Congress Quality and Innovation September 19-22 septembre Liverpool, UK Web Site/Site Int. : http://congress.boa.ac.uk/ European Orthopaedic Research Society (EORS) 25th Annual Meeting September 13-15 septembre Munich, Germany Web Site/Site Int. : http://eors2017.org/

2017 CORA Annual Meeting June 15 juin Ottawa, ON E-mail/Courriel : coraweb@canorth.org Web Site/Site Int. : www.coraweb.org

Australian Orthopaedic Association (AUST.OA) & New Zealand Orthopaedic Association (NZOA) Combined Scientific Meeting Meeting October 8-12 octobre Adelaide, Australia Web Site/Site Int. : http://asm.aoa.org.au/

18th Congress of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) June 1-3 juin Vienna, Austria Web Site/Site Int. : https://www.efort.org/vienna2017/

New Zealand Orthopaedic Association (NZOA) Annual Congress October 15-18 octobre Auckland, New Zealand Web Site/Site Int. : http://nzoa.org.nz

South African Orthopaedic Association (SAOA) 63rd Annual Congress September 4-7 septembre Port Elizabeth, South Africa Web Site/Site Int. : http://www.saoa.org.za/

Le 92ème Congrès de la SOFCOT November 6-9 novembre Paris, France Web Site/Site Int. : www.sofcot-congres.fr

38th SICOT Orthopaedic World Congress November 30 novembre – December 2 décembre Cape Town, South Africa E-mail/Courriel : congress@sicot.org Web Site/Site Int. : http://www.sicot.org/cape-town

CAS 6th Annual Meeting November 23-24 novembre Vancouver, BC E-mail/Courriel : cas@canorth.org Web Site/Site Int. : http://www.coa-aco.org/cas/cas/

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2018

2017

June 15-18 juin CORA Meeting/Réunion de l’ACRO June 15 juin 12th Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip Held in conjunction with the COA Annual Meeting June 15-17 Web Site/Site Int. : http://www.ottawa2017.ca/ COA Bulletin ACO - Spring / Printemps 2017

June 20-23 juin CORA Meeting/Réunion de l’ACRO June 20 juin Victoria, BC

2019

Combined with the 2nd ICORS Meeting June 19-22 juin CORA Meeting/Réunion de l’ACRO June 19 juin Montréal, QC www.2019icors.org

Training & Practice Management / Formation et gestion d’une pratique

Times are a Changin’

Reflections from a Past President of the COA D. William C. Johnston, M.D., FRCSC COA Past President, 2000 Edmonton, AB

reduction and internal fixation of fractures, spinal instrumentation for deformity and fracture, along with correction of deformity with external fixators to name but a few. Of course, joint replacement has revolutionized the treatment of arthritis. It is certain that change will be a constant in the future of orthopaedics.

ur illustrious new Editor-in-Chief of the COA Bulletin, Dr. Alastair Younger, asked me to write the recent history of the University of Alberta Hospital and the University of Alberta Division of Orthopaedics. I agreed, but then immediately had second thoughts for two reasons. The I believe that when the new residents first reservation was related to my being the co-medical direcof today look back on their careers, tor of the University of Alberta Hospital for the last fourteen they will think it rather archaic that we years of my career resulting in little direct contact with the cut out diseased joints and inserted D. W. C. (Bill) Johnston Division of Orthopaedic Surgery. I did not have residents assistmetal and plastic replacements. I am COA Past President (2000) ing in the operating room and was not active sure there will be celin the teaching program. My second reason lular cartilage implants that will deal with “This certainly means that students for hesitation was that the history of most many joint problems in the future. I am sure and residents of today must be hospitals and most divisions/departments of there will be less invasive surgeries, and that lifelong learners who are willing orthopaedics, is really much the same. cellular biology and cellular manipulation will to adapt to huge changes that will become mainstays of treatment. be forthcoming. In order for these There is recruitment and there is retirement. changes to be in the best interests of our patients, we must be at the table There is interviewing, bringing in new resiIt is certainly something I felt strongly about where decisions are made.” dents and graduating of those residents. throughout my career, which is why I tried There is teaching of medical students and felto pursue different administrative roles to lows. There is new technology that comes and much of it goes. see if I could play a role in the direction things were heading. Telling the same story about our institutions did not seem a Unfortunately, in many places in Canada, political and adminparticularly useful exercise. istrative interference have crushed many innovative plans that many of you have worked towards. As one of my esteemed What I did begin to think of, as I have finished my colleagues once told me, hospital and university active orthopaedic career, was the amount administration was like running at a big pile of of change I have seen in orthopaedics Jell-O. You were able to make an indent for since I started my residency in 1977. a period of time, but eventually, things This made me think even further, went back pretty much to the way Social Soirée going back to my grandfather, they were previously. Event au Musée who was a horse and buggy docHeads to de l’aviation tor in the Crowsnest Pass of I do not think that this should Southwestern Alberta in the deter young orthopaedic surthe Canadian et de l’espace du early 1900’s. geons from getting involved Aviation and Canada in decision-making roles, Space Museum Un souper dansant avec He lived to the ripe old age whether it be in provincial groupe invité parmi les pièces of 92 and it is incredible or national associations, An evening of dinner, dancing de collection du Musée de to think of the changes university divisions and and live entertainment amid the l’aviation et de l’espace du Canada he saw within medicine. departments or hospital Canadian Aviation and Space vous attend le samedi 17 juin. Museum’s aircraft collection Operative procedures administration. We must Procurez-vous vos billets pour awaits you on Saturday, June 17. were rarely done except be helping guide decision le Souper dansant au hangar Purchase your tickets for Hangar en vous inscrivant en ligne à la in the face of injury or making if we are going to Dinner n’ Dance Réunion. accident. Traction was be able to do the best job Party when often the mainstay of fracpossible for our patients you register ture treatment and K-wires into the future. Don’t sit on online. were used for fixation. There the sidelines and leave it to were no antibiotics available someone else to take care at that time and childhood of. Get involved and try and diseases such as polio were make a difference. Our patients extremely prevalent. deserve it. In my career, there have also been gigantic leaps forward in terms of open COA Bulletin ACO - Spring / Printemps 2017

Training & Practice Management / Formation et gestion d’une pratique

Using the CanMEDS Roles in Your Practice

New COA Bulletin series focuses on effective use of the CanMEDS framework

he CanMEDS framework is a tool used for teaching and for our continuing medical education. It is well established, benefits our profession and has been integrated into the Royal College’s programs including Maintenance of Certification. The seven roles of the CanMEDS are: • • • • • • •

Medical Expert (the integrating role) Communicator Collaborator Leader Health Advocate Scholar Professional

Over the next few editions of the COA Bulletin, I will be asking various members of the COA to define each of the roles and how they can be used in day-to-day practice and education. This series will provide guidelines on how to use the CanMEDS roles to their full advantage in your orthopaedic practice. Drs. Andrea Veljkovic and Peter Salat have kindly agreed to examine the role of Scholar in this edition’s feature. Enjoy! – Ed.

Scholar Peter Salat, M.D. Rockyview Hospital, Department of Radiology, Cumming School of Medicine, University of Calgary Calgary, AB Andrea Veljkovic, M.D., MPH(Harvard), BComm, FRCSC Foot and Ankle Reconstruction/Arthroscopy & Athletic Injuries/Trauma Associate Clinical Professor St. Paul’s Hospital, Division of Distal Extremities, Department of Orthopaedics, University of British Columbia Vancouver, BC

he role of scholar is integral to the development of an orthopaedic career, whether in the academic or community setting. The 2005 CanMEDS framework (Frank et al.) defined the role of scholar as a physician demonstrating a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge1. The scholar role is diverse, describing four key competencies that physicians should master. Maintaining and enhancing professional activities through ongoing learning is the first of these competencies. Being able to critically evaluate information and its sources, and applying it appropriately to practice decisions is the second. Facilitating the learning of others, including patients, families, medical students, residents, and other health-care professionals is the third competency. Finally, physicians should be able to contribute to creation, dissemination, application, and translation of new medical knowledge and practices1.

COA Bulletin ACO - Spring / Printemps 2017

Based on historical perceptions and tradition, the role of scholar has been ranked as second to last, next to the role of professional2. In a study of the relative importance of the various CanMEDS roles, polled Canadian physicians rated the role of scholar slightly higher than average for other roles in terms of complexity, lower than the mean for frequency in clinical practice and below average for criticality. Overall importance of the scholar role, calculated as a product of frequency and criticality, was rated below the average for other roles. There was no significant difference in the rating of the various roles by family and specialist physicians in this questionnaire-based study looking at the importance of the various CanMEDS roles in clinical practice3. The first competency of the scholar role highlights the importance of an ongoing process of professional development in the role of scholar. This competency is intrinsic to performance of the three other competencies. In all cases, a more accurate reflection of their performance will be obtained with independent performance measures as compared to self-assessment. When these assessments provide feedback, physician performance is more likely to change and patient outcomes can be improved4. The second competency of the scholar role is centered on skills to evaluate information critically and to their application to practice decisions. The importance adequate skills in critical appraisal of the literature cannot be understated and is well highlighted by episodes of societal harm caused by irresponsible research. Several different avenues are available to the physician to develop in this competency. From formal courses to online podcasts, a

Training & Practice Management / Formation et gestion d’une pratique (continued from page 54)

physician can develop further competence at their own pace. One effective way to accomplish this is to develop a personal learning project as such projects are eligible for Section 2 credits of the College MOC5 . Over the five-year cycle, Fellows of the Royal College are required to complete a minimum of 25 Section 2 credits5. A personal learning project requires a defined objective or question, a plan to search for evidence and an assessment of the outcome. For documentation and credit, the College requires that the online submission include the question that was studied, the length of time spent on the project, the date the activity was completed and a statement of the outcome or conclusion. A limited but growing program is available from the Committee on Specialties of the College that would enhance physician development in the third competency - facilitating the learning of others. The Area of Focused Competence (AFC) Diploma in Clinical Education is a College-approved designation recognizing enhanced scope of practice. Typically, successful completion of the AFC program requires one to two years of additional competency-based training. The program is built upon training in a broader discipline and supported within the existing Specialty Committee of the primary discipline. The program is made available through Royal College accredited programs and assessed through a summative portfolio. The successful candidates are granted a Diploma of the Royal College of Physicians and Surgeons of Canada designation, DRCPSC6. While the DRCPSC program may be most efficiently incorporated into an existing residency program, practicing physicians are often already involved in facilitating the learning of others. Teaching of medical students and residents is often integral to a physician’s practice. The research and learning undertaken in preparation for formal teaching sessions can be claimed for credits under Section 25. Development of curricula or exams for learners is also eligible for Section 2 credit and would fulfil the third competency of the scholar role. Review of feedback received by the physician for teaching is eligible for Section 3 credits5. The final competency encompasses all activities of medical knowledge generation and implementation. Formal research activities may be a fixed requirement of some physician’s practice or a sporadic element but knowledge translation may occur more frequently as a natural result of participating in the MOC program. Physician development in the CanMEDS competencies faces challenges that are similar across the seven roles. The primary challenges arise from geographically limited availability of courses7, economic priorities or time restrictions8,9,10. A potential option that may overcome some of these barriers are massive open online courses (MOOCs). These are free online classes open to any participant at any time. The short series of courses are typically offered in weekly five to ten minute videos with accompanied questions, assignments, or case discussions to provide an interactive experience. The most widely known providers currently are Coursera and EdX11.

The role of scholar within the CanMEDS framework encompasses the competencies of critical appraisal, teaching and research. There are a number of resources available to orthopeadic surgeons and other physicians to develop their competencies in this role as discussed above. The underlying value of improved competencies should ultimately be reflected in system-wide improved patient outcomes and a more efficient delivery of health care. References 1. Frank J.R. (Ed.) The CanMEDS 2005 physician competency framework. Ottawa: The Royal College of Physicians and Surgeons of Canada. 2005. The RCPSC. 2. Frank J.R.: (Ed): The CanMEDS 2005 physician competency framework: Better standards. Better physicians. Better care. Ottawa: Royal College of Physicians and Surgeons of Canada; 2005. 3. Stutsky et al. BMC Research Notes 2012, 5:354 4. Davis D.A. et al. Changing physician performance: A systematic review of the effect of continuing medical education strategies. JAMA 1995;274(9):700-5 5. www.royalcollege.ca/rcsite/documents/canmeds/ canmeds-full-framework-e.pdf 6. www.royalcollege.ca/portal/page/portal/rc/credentials/ discipline_recognition/acf/program. 7. Murphy K., Munk P.L. Continuing medical education: MOOCs (Massive Open Online Courses) and their implications for radiology learning. Can Assoc Radiol J 2013;64:165. 8. Rusius V. Using the European working time directive for surgical trainees: how to make it work. Med Educ 2010;44:632-3. 9. Andresen K., Achiam M.P., Rosenberg J. Increase in working hours is an option for improving surgical education in Denmark. Ugeskr Læger 2013;175:1328-31. 10. Deshpande G.A., Soejima K., Ishida Y et al. A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group. Med Teach 2012;34:232-9. 11. Hoy M.B. MOOCs 101: An introduction to massive open online courses. Med Ref Serv Q 2014;33:85-91.

COA Bulletin ACO - Spring / Printemps 2017

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Canadian Orthopaedic Asssociation

Published on May 8, 2017

COA Bulletin #116 Spring 2017

The Spring 2017 edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association.

COA Bulletin #116 Spring 2017

Published on May 8, 2017

The Spring 2017 edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association.

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